Assisted Suicide & the Cure of Souls

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Writing about death is difficult for a priest. It is difficult because to write about death in the abstract is to miss the reality that death never comes in the abstract. When death comes, it comes to people I know and love. And for them to invite me into this last passage of their lives is to offer me a sacred trust. I cannot write about their experiences, or my experiences with them, unless I erase the details of their lives that make their ends so unique. So, I have to write about death in the abstract, thinking about it as a concept or an idea. Nobody who faces death faces it as a concept; they face it as an enemy to be vanquished one way or another.

One way or another we must eliminate death. The usual course for eliminating death is by passing through it. Even in a society like Canada’s, which is increasingly secularized (or at least de-Christianized), I’ve learned that the Church still has a place in helping people as they prepare to pass through death. But in Canada this is complicated by our policy of medical assistance in dying, known as MAiD—the euphemism we use for euthanasia. MAiD is not about palliative care, though it can include elements of palliative care. MAiD is about the use of medicine to shorten the lifespans of those who request it.

Writing about MAiD as a priest is difficult for the same reason that writing about death is difficult. To write about either is to write in the abstract, or to write about faceless people with indistinct illnesses, fears, and anxieties. But I will nevertheless attempt to point to the problems with Canada’s embrace of MAiD, from my perspective as a Christian priest. Some of the problems are conceptual, and these are somewhat easier to write about. But the human problems with MAiD only ever emerge in context, and while I have to respect the privacy of those who have confided in me because of my office, I will try to gesture toward some of these problems as well.

In the English Reformation, Archbishop Thomas Cranmer drew together a number of homilies to read in parish churches, especially in settings in which there was no licensed preacher. These homilies were meant to set out doctrine in plain form. They privileged simplicity and applicability over eloquence.

The “Exhortation Against the Fear of Death” is one of the more pastoral sermons. Its aim is to buttress the Christian against the inevitability of death by pointing out the way Christian hope—especially hope unmarred by “popish” notions of purgatory—can guarantee the nearness of Christ, avoidance of damnation, and joy in the world to come. Thus death, though it is cast as fearsome, can be borne with courage.

If the language of the same exhortation were modernized, the homily would sound right at home in many Christian churches today. In Canada, it would have been compelling until around five years ago, when MAiD was first enacted. But if the logic behind homilies like the “Exhortation Against the Fear of Death” still remains broadly applicable, it may not be for much longer. Increasingly, many Canadians, including Christians, are opting to hasten death’s arrival. In the next year, new legislation will allow people the option to die even if they can’t see their end on the horizon at all.

This is evidence of how the ancient patterns of life that once shaped the cure of souls are changing. The cure of souls is bound to the concrete texture of human existence as much as it is bound to religious life and its scriptural roots. With the shifting of the patterns of human existence, the task of caring for human beings whom God loves changes, too. Are the changes leading to further human flourishing? What does it mean for pastors to keep up with the shifting values?

Canada’s federal government passed legislation making MAiD legal for eligible Canadian adults in June 2016. The most recent annual report on MAiD, published in July 2022, found that since 2016 there have been 31,664 MAiD deaths, with the numbers increasing annually. While there were 2,838 deaths in 2017, the first full year of reporting, in 2021, there were 10,064. The majority of MAiD requests (just under 66 percent in 2021) come from cancer patients.

Until March 2021, to be eligible for MAiD, Canadians had to have a severe and incurable illness or disability; to be in an advanced state of irreversible decline in capabilities, with intolerable physical or psychological suffering; and to expect death in the foreseeable future. The rules for eligibility were then broadened to include those whose death is not necessarily foreseeable in the near future, so eventually those with mental illnesses (such as depression) could opt for MAiD as well. These new rules were set to take effect in March 2023 but have since been delayed. There are “robust safeguards” for those seeking MAiD, however, including the support of a qualified medical professional, informed consent from the person seeking MAiD, and an independent witness who will not benefit from the death of the patient, to name a few.

While there are plenty of important ethical and legal questions that Canada’s MAiD legislation raises, and while many of these changes become more pressing with the recent amendments, I am especially interested in the way that the introduction of MAiD shapes life for Christians.

What has technology changed about the way Christians face death? Not much, really. While it’s true that MAiD utilizes “advances” in medicine, new medications and technologies do nothing that could not be done with a guillotine or a bullet.

Those who request MAiD in Canada have two options. They can choose to receive their medication intravenously or orally. Both methods have as their end the termination of human life. Both are meant to be efficient means of accomplishing this end. Both are meant to cause as little physical and psychological discomfort as possible.

The intravenous method includes a few steps. First, patients are given drugs to sedate them and induce a coma; then, bupivacaine is administered to bring about cardiac arrest. The oral method relies less on medical equipment, though a professional presence is still recommended. Patients ingest a compound of drugs that eases pain and then ultimately ends their lives. After taking an antiemetic to reduce nausea, they can select from an array of drugs (a liquid mixed with 15 grams of secobarbital is recommended) meant to induce a coma from which the patient will never awake.

But what are the practical differences between the methods of MAiD and much cruder technologies like the guillotine, which were themselves meant to be humane methods of killing? The effect is the same for the guillotine and the bupivacaine injection. The process is arguably painless in either case.

What has changed is how dying appears to those who are present. Bupivacaine injections are far more sanitized. A simple needle and a comfortable bed give the appearance that one is drifting off to sleep. Or, patients might opt for the secobarbital cocktail—not too different from a nightcap. There is no head rolling on the floor; there is no blood dripping from a severed neck. Everything is tidy. This is what has changed. Technology has allowed not only for a painless death but a sanitized death, a death that does not look like a death at all. It’s not that a peaceful death is undesirable; most people would prefer to die painlessly. Good palliative care aims, in part, at just this end. But the outwardly serene practices of MAiD make the choice to die (or to hasten death) a bit more palatable.

Lifespans for those born in 2019 will stretch, on average, to about eighty-two years in Canada. This is more than double what those living in seventeenth-century England could expect. Despite this lengthening, however, the pastoral task remains virtually the same. Folks have the same questions about death. Will it be painful? Where is God in the midst of it? How can I bear it? Will there be hope on the other side? Each of these questions is poignant, and my answers, rooted in Christian Scripture, are not too different from those offered in the “Exhortation Against the Fear of Death.”

Something about the conversations I have with the dying always feel somewhat theoretical to me. I really do believe that Christ is present in suffering, and to be with him in the life to come will be a thing of great joy. But my answers to these questions are inevitably bound by my own experience of not yet being close to the point of my own death. To talk about death at all is to reach beyond human experience to the teaching of Scripture that has been received in the Church. This teaching is either revelatory or an expression of wishful thinking. That I believe it to be the former does not mean that I have access to any knowledge my dying parishioners do not, and so my vocation is simply to point to a witness that is not my own.

To watch a parishioner who is dying and clings, however falteringly, to hope in Jesus Christ is deeply moving. For them to lose that grip and descend into despair is not a surprise. Indeed, it is probably closer to what I expect from most people, and the surprise comes when the words that I speak in Jesus’ name—“I am the Resurrection and the life”—ring true enough to bolster them in the midst of terrible pain and dimming light.

And then there are the few heroic saints with whom I have walked through the valley of the shadow of death. These usually are the kind of women and men who slip quietly into the pew on Sunday morning, and slip quietly out, perhaps appearing now and then to feed some hungry guest or serve in some unsensational capacity. These few I have watched not only bear death but pass through it as conquerors. My role has been mostly to pray, to anoint, to pass on the sacrament that at that moment feels so meager. I then simply watch and learn.

I can imagine that if I were serving in the same parish one hundred years ago, or perhaps in some sleepy village in England five hundred years ago, my role would not be much different. Perhaps I would arrive more often on foot to see the dying, and I would utter the final prayers in a home rather than a hospital unit. I would smell the odors of death, see the bile and the blood, now hidden under faded green hospital gowns. But though the setting has changed, the attitudes, actions, and words are the same.

Yet MAiD does change the picture. It presents something of an off-ramp from the longer journey toward death. The light at the end of the tunnel to which Scripture and the Prayer Book both point is obfuscated by the lesser glow of a much nearer light, the dim promise of ending the pain now. For perhaps understandable reasons, those nearing the end of their sojourn will opt for the promise of nothingness if it means ending the pain, especially when they see the ultimate terminus of their journey as the same either way.

Is this an act of presumption for an otherwise faithful Christian? I suppose it is, entrusting oneself to the mercy of God even as one exits this world too soon. Still, I cannot help but believe that this mercy is sure, despite the attempts to wrest early what God will give in his good time.

And yet, this off-ramp is available only to the few who meet relatively stringent conditions, though their number is increasing and will increase further as restrictions loosen. MAiD remains an option for a minority, a socially acceptable method of tapping out that is attractive precisely because it is so efficient. Why wait around to die when death is inevitable anyway?

The logic is slippery. In my experience, though, most of the folks I’ve walked with remain convinced that a natural death is the proper ending to their story. This remains the default, and by and large the onus is on the dying to justify opting for MAiD. This decision is often awkward and laden with guilt about the burden that one might be to family members. In some cases, family members quite agree.

If the progression toward easier access to MAiD for increasing numbers of Canadians continues with this trajectory, the risk is that those opting for a natural death will be faced with having to offer the burden of proof for their continued existence. Since MAiD will be offered to those with mental illnesses in coming years, the most psychologically vulnerable may begin asking not if death might be a way out of their suffering, but whether they deserve to live at all.

While I must keep the conversations and meetings I’ve had confidential, I can note a general trend that I’ve observed over the past several years. In almost every conversation I have had about MAiD, whether with those who are suffering now or those who are simply looking deep into the future, people say they fear that their existence will be a burden to their family and friends.

I suppose this fear is legitimate. As the father of four young children, I understand that having responsibility for someone who is not able to independently care for himself is a burden on the caregiver. I suspect most parents would say the same thing. Waking early, preparing meals for another, bathing them, dealing with accidents—this all takes a tremendous toll on the one who’s doing it. But I can honestly say that I have never wished that my sons would cease to exist, that their lives would end to free me from the menial and repetitive tasks that keep them alive and in good health. Their nurture is a burden, but it is a burden I bear out of love. I suspect most parents would have similar feelings.

When we think about the elderly, the mentally ill, or those with terminal illness, I do not see why the feeling would be any different. Their caregivers—often their own children—will be burdened and inconvenienced. But for most of human history, this burden of care was borne with love and grace. Of course, a suspicious response to the increasing prevalence of long-term care homes might be to suggest that these facilities are to spare children the toil of caring for an aging parent. But I suspect that while that motivation might be part of the picture, many children are torn about resorting to long-term care and really believe it is in the best interests of their parents. I think for most children, whether they opt to provide in-home care or instead look to a retirement home, the decision is grounded in deep love and affection for their parents. I have spoken to many parishioners who describe caring for their ailing parents—at home or in retirement centers—in the most intimate terms. There is a role reversal, where children in the last stage of their elderly parents’ lives are able to care for them with the same tenderness and love with which their parents nurtured them as infants.

And yet for all of this, as I meet with those in my parish whose deaths are on the horizon, they recognize that MAiD is on the table, whether they would like it to be or not. They sense they will be a burden to their children and loved ones, and so are willing to sacrifice their lives to spare them the trouble. This is more often implied than said explicitly. To tell one’s children, “I would rather be put to death early to save you the time,” is to risk their saying, “Yes, that would be convenient for me,” and a whole lifetime of trust and love is toppled in an instant.

The reality is that most children would not respond in this way, and the sense that one’s life is or will be a burden is seldom a notion that one lives with constantly, but a notion that one finds at the bottom of the despair into which one falls from time to time. Life is seldom utterly bleak, and even the most hopeless prognosis allows for moments of levity and even joy.

How can Christian pastors, and others committed to a traditional Christian vision of death and dying, continue to be faithful to their callings in a shifting medical landscape?

To begin, pastors must recognize that MAiD is on the table for everyone, including faithful parishioners. This should not come as a surprise, nor should it be felt as a betrayal. The assumption in our late-modern milieu is that to end one’s life—like everything else—comes into the realm of personal choice. Individual autonomy reigns supreme. Pastors ought to be surprised when one of their flock looks at end-of-life in any other way.

Moreover, pastors should assume that MAiD is on the table especially for Christians, because there is, baked in with this belief that one chooses one’s own end, the deeply Christian impulse toward self-sacrifice for the sake of the other. This is a dangerous combination, because the vision of the crucified one who died for us becomes the rallying point for euthanasia. Though Christian, when the impulse is applied in the context of the most vulnerable, it can be misleading. The logic goes something like this: “To go on living or to die is a choice that I must make, and I know that to go on living might cause difficulty for those I love, so in order to protect them, I will sacrifice myself.” One sees, then, a Christian vision of sacrifice that is tied to the cross. The difference is that this sacrifice is not vicarious, nor is it redemptive. It is cheap, because it frees up those whom we love from their own sacrifice and allows them only to go on living in their small comfort.

Besides recognizing that MAiD is on the table for everyone, I think priests and Christian caregivers are under an obligation to articulate a Christian vision of dying. Namely, they must affirm that life and death both come from the hand of the Lord, that ultimately, we are creatures who are fashioned by God, and that the greatest good of our life is only fully realized in having passed from life through death to fuller life. To receive death as one who is not in control of it is an opportunity for Christians to draw near to Christ who gave up his own control. There is a darkness in approaching death with Christ on God’s terms that bonds us to him, so that we are present to him more fully than would otherwise be the case.

I’ve opted to avoid quoting Scripture here, but this form is found in Scripture, and the narrative that Scripture gives us of life, death, and its transformation in Christ remains the deep ground for Christian ethics.

And even then, even after internalizing the traditional Christian vision of death and dying, many folks—practicing Christians or otherwise—will opt for MAiD. This is not the time for a priest to make a moral stand and leave a reeling and confused family out in the cold. Rather, after having graciously given an account of Christian death, it is the time for pastors to walk alongside those who are ending their own lives, even if this means walking with some distance. A pastor can point out that a path is dangerous and is not meant to be trod, and still—not without risk—follow behind in the hope that repentance will come in due course. The vocation of the pastor in this instance is to be a physical reminder of the judgment and mercy of God, even when both have been flouted.

Who knows that the future may hold for the West? I suspect that when it comes to MAiD (however it is labeled), the die is already cast. The time and means of one’s death will increasingly fall under the domain of personal choice, another decision in the long series of lifestyle questions. Christians will not be immune to these pressures. The decision to leave the end of one’s life in God’s hands will therefore become increasingly radical, an ever brighter gesture of hope.