Assisted Dying: A History of Ethical Principles

Stuart Chambers describes the ethical principles that have shaped the historical debates surrounding medical assistance in dying in Canada.

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Canada’s proposed legislation on medical assistance in dying, (Bill C-14), is arguably the result of a transition or evolution of bioethical principles from sanctity of life, to qualified sanctity of life, to quality of life.

According to the sanctity of life principle, life is of intrinsic value. Grounded in mainstream Christian beliefs, this principle prohibits intentional killing—in both active and passive forms.  Life is considered a stewardship or loan from the Creator, and the power to live or die resides with the Creator alone.

According to the qualified sanctity of life principle, one cannot actively and intentionally hasten death; however, one can refrain from preventing natural death.  Treatment can, therefore, be omitted, allowing death to occur “naturally.”

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The quality of life principle, in sharp contrast, permits intentionally hastening death using either acts of omission (withholding or withdrawing treatment) or commission (prescribing overdoses or administering lethal injections).  Although the quality of life principle is now the dominant ethos, its acceptance unfolded gradually over time. This occurred largely in response to shifting public attitudes towards intentional death, as reflected in legal documents and case law.

In1982, the Law Reform Commission of Canada shepherded the transition from the sanctity of life principle to the qualified sanctity of life principle. In its report, Aiding Suicide and Cessation of Treatment, the Commission concluded that a moral distinction between acts of omission and commission was legitimate. In other words, “letting die” was ethically distinct from “intending death.” In this report, the prohibition against euthanasia and assisted suicide was maintained.

Then in 1989, there was the Nancy B. case in Quebec.  Nancy B. was a young woman who was completely paralyzed after being afflicted with Guillain-Barré syndrome, a disease in which the body’s immune system attacks part of the peripheral nervous system.  She asked to have her ventilator removed so that she could die.  The hospital responsible for her care, the Hôtel-Dieu de Québec, went to court to ensure that removing the ventilator and “letting Nancy B.” die did not constitute murder.  In 1992, the Quebec Superior Court declared that removal of the ventilator was simply allowing nature to take its course, and would not involve the active killing of a patient. Positive acts that hastened death remained illegal.  With this decision, the moral distinction between acts of omission and commission became the new medico-legal standard.

In 1993, Sue Rodriguez, a 41-year-old British Columbia woman suffering from amyotrophic lateral sclerosis, or ALS, challenged the constitutionality of the law prohibiting doctor-assisted suicide.  In a split decision, Rodriguez’s appeal was denied by the Supreme Court of Canada for two reasons. First, her request involved active measures to hasten death, which the Court considered contrary to the sanctity of life and the qualified sanctity of life principles. Second, the Court felt that decriminalization could lead to a slippery slope where vulnerable members of society—the poor, the elderly and the disabled—would be at risk.  Consequently, the previous moral distinction between “letting die” and “intending death” was upheld, even for competent, terminally ill adults whose suffering was unbearable.  The impact of this decision would be felt for nearly two decades.

In 2012, British Columbia’s Supreme Court “unsanctified” human life by permitting the intentional hastening of death for a terminally ill woman named Gloria Taylor.  In Carter v. Canada, Justice Lynn Smith endorsed the quality of life principle. In her decision, she allowed that Taylor’s death could be intentionally hastened based on quality of life considerations.  Three years later, the Supreme Court of Canada upheld this decision. Consequently, any remaining traces of the traditional sanctity of life doctrine in law all but disappeared.

Today, in 2016, active methods of hastening death are no longer stigmatized. With the proposed federal legislation, two types of medical assistance in dying are legal. First, a physician or nurse practitioner can directly administer a substance that causes the death of the person who has requested it (commonly called voluntary euthanasia). Second, a physician or nurse practitioner can give or prescribe to a person a substance that they can self-administer to cause their own death (commonly known as physician-assisted suicide – and, in Canada, medical assistance in dying). With this shift towards the quality of life principle, Canada’s approach to medical assistance in dying is now one of the most permissive in the world.

The Liberal government’s proposed legislation on medical assistance in dying has achieved its main objective: the expansion of choices for those who “have a grievous and irremediable medical condition.”  In this way, the federal government has ushered in a more comprehensive and inclusive application of the quality of life ethos.

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Stuart Chambers is a professor in the Faculties of Arts and Social Sciences at the University of Ottawa.