I'm a medical resident in Canada. I'm not sure that I remember specific instruction in medical school on how to talk with or about patients who are very sick or near death, at least until starting my palliative care rotation 3 weeks ago. For this reason, this rotation has been an instructive and helpful experience. However, it's been complicated by the fact that Canada has, in the past 5 years or so, liberalized its laws regarding euthanasia to an extent that truly beggars belief. It's strange to be currently working in a discipline (palliative care) that, from its origins, has been bravely and humanely committed to extending personhood and respect to all people, regardless of level of function or disease, while simultaneously being expected to act like it's a normal and good thing for people to be classified by legislation and physician assessment into a group deserving suicide prevention, and a group whose condition is such that suicide assistance is seen as a good idea. So many of my patients are driven to consideration of euthanasia by worry about "being a burden". In this cultural and legislative environment, the "dignity of dependence" really is such foreign vocabulary. Instead, we have "Dying With Dignity", a group committed to universalizing and enshrining in law the fears and prejudices of the rich, able and educated (don't even get me started!).
During medical school, we did have a fair amount of teaching during our "professionalism" classes (which were so well-intentioned, but bland, milquetoast, lowest-common-denominator stuff - but that's a rant for another time!) where we were told to refer to our patients by name, rather than room number, and to use 'person-first language': ie "a 62-year-old man with diabetes" rather than "a 62-year-old diabetic". This was useful, as far as it goes, but that's just it: it doesn't go very far. Because of the inability to assume any substantive shared moral commitments, we were fed a sort of thin, watery moral gruel, which was unable to really open our eyes to the true value and dignity of all people, (visibly) dependent and suffering or not. You can call someone a "person with diabetes" rather than a "diabetic" all you want (and more power to you!), but if you go ahead and offer them medically sanctioned suicide, you are saying that their life and other lives like them are, in your professional judgement, not worth preserving.
I find myself very wary of this (very well written) phrase, "Because of the inability to assume any substantive shared moral commitments, we were fed a sort of thin, watery moral gruel..."
I have little doubt that your training was bland & milquetoast, but I'm troubled by the assertion that it's because of the lack of *any* substantial shared moral commitments among your fellow doctors-to-be. I have little doubt that you share many more moral commitments with your fellow doctors than you don't, including those doctors who discuss all the options available to terminally ill patients.
Let's try and think through a reply here. I think that the phrase "shared substantive moral commitments" is doing a lot of work in my post above, and depending on where I put the emphasis, it brings out different things. Let me try and parse it:
1. "A lack of shared *substantive* moral commitments": I think there's some truth to the assertion that my colleagues and I have a fair amount of shared moral commitments, but it seems to me that they are not truly *substantive*. What I mean is, while we can all agree on relatively bland phrases like "we should treat each person with respect", or "it's good to be kind", these are relatively surface-level commitments, which make for the "moral gruel" I was talking about earlier. These kind of commitments don't get you very far when you're in the moral trenches, trying to work out their implications with real, embodied, suffering people. To come back to what I touched on earlier, is the acceptance of medically-sanctioned euthanasia an implication of "treating each person with respect", or does it in fact make a mockery of the respect we owe each other? You can probably guess where I stand on this, but I guess the point I'm trying to make is that the commitments I *do* share with my colleagues are not fit for use at the level at which we share them; they are not substantive enough to help anyone really navigate the everyday moral minefield. That brings me to:
2. "A lack of *shared* substantive moral commitments": while I tried to be a little more optimistic about how much my colleagues and I share in point #1 above (yes, that's me being optimistic!), the degree of divergence on important issues I am seeing day-to-day makes me often feel like a "stranger in a strange land", where I truly seem to inhabit a different moral universe than those around me (kind and pleasant people, all!). For instance, you mentioned "doctors who discuss all the options available to terminally ill patients". When euthanasia was first legalized in Canada (2016), it was restricted to those with a "grievous and irremediable medical condition" whose death was "reasonably foreseeable" - in short, the terminally ill patient you mentioned above. When I'm trying to be charitable, I try to think that the legislature hoped it would stay there. But soon enough, people were interpreting the law in the most elastic way you can imagine - for instance, euthanizing patients with a life expectancy of TEN YEARS, because they were deemed to have a "reasonably foreseeable" death. Very quickly, we were very far away from the just discussing options available to "terminally ill patients". And most recently, just this March, the "reasonably foreseeable" clause was dropped altogether, meaning that any chronic condition which causes "grievous and irremediable suffering" makes you eligible for euthanasia, regardless of your prognosis. Next on the agenda, in 2023, is euthanasia for mental illness *alone*. (As much as I know I sound like a crank, this is all a matter of public record!). Getting back to the original point here, despite the magnitude of these changes and the speed at which they have happened, there are few of my colleagues who are at all distressed by this, and almost none who will speak about it publicly. *This* is why I feel as though we have no "shared substantive moral commitments" - my colleagues look at this advancing euthanasia regime and barely bat an eyelash, or even enthusiastically support it, while I see an almost perfect enactment of the dictum, "the road to hell is paved with good intentions". We live in separate moral universes, and I don't know what to do about it.
Anyways, I hope you'll forgive me my overlong reply. I suspect it's as much therapy for me as anything else, but I hope it is clarifying in our discussion as well.
I so appreciate your thorough response! And pondering this complicated topic in this forum.
I think it's worthwhile to really identify what you'd characterize as substantive moral commitments. For instance, a doctor who's ethic of preserving life doesn't include insisting on keeping a brain dead woman on life support despite her and her family's wishes - they would share much of the same substantive moral commitments as you, but perhaps not all of them? Or a doctor who's ethic of preserving life doesn't include insisting on a pregnant woman risking her life until her dying fetus' heartbeat can no longer be picked up on a doppler?
Any set of moral commitments has, as you say, "implications with real, embodied, suffering people" and there are a bunch of substantive moral commitments at play in any hairy scenario.
On *shared* - more than 1,000 docs have signed on to a letter in opposition to the laws on the books, and 25% of med students (and potentially 70%+ of practicing physicians, small sample ~250) would not provide MAiD. Many folks appear to share your beliefs!
That said, I'm also curious in your palliative care work if you've heard any somewhat convincing, meaningful arguments in favor of MAiD - either in its current state or expanded version. What is the best argument you've heard, for the most reasonable case? Or are you convinced MAiD in all cases is completely morally incomprehensible?
Thanks again for the reply! It's very refreshing to discuss this important issue, clearly and frankly and without rancour.
It's a helpful exercise for me to try and clarify what I mean by "shared substantive moral commitments". I suppose I mean something like this: a vision of the human person which leads me and my colleagues to have largely similar opinions about what sorts of things do or don't conduce to their dignity and flourishing. Certainly, we don't need to walk in lockstep, but I think that shared ideas about what is good for a human being (and what a human being is good for) would go a long way towards giving my colleagues and I some "shared substantive moral commitments". I recognize that it's unlikely, in this time and place, to have complete agreement, but I guess what's prompting my angst about all this is that there seems to be so little overlap between my vision of the human person, and the vision of the advocates of euthanasia expansion, that it seems like we are focused on treating different species!
With regards to your (excellent) question regarding "convincing, meaningful arguments in favour of [euthanasia]":
It was once the case that, although I could not in good conscience condone it, I had some degree of sympathy for advocates for euthanasia - it seemed to be driven by a simple desire to reduce suffering, of which there is so much in medical practice. To this extent, our visions of the human good overlapped: we both thought that there was very much unnecessary suffering, that this is a tragedy and a travesty, and that it is a good thing to try to address it. We also agreed that it's not uncommon for medical practice to worsen rather than ameliorate suffering. The locus of our disagreement, at that time, seemed to be at the level of means vs. ends.
However, as access to euthanasia rapidly expanded, it seemed to me to become clearer and clearer that our visions of the human person and the human good were rapidly and radically diverging from one another. The way things are currently heading, the current Canadian law is underwritten by an extreme "expressive individualist" (to borrow a phrase from O. Carter Snead) vision of the human person. The closer we get to this vision of the ideal human as independent, untethered, autonomous chooser and "consumer" of "health care services", the more and more "morally incomprehensible" I find it.
One thing that really illustrates this is the idea of "being a burden". This is such a common reason to request euthanasia, and our response to it illustrates quite well these different visions of the human person. It seems to me that the euthanasia advocates equate human dignity with autonomy, and if someone says that "being a burden" makes their life no longer worthwhile, then they agree! By contrast, I think that "being a burden" is just a fact of life (a "feature, not a bug"), from conception to death, and that part of a healthy human life and human society is coming to terms with that: perhaps easing the burden, but not throwing it in the trash, so to speak. Knowing how to approach this deep spiritual malaise is puzzling, and troubling to me.
While I admit to probably being susceptible to the kind of narrative of decline so common amongst certain cultural "conservatives", the statistics you shared are certainly encouraging! That having been said, I do wonder how these statistics would change if they assessed willingness to refer for euthanasia, and not just provide it.
Anyways, I'll stop my rambling for now. I hope it's provided something of a clear answer to some of your excellent questions! Thanks again.
Part of the reason I think it's important to dig in here is because I too am very disturbed by the way, societally, we idealize independence over interdependence. And that means and has meant a lot of harm for the health of our societies and communities and families.
But I also take as a given that *many* people agree with me, and that in our delightfully pluralistic and diverse societies the forms of agreement can look very different - and that that is *not* a bad thing. And is actually a beautiful thing!
From my perspective, a way to tackle the "deep spiritual malaise" would start with comprehending the conditions that have led people to choose and to advocate for euthanasia, then dig into the source of those conditions.
I think a more primary driver of euthanasia is fear than autonomy. Fear of inadequate care (including intolerable and persistent pain), fear of abuse as your condition deteriorates, fear that when all your money has been spent to prolong your life, you'll be left with nothing and treated by those paid to care for you with disregard. These are legitimate fears in our society. And the flip - cherishing our elders - has widespread support!
Similarly, the arguments to support our sick & elderly can easily be applied to fixing so many other pieces of our broken systems - making it possible for families to (financially, physically) to keep their sick & dying in their homes. Stepping up our resourcing of homes for those who can stay 'home'. Solidifying our societal commitment to everyone's dignity regardless of their financial worth.
Instead, much of the discussion around euthanasia evolves into a 'patient desires relief from pain' vs 'my ideology says no, never' debate. It provides an easy way out for both sides, "I don't share that ideology" and "I don't need to comprehend your fear & pain."
I do think there's a winning coalition of euthanasia skeptics, but that requires seeing & building common ground.
I agree that those fears are a big push toward Euthanasia, and that more resources would help. But I think they only solve part of the problem: one of the reasons people fear end of life care isn’t just not being able to *afford* good care. Even well off people suspect that their need will unperson them in the eyes of their caregivers. We assume vulnerability draws contempt, not care.
I recently had a very positive experience around this topic. We had our first ever miscarriage last month. I reached out to our deacon to celebrate a funeral rite for an unbaptized child. He told me he would be honored and asked if we had chosen a name and if we knew the baby’s sex. My napro doctor, who had been monitoring my hormones, called me to offer her condolences. I hadn’t seen my secular midwives yet, since it was so early, and I ended up being grateful I only had to interact with them over the phone, having heard stories like yours in the past.
Oh my goodness this is so powerful. My mother has dementia and I’m now thinking and watching for this. Thank you so much for sharing all you have here. ❤️
The fact is that the word “baby” has no meaning in science. Our high school bio teacher dinged us if we used “baby” rather than “young” for nursing young mammals. She was staunchly Christian and against abortion but she was also a scientist.
There are stages in the development of “babies.” Blastocyst, embryo, fetus. None of those accurate terms make this being les worthy of life and dignity. Be accurate and insist that fetuses have the same right to life as “babies.”
Strictly speaking, you're right. Fetuses ought to have the same right to life as "babies", and "Baby" is not a scientific word, The thing is, though, that we're talking about these conversations which are had in a medical context, and medicine is not a science. It *uses* science - and at its best moments, to great effect! - but it is not itself a science. It is a practice, whose goal is to care for suffering human beings. A very large part of the care that we provide is in how we communicate with our patients, and while it might be technically accurate not to say "baby", I'd argue that in preserving scientific accuracy, we've sacrificed human care for our suffering patients. I say all this as a physician-in-training myself.
I don't have experience with this personally, but a close friend of mine worked as medical scribe at an ER for about a year-- simply standing in the room, taking down the details of the patients, any procedures undertaken, and so forth. That sort of depersonalizing language is exactly what he was trained to use, and he found himself having to fight off that sort of mindset in himself. He noticed that the ER docs, while generally capable and professional when working with patients, could be extremely irreverent behind closed doors. While I don't know for sure, I suspect that there's two things going on: 1, it's important that medical language be very specific, in that every term have a clear and precise meaning that's not easily confused; and 2, in tense or high-stakes situations it's typically an immense advantage to be able to emotionally remove yourself from what's going on so you can focus on the material details. And at least in the ER (and likely elsewheres) I think this is exactly what doctors are trained to do, so that they don't crack in the middle of a lifesaving operation or let their emotions get in the way of solving the problem at hand. The flipside, unfortunately, is that thinking in this way for an extended period of time makes it easy to actually embrace that depersonalization, not as a defensive mechanism or temporary way of thinking, but rather as how they actually think about people. Furthermore, it seems that this way of thinking has spread to situations or positions where it's less warranted, like the OB office.
In a way, it strikes me as something of a catch-22, in that by wanting doctors to be as effective as they can be at saving lives, they in turn adopt a depersonalizing way of thinking and speaking which leads them to devalue those very lives we want them to save. I don't really have any good ideas to solve this dilemma off the top of my head, but I think it's important. It probably doesn't help that many doctors are likely "no feelings, just facts" sort of people to begin with (think of the media trope of the brilliant-but-extremely-rude doctor).
I really appreciate hearing from medical professionals about why this type of language is used. I have noticed communitarian or pro-life feminists challenging various practices of the medical profession, including depersonalizing language, and that worries me amid our society's current trend to undermine and diminish expertise. It seems to me that communitarians, and everyone concerned with the common good, wants doctors and nurses to be respected and taken seriously by the public, and that demands at least some good-faith effort to understand why they do things in ways that might seem strange (and certainly this discussion is an example of that good-faith effort.)
In the same vein, I think the pro-life movement looks silly when they insist that one can have a heartbeat before one has a heart. This position challenges medical expertise on embryology while paradoxically ceding philosophical/religious expertise on a much greater question: what confers life. To insist that a six-week-old fetus whose heart has not yet developed has a "heartbeat" tacitly accepts the medical claim that a heartbeat is necessary for life and thus for concern. Leah has often advocated for a different position: vulnerability and dependency are key to humanity. That understanding is sitting right there waiting for someone to apply it to a preborn human possessed, not of a heart and a heartbeat, but of a fetal pole and its electrical impulses.
This is super-inside baseball, but as a Catholic I would point out that priests don't apply medical declaration of death (heartbeat or brain activity cessation) when deciding whether they can anoint someone who may have recently died. The Catholic philosophical understanding of death is when the soul separates from the body, and it's possible that takes place shortly after the heartbeat has stopped, not at the exact moment. When it comes to death, we don't use heartbeat as proof of life, so we could quite consistently claim that even a very early-stage embryo is a living person without needing to pretend it has a heart and a heartbeat.
The challenging of medical expertise when doctors and nurses use the language of their training also sits uneasily with me seeing that pro-lifers are happy to appropriate the medical expertise that allows us to confirm pregnancy before the next period and view fetal development at very early stages. For most of human history, many women would have experienced something like a ten-week miscarriage as one missed period followed by a heavy one. She may well never have known she was pregnant. Now, parents have the technology to know about and grieve losses that earlier generations may never even have known about. The burden there is mainly on the parents. But (and I apologize for straying so far from your original post) some of the more strident corners of the pro-life movement use pictures of fetal development, etc, which the medical profession has given us, while acting like doctors are ghouls for pointing out that you need a heart to have a heartbeat.
I want to add to this excellent comment that my understanding (I'm not a medical professional) is that the phrase “The pregnancy has been completely expelled" refers to both the embryo/fetus and the placenta. If the placenta does not come out completely it's extremely dangerous for the mother and might require surgery.
it's a bit hard to pinpoint exactly what all of your anger is about - the actual events of your loss or the words used to describe or to fail to describe the losses. you have a lot of anger. 40 years ago, i had a miscarriage at 12 weeks followed by years of infertility. i was angry at being dismissed about the infertility because i had a 2 year old when i lost the second pregnancy. finally, i took myself to a specialist and within 3 years had 2 more children. i was very fortunate given my situation. i found that the 'cluelessness' was equal across genders and ages of caregivers. my own mother (an RN) was highly dismissive of my miscarriage. a good female friend who is an OB/GYN summed it up fairly well when she told me that many male OB's are more sympathetic to women than other women are - the women OB's figure that if they got thru it (childbirth), other women can get through it without complaining too much. as for the OB or med student recording the name of one's children, i'm quite sure that none of my physicians or caregivers has ever asked or recorded my childrens' names. why should they? the children are not their patients. i believe you might be asking too much when it comes to that. as for caregivers referring to patients by something other than their names, this is a common occurrence. i worked in hospitals most of my adult life. adult patients in the hospital were and are routinely referred to by their room/bed assignment.. some of that is merely logistics and some of it is a need for an emotional spacing from fragile (especially pediatric) patients. the emotional well being of caregivers is part of the overall picture of healthcare. we've become especially aware of that during COVID - or it's been written about a great deal. people are still dismissing it. doctors and nurses, technicians and aides are not robots. i have known and worked with literally thousands of them since 1967. only a handful would fall into the category of uncaring. the vast majority are deeply caring and work hard for their patients. they are balancing the art and science of medicine every time they greet a patient. some are better at the science than the art. i have known some that were downright cantankerous but whose hands i would gladly place my well being in. kind words are great - knowledge, skill, and a desire to do the best for the patient even greater.
I think there's a real transactional quality to medicine today - personally, I don't blame the doctors or nurses for it. After all, as you point out, the doctors and nurses emotional (and physical!) well being is treated with callous disregard by hospital administration.
I share at least some of Leah's anger - the anger directed at a whole system that has evolved to be less humane, and incentivizes people to be less kind, generous, and human with one another.
My GYN was never asked the name of my living child, and neither has my primary care doctor. I also haven't shared it. My son's name isn't relevant to the transactional relationship taking place, and I know that neither has the time to sit with me for much longer than taking care of basics. I don't blame them for that. But wouldn't a better world be one where we got to know each other as people? And shared more of ourselves with those we encounter?
This reminds me of the lovely book I'm currently reading: The Dawn of Everything. It questions what a healthy society looks like, and looks at what healthy societies *have* looked like through the ages. I think there's very little that's healthy or humane about our current set up - it just happens that our society's most barbaric decisions happen quietly, in insurance company cubicles, courtrooms, and sterile corporate boardrooms.
I think it's worth pulling this out: "The first time I became pregnant, the intake nurse asked, “And how do you feel about being pregnant?” only using “baby” once I’d dignified the child by clarifying I didn’t want an abortion."
This is one of those questions that doctors use to start a conversation (and assessment) of other factors that can impact a pregnancy - worries about finances, a physical job, domestic violence, childcare, degree of ambivalence toward the pregnancy. Staff will use this question and the follow up to connect their patient to more resources where appropriate. That's a good thing!
I do think you make a good point about when medical professionals use (inaccurate) language that has an emotional resonance vs (accurate) clinical language that feels impersonal/less kind. But I do wonder if we shouldn't strive for a delight in accuracy? I personally do believe a fetus has dignity, whether or not it becomes or can become a baby or a child. I also believe there should absolutely not be any legal restrictions on abortion. As the fetal pole cardiac activity post you linked to points out - there are real and horrific consequences for the perpetuation of inaccuracies (ex: pregnant folks being denied real and life saving care by politicians who think pregnancy complications don't exist).
I also experienced "and how do you feel about being pregnant?" as a positive question - I went to an urgent care clinic to get a blood test for pregnancy because the at-home test I was using looked weird, and the nurse who was taking my blood pressure and screening me for Covid made some offhand comments that made it clear he was assuming I must not want to be pregnant. So when the doctor who was doing my blood test asked me "how do you feel about the possibility of being pregnant?", I felt relieved at being able to express my actual feelings (overwhelmed, but excited), especially because only three other people knew there was even a chance I could be pregnant and I really wanted to talk about how I felt!
I know I'm late, but I had a somewhat similar experience when my third baby was diagnosed with a cleft lip and palate at the 20 week ultrasound. The midwife, and two separate doctors had to delicately ask if I still wanted my baby (all seemed visibly relieved when I said of course and no condition would change how I felt about my baby). But I think the most striking thing was how many of the doctors I talked to opened the conversation with congratulating me on my beautiful baby. It was such a relief to not enter into a conversation defensive and feeling like I needed to protect my baby FROM the doctors.
Holland is 16 months old now and is a bundle of energy, goofiness, and delight!
I'm a medical resident in Canada. I'm not sure that I remember specific instruction in medical school on how to talk with or about patients who are very sick or near death, at least until starting my palliative care rotation 3 weeks ago. For this reason, this rotation has been an instructive and helpful experience. However, it's been complicated by the fact that Canada has, in the past 5 years or so, liberalized its laws regarding euthanasia to an extent that truly beggars belief. It's strange to be currently working in a discipline (palliative care) that, from its origins, has been bravely and humanely committed to extending personhood and respect to all people, regardless of level of function or disease, while simultaneously being expected to act like it's a normal and good thing for people to be classified by legislation and physician assessment into a group deserving suicide prevention, and a group whose condition is such that suicide assistance is seen as a good idea. So many of my patients are driven to consideration of euthanasia by worry about "being a burden". In this cultural and legislative environment, the "dignity of dependence" really is such foreign vocabulary. Instead, we have "Dying With Dignity", a group committed to universalizing and enshrining in law the fears and prejudices of the rich, able and educated (don't even get me started!).
During medical school, we did have a fair amount of teaching during our "professionalism" classes (which were so well-intentioned, but bland, milquetoast, lowest-common-denominator stuff - but that's a rant for another time!) where we were told to refer to our patients by name, rather than room number, and to use 'person-first language': ie "a 62-year-old man with diabetes" rather than "a 62-year-old diabetic". This was useful, as far as it goes, but that's just it: it doesn't go very far. Because of the inability to assume any substantive shared moral commitments, we were fed a sort of thin, watery moral gruel, which was unable to really open our eyes to the true value and dignity of all people, (visibly) dependent and suffering or not. You can call someone a "person with diabetes" rather than a "diabetic" all you want (and more power to you!), but if you go ahead and offer them medically sanctioned suicide, you are saying that their life and other lives like them are, in your professional judgement, not worth preserving.
I find myself very wary of this (very well written) phrase, "Because of the inability to assume any substantive shared moral commitments, we were fed a sort of thin, watery moral gruel..."
I have little doubt that your training was bland & milquetoast, but I'm troubled by the assertion that it's because of the lack of *any* substantial shared moral commitments among your fellow doctors-to-be. I have little doubt that you share many more moral commitments with your fellow doctors than you don't, including those doctors who discuss all the options available to terminally ill patients.
Thanks for the pushback, Martha. I appreciate it!
Let's try and think through a reply here. I think that the phrase "shared substantive moral commitments" is doing a lot of work in my post above, and depending on where I put the emphasis, it brings out different things. Let me try and parse it:
1. "A lack of shared *substantive* moral commitments": I think there's some truth to the assertion that my colleagues and I have a fair amount of shared moral commitments, but it seems to me that they are not truly *substantive*. What I mean is, while we can all agree on relatively bland phrases like "we should treat each person with respect", or "it's good to be kind", these are relatively surface-level commitments, which make for the "moral gruel" I was talking about earlier. These kind of commitments don't get you very far when you're in the moral trenches, trying to work out their implications with real, embodied, suffering people. To come back to what I touched on earlier, is the acceptance of medically-sanctioned euthanasia an implication of "treating each person with respect", or does it in fact make a mockery of the respect we owe each other? You can probably guess where I stand on this, but I guess the point I'm trying to make is that the commitments I *do* share with my colleagues are not fit for use at the level at which we share them; they are not substantive enough to help anyone really navigate the everyday moral minefield. That brings me to:
2. "A lack of *shared* substantive moral commitments": while I tried to be a little more optimistic about how much my colleagues and I share in point #1 above (yes, that's me being optimistic!), the degree of divergence on important issues I am seeing day-to-day makes me often feel like a "stranger in a strange land", where I truly seem to inhabit a different moral universe than those around me (kind and pleasant people, all!). For instance, you mentioned "doctors who discuss all the options available to terminally ill patients". When euthanasia was first legalized in Canada (2016), it was restricted to those with a "grievous and irremediable medical condition" whose death was "reasonably foreseeable" - in short, the terminally ill patient you mentioned above. When I'm trying to be charitable, I try to think that the legislature hoped it would stay there. But soon enough, people were interpreting the law in the most elastic way you can imagine - for instance, euthanizing patients with a life expectancy of TEN YEARS, because they were deemed to have a "reasonably foreseeable" death. Very quickly, we were very far away from the just discussing options available to "terminally ill patients". And most recently, just this March, the "reasonably foreseeable" clause was dropped altogether, meaning that any chronic condition which causes "grievous and irremediable suffering" makes you eligible for euthanasia, regardless of your prognosis. Next on the agenda, in 2023, is euthanasia for mental illness *alone*. (As much as I know I sound like a crank, this is all a matter of public record!). Getting back to the original point here, despite the magnitude of these changes and the speed at which they have happened, there are few of my colleagues who are at all distressed by this, and almost none who will speak about it publicly. *This* is why I feel as though we have no "shared substantive moral commitments" - my colleagues look at this advancing euthanasia regime and barely bat an eyelash, or even enthusiastically support it, while I see an almost perfect enactment of the dictum, "the road to hell is paved with good intentions". We live in separate moral universes, and I don't know what to do about it.
Anyways, I hope you'll forgive me my overlong reply. I suspect it's as much therapy for me as anything else, but I hope it is clarifying in our discussion as well.
I so appreciate your thorough response! And pondering this complicated topic in this forum.
I think it's worthwhile to really identify what you'd characterize as substantive moral commitments. For instance, a doctor who's ethic of preserving life doesn't include insisting on keeping a brain dead woman on life support despite her and her family's wishes - they would share much of the same substantive moral commitments as you, but perhaps not all of them? Or a doctor who's ethic of preserving life doesn't include insisting on a pregnant woman risking her life until her dying fetus' heartbeat can no longer be picked up on a doppler?
Any set of moral commitments has, as you say, "implications with real, embodied, suffering people" and there are a bunch of substantive moral commitments at play in any hairy scenario.
On *shared* - more than 1,000 docs have signed on to a letter in opposition to the laws on the books, and 25% of med students (and potentially 70%+ of practicing physicians, small sample ~250) would not provide MAiD. Many folks appear to share your beliefs!
That said, I'm also curious in your palliative care work if you've heard any somewhat convincing, meaningful arguments in favor of MAiD - either in its current state or expanded version. What is the best argument you've heard, for the most reasonable case? Or are you convinced MAiD in all cases is completely morally incomprehensible?
Thanks again for the reply! It's very refreshing to discuss this important issue, clearly and frankly and without rancour.
It's a helpful exercise for me to try and clarify what I mean by "shared substantive moral commitments". I suppose I mean something like this: a vision of the human person which leads me and my colleagues to have largely similar opinions about what sorts of things do or don't conduce to their dignity and flourishing. Certainly, we don't need to walk in lockstep, but I think that shared ideas about what is good for a human being (and what a human being is good for) would go a long way towards giving my colleagues and I some "shared substantive moral commitments". I recognize that it's unlikely, in this time and place, to have complete agreement, but I guess what's prompting my angst about all this is that there seems to be so little overlap between my vision of the human person, and the vision of the advocates of euthanasia expansion, that it seems like we are focused on treating different species!
With regards to your (excellent) question regarding "convincing, meaningful arguments in favour of [euthanasia]":
It was once the case that, although I could not in good conscience condone it, I had some degree of sympathy for advocates for euthanasia - it seemed to be driven by a simple desire to reduce suffering, of which there is so much in medical practice. To this extent, our visions of the human good overlapped: we both thought that there was very much unnecessary suffering, that this is a tragedy and a travesty, and that it is a good thing to try to address it. We also agreed that it's not uncommon for medical practice to worsen rather than ameliorate suffering. The locus of our disagreement, at that time, seemed to be at the level of means vs. ends.
However, as access to euthanasia rapidly expanded, it seemed to me to become clearer and clearer that our visions of the human person and the human good were rapidly and radically diverging from one another. The way things are currently heading, the current Canadian law is underwritten by an extreme "expressive individualist" (to borrow a phrase from O. Carter Snead) vision of the human person. The closer we get to this vision of the ideal human as independent, untethered, autonomous chooser and "consumer" of "health care services", the more and more "morally incomprehensible" I find it.
One thing that really illustrates this is the idea of "being a burden". This is such a common reason to request euthanasia, and our response to it illustrates quite well these different visions of the human person. It seems to me that the euthanasia advocates equate human dignity with autonomy, and if someone says that "being a burden" makes their life no longer worthwhile, then they agree! By contrast, I think that "being a burden" is just a fact of life (a "feature, not a bug"), from conception to death, and that part of a healthy human life and human society is coming to terms with that: perhaps easing the burden, but not throwing it in the trash, so to speak. Knowing how to approach this deep spiritual malaise is puzzling, and troubling to me.
While I admit to probably being susceptible to the kind of narrative of decline so common amongst certain cultural "conservatives", the statistics you shared are certainly encouraging! That having been said, I do wonder how these statistics would change if they assessed willingness to refer for euthanasia, and not just provide it.
Anyways, I'll stop my rambling for now. I hope it's provided something of a clear answer to some of your excellent questions! Thanks again.
Love love love this discussion! Thank you again.
Part of the reason I think it's important to dig in here is because I too am very disturbed by the way, societally, we idealize independence over interdependence. And that means and has meant a lot of harm for the health of our societies and communities and families.
But I also take as a given that *many* people agree with me, and that in our delightfully pluralistic and diverse societies the forms of agreement can look very different - and that that is *not* a bad thing. And is actually a beautiful thing!
From my perspective, a way to tackle the "deep spiritual malaise" would start with comprehending the conditions that have led people to choose and to advocate for euthanasia, then dig into the source of those conditions.
I think a more primary driver of euthanasia is fear than autonomy. Fear of inadequate care (including intolerable and persistent pain), fear of abuse as your condition deteriorates, fear that when all your money has been spent to prolong your life, you'll be left with nothing and treated by those paid to care for you with disregard. These are legitimate fears in our society. And the flip - cherishing our elders - has widespread support!
Similarly, the arguments to support our sick & elderly can easily be applied to fixing so many other pieces of our broken systems - making it possible for families to (financially, physically) to keep their sick & dying in their homes. Stepping up our resourcing of homes for those who can stay 'home'. Solidifying our societal commitment to everyone's dignity regardless of their financial worth.
Instead, much of the discussion around euthanasia evolves into a 'patient desires relief from pain' vs 'my ideology says no, never' debate. It provides an easy way out for both sides, "I don't share that ideology" and "I don't need to comprehend your fear & pain."
I do think there's a winning coalition of euthanasia skeptics, but that requires seeing & building common ground.
I agree that those fears are a big push toward Euthanasia, and that more resources would help. But I think they only solve part of the problem: one of the reasons people fear end of life care isn’t just not being able to *afford* good care. Even well off people suspect that their need will unperson them in the eyes of their caregivers. We assume vulnerability draws contempt, not care.
I recently had a very positive experience around this topic. We had our first ever miscarriage last month. I reached out to our deacon to celebrate a funeral rite for an unbaptized child. He told me he would be honored and asked if we had chosen a name and if we knew the baby’s sex. My napro doctor, who had been monitoring my hormones, called me to offer her condolences. I hadn’t seen my secular midwives yet, since it was so early, and I ended up being grateful I only had to interact with them over the phone, having heard stories like yours in the past.
Oh my goodness this is so powerful. My mother has dementia and I’m now thinking and watching for this. Thank you so much for sharing all you have here. ❤️
The fact is that the word “baby” has no meaning in science. Our high school bio teacher dinged us if we used “baby” rather than “young” for nursing young mammals. She was staunchly Christian and against abortion but she was also a scientist.
There are stages in the development of “babies.” Blastocyst, embryo, fetus. None of those accurate terms make this being les worthy of life and dignity. Be accurate and insist that fetuses have the same right to life as “babies.”
Strictly speaking, you're right. Fetuses ought to have the same right to life as "babies", and "Baby" is not a scientific word, The thing is, though, that we're talking about these conversations which are had in a medical context, and medicine is not a science. It *uses* science - and at its best moments, to great effect! - but it is not itself a science. It is a practice, whose goal is to care for suffering human beings. A very large part of the care that we provide is in how we communicate with our patients, and while it might be technically accurate not to say "baby", I'd argue that in preserving scientific accuracy, we've sacrificed human care for our suffering patients. I say all this as a physician-in-training myself.
I don't have experience with this personally, but a close friend of mine worked as medical scribe at an ER for about a year-- simply standing in the room, taking down the details of the patients, any procedures undertaken, and so forth. That sort of depersonalizing language is exactly what he was trained to use, and he found himself having to fight off that sort of mindset in himself. He noticed that the ER docs, while generally capable and professional when working with patients, could be extremely irreverent behind closed doors. While I don't know for sure, I suspect that there's two things going on: 1, it's important that medical language be very specific, in that every term have a clear and precise meaning that's not easily confused; and 2, in tense or high-stakes situations it's typically an immense advantage to be able to emotionally remove yourself from what's going on so you can focus on the material details. And at least in the ER (and likely elsewheres) I think this is exactly what doctors are trained to do, so that they don't crack in the middle of a lifesaving operation or let their emotions get in the way of solving the problem at hand. The flipside, unfortunately, is that thinking in this way for an extended period of time makes it easy to actually embrace that depersonalization, not as a defensive mechanism or temporary way of thinking, but rather as how they actually think about people. Furthermore, it seems that this way of thinking has spread to situations or positions where it's less warranted, like the OB office.
In a way, it strikes me as something of a catch-22, in that by wanting doctors to be as effective as they can be at saving lives, they in turn adopt a depersonalizing way of thinking and speaking which leads them to devalue those very lives we want them to save. I don't really have any good ideas to solve this dilemma off the top of my head, but I think it's important. It probably doesn't help that many doctors are likely "no feelings, just facts" sort of people to begin with (think of the media trope of the brilliant-but-extremely-rude doctor).
There's a really good write up of using Baby A, Baby B standards in a survey by the Institute for Safe Medical Practices. The short version is concern among staff that creating a new medical record for the babies with their names will lead to them either not receiving meds, or receiving the wrong ones. Here's the link: https://www.ismp.org/resources/whats-name-survey-finds-wide-variety-error-prone-newborn-naming-conventions-use-today
That said, the ISMP isn't convinced using the generic names is a best practice to avoid mixups.
I really appreciate hearing from medical professionals about why this type of language is used. I have noticed communitarian or pro-life feminists challenging various practices of the medical profession, including depersonalizing language, and that worries me amid our society's current trend to undermine and diminish expertise. It seems to me that communitarians, and everyone concerned with the common good, wants doctors and nurses to be respected and taken seriously by the public, and that demands at least some good-faith effort to understand why they do things in ways that might seem strange (and certainly this discussion is an example of that good-faith effort.)
In the same vein, I think the pro-life movement looks silly when they insist that one can have a heartbeat before one has a heart. This position challenges medical expertise on embryology while paradoxically ceding philosophical/religious expertise on a much greater question: what confers life. To insist that a six-week-old fetus whose heart has not yet developed has a "heartbeat" tacitly accepts the medical claim that a heartbeat is necessary for life and thus for concern. Leah has often advocated for a different position: vulnerability and dependency are key to humanity. That understanding is sitting right there waiting for someone to apply it to a preborn human possessed, not of a heart and a heartbeat, but of a fetal pole and its electrical impulses.
This is super-inside baseball, but as a Catholic I would point out that priests don't apply medical declaration of death (heartbeat or brain activity cessation) when deciding whether they can anoint someone who may have recently died. The Catholic philosophical understanding of death is when the soul separates from the body, and it's possible that takes place shortly after the heartbeat has stopped, not at the exact moment. When it comes to death, we don't use heartbeat as proof of life, so we could quite consistently claim that even a very early-stage embryo is a living person without needing to pretend it has a heart and a heartbeat.
The challenging of medical expertise when doctors and nurses use the language of their training also sits uneasily with me seeing that pro-lifers are happy to appropriate the medical expertise that allows us to confirm pregnancy before the next period and view fetal development at very early stages. For most of human history, many women would have experienced something like a ten-week miscarriage as one missed period followed by a heavy one. She may well never have known she was pregnant. Now, parents have the technology to know about and grieve losses that earlier generations may never even have known about. The burden there is mainly on the parents. But (and I apologize for straying so far from your original post) some of the more strident corners of the pro-life movement use pictures of fetal development, etc, which the medical profession has given us, while acting like doctors are ghouls for pointing out that you need a heart to have a heartbeat.
I want to add to this excellent comment that my understanding (I'm not a medical professional) is that the phrase “The pregnancy has been completely expelled" refers to both the embryo/fetus and the placenta. If the placenta does not come out completely it's extremely dangerous for the mother and might require surgery.
it's a bit hard to pinpoint exactly what all of your anger is about - the actual events of your loss or the words used to describe or to fail to describe the losses. you have a lot of anger. 40 years ago, i had a miscarriage at 12 weeks followed by years of infertility. i was angry at being dismissed about the infertility because i had a 2 year old when i lost the second pregnancy. finally, i took myself to a specialist and within 3 years had 2 more children. i was very fortunate given my situation. i found that the 'cluelessness' was equal across genders and ages of caregivers. my own mother (an RN) was highly dismissive of my miscarriage. a good female friend who is an OB/GYN summed it up fairly well when she told me that many male OB's are more sympathetic to women than other women are - the women OB's figure that if they got thru it (childbirth), other women can get through it without complaining too much. as for the OB or med student recording the name of one's children, i'm quite sure that none of my physicians or caregivers has ever asked or recorded my childrens' names. why should they? the children are not their patients. i believe you might be asking too much when it comes to that. as for caregivers referring to patients by something other than their names, this is a common occurrence. i worked in hospitals most of my adult life. adult patients in the hospital were and are routinely referred to by their room/bed assignment.. some of that is merely logistics and some of it is a need for an emotional spacing from fragile (especially pediatric) patients. the emotional well being of caregivers is part of the overall picture of healthcare. we've become especially aware of that during COVID - or it's been written about a great deal. people are still dismissing it. doctors and nurses, technicians and aides are not robots. i have known and worked with literally thousands of them since 1967. only a handful would fall into the category of uncaring. the vast majority are deeply caring and work hard for their patients. they are balancing the art and science of medicine every time they greet a patient. some are better at the science than the art. i have known some that were downright cantankerous but whose hands i would gladly place my well being in. kind words are great - knowledge, skill, and a desire to do the best for the patient even greater.
I think there's a real transactional quality to medicine today - personally, I don't blame the doctors or nurses for it. After all, as you point out, the doctors and nurses emotional (and physical!) well being is treated with callous disregard by hospital administration.
I share at least some of Leah's anger - the anger directed at a whole system that has evolved to be less humane, and incentivizes people to be less kind, generous, and human with one another.
My GYN was never asked the name of my living child, and neither has my primary care doctor. I also haven't shared it. My son's name isn't relevant to the transactional relationship taking place, and I know that neither has the time to sit with me for much longer than taking care of basics. I don't blame them for that. But wouldn't a better world be one where we got to know each other as people? And shared more of ourselves with those we encounter?
This reminds me of the lovely book I'm currently reading: The Dawn of Everything. It questions what a healthy society looks like, and looks at what healthy societies *have* looked like through the ages. I think there's very little that's healthy or humane about our current set up - it just happens that our society's most barbaric decisions happen quietly, in insurance company cubicles, courtrooms, and sterile corporate boardrooms.
well stated.
I think it's worth pulling this out: "The first time I became pregnant, the intake nurse asked, “And how do you feel about being pregnant?” only using “baby” once I’d dignified the child by clarifying I didn’t want an abortion."
This is one of those questions that doctors use to start a conversation (and assessment) of other factors that can impact a pregnancy - worries about finances, a physical job, domestic violence, childcare, degree of ambivalence toward the pregnancy. Staff will use this question and the follow up to connect their patient to more resources where appropriate. That's a good thing!
I do think you make a good point about when medical professionals use (inaccurate) language that has an emotional resonance vs (accurate) clinical language that feels impersonal/less kind. But I do wonder if we shouldn't strive for a delight in accuracy? I personally do believe a fetus has dignity, whether or not it becomes or can become a baby or a child. I also believe there should absolutely not be any legal restrictions on abortion. As the fetal pole cardiac activity post you linked to points out - there are real and horrific consequences for the perpetuation of inaccuracies (ex: pregnant folks being denied real and life saving care by politicians who think pregnancy complications don't exist).
I also experienced "and how do you feel about being pregnant?" as a positive question - I went to an urgent care clinic to get a blood test for pregnancy because the at-home test I was using looked weird, and the nurse who was taking my blood pressure and screening me for Covid made some offhand comments that made it clear he was assuming I must not want to be pregnant. So when the doctor who was doing my blood test asked me "how do you feel about the possibility of being pregnant?", I felt relieved at being able to express my actual feelings (overwhelmed, but excited), especially because only three other people knew there was even a chance I could be pregnant and I really wanted to talk about how I felt!
I know I'm late, but I had a somewhat similar experience when my third baby was diagnosed with a cleft lip and palate at the 20 week ultrasound. The midwife, and two separate doctors had to delicately ask if I still wanted my baby (all seemed visibly relieved when I said of course and no condition would change how I felt about my baby). But I think the most striking thing was how many of the doctors I talked to opened the conversation with congratulating me on my beautiful baby. It was such a relief to not enter into a conversation defensive and feeling like I needed to protect my baby FROM the doctors.
Holland is 16 months old now and is a bundle of energy, goofiness, and delight!