About This Episode

Rosemarie Garland-Thomson and Alexander Raikin discuss euthanasia and eugenics. What has happened in the law and society in Canada since 2016 such that MAID has exploded, becoming one of the most common causes of death there? What is the relationship of national healthcare to this expansion? Alexander Raikin brings in a review of the statistics over the past decade or so.

Rosemarie Garland-Thomson then discusses the history of the euthanasia movement, beginning in the late nineteenth century with its connection to eugenics, through its fall into disfavor subsequent to its association with Nazism, through its rise again in the 1970s. What are the different kinds of arguments that have been used, and how can we think about those arguments?

Raikin and Thomson then discuss the relationship between voluntary and involuntary euthanasia, and Thomson discusses the particular vulnerability of disabled people to pressure to choose MAID.

[You can listen to this episode of The PloughCast on Apple, Spotify, Amazon Music, Google or wherever you get your podcasts.]

Recommended Reading

Transcript

Susannah Black Roberts: Welcome back to The PloughCast! I’m Susannah Black Roberts, senior editor at Plough. I’m speaking today with Alexander Raikin and Rosemarie Garland-Thomson. Alexander Raikin is a writer in Washington, DC who has recently begun to specialize in reporting on the ongoing normalization of euthanasia; he tweets at @AlexanderRaikin. Rosemarie Garland-Thomson is a Hastings Center Fellow and senior advisor and professor emerita of English and bioethics at Emory University. She is co-editor of About Us: Essays from the Disability Series of the New York Times, and the author of Staring: How We Look.

Sasha, Rosemarie, welcome to The PloughCast! It is so good to have you both on. You were the two that I really felt were the ones I’d like to talk with about this ongoing slow devolution of civilization that we are experiencing, in my opinion.

Alexander Raikin: Rosemarie, do you know Joel Zivet?

Rosemarie Garland-Thomson: Yes, I do.

Alexander Raikin: Yeah, so I’m actually relatively close with him now since I started looking into assisted suicide. Because he’s Canadian.

Rosemarie Garland-Thomson: He and I were in a class together a number of years ago and we really got on with each other and then the pandemic separated us because it separated me from my school so I haven’t been in touch with him for a while but I would love to be back in touch with him.

Alexander Raikin: Yeah, I could connect both of you. He’s been extremely outspoken on capital punishment.

Rosemarie Garland-Thomson: Yes, that’s right.

Alexander Raikin: And obviously, the criticisms he has of capital punishment, he also has of euthanasia as well, right?

Rosemarie Garland-Thomson: Yes, of course. He’s been extremely outspoken about this and he is very much against the notion that dying with dignity is actually very dignified. That said, he’s a remarkable man. He’s very brilliant.

Also, I had fantastic conversations with him that were pretty fascinating because he’s an anesthesiologist at the ICU unit at Emory as well as being a full professor. He has been very much impacted by Covid and most of his patients are obviously the community around Emory, right? Which is disproportionately African American. And just the conversations he was telling me of conversing with his patients, right? And the difference between how African Americans view health care, especially an end of life versus people who are more privileged was pretty fascinating. And especially because it very much reinforced a lot of the sort of academic articles, which show that the more that someone is disprivileged in life, the more likely they’re going to want to have more aggressive medical treatment.

So the common criticism – and you see this obviously in assisted suicide regimes, right? That it’s typically white, typically middle-class citizens, right? Who are the first to push for assisted suicide and also, you know, in Oregon or Washington state or California, right? It’s very difficult to find any people of color, let’s just say, who are pro assisted suicide.

Alexander Raikin: That’s fascinating. And I actually wrote an article for the Free Beacon last year about how the Alzheimer’s Association had a secret partnership with Compassion and Choices to “improve end of life options for marginalized Americans.”

Rosemarie Garland-Thomson: Oh my gosh.

Alexander Raikin: And they were going to use the Alzheimer’s Association’s database to reach out to Black Americans and Asian Americans. They had a whole list of people that they were trying to push. And after the piece came out within the span of like six hours, the Alzheimer’s Association actually issued an emergency press release, that they were severing the relationship with Compassion and Choices. And that palliative care is the ultimate goal for end of life options. That’s so fantastic. And of course, there’s some history with this, too, right? Jack Kevorkian’s first “patient,”was a woman with Alzheimer’s. And the Alzheimer’s Association of America at that time issued a pretty strong press release, essentially, obviously, not condemning any individual person’s decisions, but saying that the proper way to deal with Alzheimer’s is a palliative approach and it is not, you know, suicide on demand by random physicians. A bit of a rant. So apologies.

Susannah Black Roberts: No, no, no. It seems like you kind of nipped that in the bud to a certain degree. That’s amazing.

Rosemarie Garland-Thomson: I’d like to comment a bit on what you had to say, Sasha, which is really important. And that is that when we look at identity groups that we think of politically and socially as vulnerable populations in America, but perhaps worldwide, but certainly in America.

We see that people in these vulnerable groups or these marginalized or subjugated identity groups often have a very different viewpoint about medical care and medical treatment and also political and social issues than what we might think of as members of the majority groups.

And this is particularly the case, I think, about issues such as euthanasia or health care in general and issues like abortion where certain populations have had a history of unequal medical treatment or even oppression and certainly inequality in relation to these issues.

And what’s interesting is that people with disabilities are considered to be a protected category legally in the United States, but also a marginalized identity group, if you will. And it’s interesting that Black people in America and people with disabilities and often women align on some of these issues as members of what might be called socially and medically vulnerable groups.

I’m just writing a chapter and sort of a history of assisted dying groups, which essentially is a summary of the different literature that exists and also the research that I’ve done just because I – long story short, one of the documents that I’m just still so, it just confounds me, right, is a document from the New Zealand censor board, right? So New Zealand and most English-speaking countries, they have different censor boards about which material is deemed valid to be imported, right? They don’t have the First Amendment and the idea is that certain materials, whether it’s, you know, terrorist literature, right? Or, you know, different materials that break the law, right? Whether it’s for child protection or whether it’s for extremism and things like that, right? Canada has its quarterly publication of materials that are deemed not valid to be imported. Remarkable how many of those books are about, are related to anti-Semitism. But I’ve got to say, it is a fantastic insight, I always get this email, right, once a quarter and it’s, it’s, you would really think that with more extremist literature that they would have a better naming scheme. Anyhow, so the New Zealand censor board in 2009, they reviewed a guide to a humane self-chosen death, which is produced by the WAS Foundation, which is a group of Dutch and also Canadian physicians and psychologists. Essentially, it’s another one of those books about a guide to how to commit suicide.

And it reviews different ways of committing suicide. It ranks them. And what was interesting is that the New Zealand Comptroller of Customs, they classified it as objectionable, except if the ability of the publication was restricted to the voluntary euthanasia society of New Zealand and its members who are over the age of eighteen. Because, and I am reading this verbatim, “in the hands of its intended readers, the seriously ill and elderly, this book is unlikely to be injurious to the public good.”

Susannah Black Roberts: Oh, boy.

Alexander Raikin: And the fact that this is 2009, right? Like, this isn’t ancient history. Right? This is 2009, right? Well before New Zealand published or New Zealand legalized assisted suicide, right? The fact that they explicitly point out, right, that the seriously ill and elderly are somehow not vulnerable to this pressure. And yet they go on to say in this review, right, that what would be objectionable, it would be minors.

So it’s fascinating. And actually, if you actually read that book, the physician, the doctors, right, the physicians and psychologists who wrote it, boast over the fact that there have been, according to their records, over four hundred assisted suicides in English-speaking countries that have not been prosecuted. Right? And in fact, they say not a single one has been prosecuted.

Rosemarie Garland-Thomson: This was 2009?

Alexander Raikin: This was 2009. So the book was published in 2006. And it’s only one in many, right? So Philip Nitschke is an Australian. I don’t know the right way to say it. He’s legally no longer a physician. I think he lost his medical license because he was such a strong assisted suicide and euthanasia practitioner. But he, you know, he has an online website where, which, by the way, you can pay using Visa or Amex, where you can pay for a copy of his book, which also details different forms of assisted suicide.

And here in the United States as well, there’s also the Final Exit Network, which also is involved with all of this. In the book, it explicitly states that this book is not meant to be distributed online because of the potential risk. And instead, it should be distributed to all of these voluntary euthanasia societies.

And yet the copy of this book is now available online. Right? And this is also it’s pretty remarkable as well, just how different preferred techniques, for lack of a better term for assisted suicide, have evolved. Right. In the 1930s. It was different types of acids that were recommended to be used and were used with very few prosecutions. More recently, I mean, in the 1960s, 1970s, it was different types of sleeping pills.

More recently, it was helium. And in fact, Philip Nitschke goes around the world to senior homes with his instructing different techniques.

Rosemarie Garland-Thomson: Oh, my God.

Alexander Raikin: Right. And so, and obviously, for now, if you look in the United States, right, for assisted suicide, the drug protocols for assisted suicide have changed like five times over the last couple of years. So it’s remarkable. And this is a point that Ilora Finlay makes. She’s the former head of the Royal Medical Society in the United Kingdom. and she’s now a Lord in the House of Lords, a lady, I should say. She points out, you know, if there really was a peaceful way, a dignified way for a humane, self-chosen death, right – Why is the protocol continuing to change?

Susannah Black Roberts: I wonder whether we could talk a little bit more generally. So you’ve both been doing work about sort of specific … Alexander, you were doing work specifically about Canada’s laws and euthanasia. Rosemarie, you sent around a piece about the state of play in California. What are the current developments in both of your experience? What are the newest laws? How are things evolving over the last year or so?

Rosemarie, do you want to talk about the California status?

Rosemarie Garland-Thomson: Well, I don’t know a lot about exactly what’s going on in California, but I can sketch out some of the differences between the application or the implementation of the medical aid and dying laws in Canada and in California, because I think it’s quite instructive. I’ve written a little bit about it and other people have written about it as well. But I think the interesting way of framing it is which will lead us to be able to think about the ethics and the politics of medical aid in dying.

So both Canada and the US passed – I’m going to call it a medical aid in dying law, although they call it two different things, in 2016. So in Canada, they called it medical aid in dying. In California, they called it the End of Life Options Act. And Canada and California are about the same size in terms of population. They both have about forty million people in them.

One big difference, of course, between Canada and California is that Canada has national health care and California does not. And so all of that factor has, I think, a lot of importance in talking about what’s really important here. And that is that the number of people who have used the Medical Aid and Dying Act in Canada has been enormous since 2016. It has expanded greatly so that many thousands of people have died under the medical aid in dying law in Canada since 2016. And that expansion has been has been tremendous.

In California, by contrast, the law is used very, very little. And there are some numbers on that, but I don’t have them available right now, but someone could look it up and tell us that it’s quite startling. And there’s been some analysis of why that might be.

And there are lots of reasons. One of them, of course, as I mentioned, is that Canada uses the law as part of its national health care, California doesn’t. Another big difference, of course, is that in Canada, the medication that causes dying is administered by health care workers. And this is very significant. In California, in order to use the medication that causes death, you must administer it yourself. So that’s a significant limitation as to how the actual death as a form of medical treatment is carried out. And I think that that’s quite a significant difference. And one reason why there may be such an uptake in Canada and not in California.

There are some arguments about the equity of that and about the ethics of that. For example, it has been argued that one limitation that California law has about the restriction of self-administration, which of course is there as a safeguard to make sure that other people are not actually killing people. But also it’s a protection in some way of both other people and of course of the person who is exercising the practice the medical practice so that you can understand that it is understood as a as a safeguard, the idea that you must administer it yourself but it also raises some medical and ethical treatment questions in the sense that the requirement to administer the medication yourself in California is not to use the law or to use the practice and to take the prescription sooner than they might take it if they were using it toward the end of their lives. And so that’s one of the limitations.

So it’s very complex to think about what the differences are in California and in Canada. I think it’s important for us to add a third perspective, if you will, to this comparison between Canada and California. And that is to look at the case of euthanasia as it exists and it has been practiced in the Netherlands and Belgium where the numbers of people who use the medication, who use the practice and the law have expanded tremendously and kind of in the parallel way that we’ve seen this expansion take place in Canada. And of course, one of the situations in Canada and in Belgium and the Netherlands that are similar is that there is national health care.

So it’s very difficult to understand exactly why there are such differences, but I think it’s important for us to take a look at those differences and we when we try to analyze both the ethics and the social and political implications of euthanasia and medical aid in dying in our modern liberal democracies.

Susannah Black Roberts: Sasha, what’s going on from your perspective legally? What have the changes been? I think New York State was the place that was about to kind of like be the next sort of domino to fall. Last time I checked in. What has the, what have the laws been, what’s been going on there, do you know?

Alexander Raikin: I have my beautiful Excel chart of all of the main deaths in all the major jurisdictions. I’ll just give the statistics just because I have it right in front of me. And I just want to preface this by saying that it is absolutely remarkable, stupefying, right? Just how quickly there’s been a worldwide increase in the number of what are described as assisted deaths. And it is, and the reason why I just want to say all this is just astonishing, is that the one of the main arguments for legalizing assisted suicide and euthanasia, whether it’s voluntary or involuntary, was from 1907 onwards, 1906 onwards, excuse me, was the fact that if you legalized euthanasia and assisted suicide, you would have a decrease in the number of suicides.

We have not seen that anywhere. In Canada, you have seen a thirteen-fold increase in the number of euthanasia deaths between 2016 to 2022, right? So in 2016, the first full year of legalization, again, assisted suicide was legalized in Canada in 2015.

But in 2016, you had slightly over a thousand deaths from euthanasia, almost all of them euthanasia. There’s only a couple cases of assisted suicide in Canada.

In 2022, the most recent year that we have data, there were over thirteen thousand deaths from euthanasia. That is the fastest increase in the number of deaths from euthanasia anywhere at any time. No other jurisdiction at any other point has seen such a dramatic growth rate.

And in fact, if you look at MAID as a percentage of total deaths, and this is going to be an article I’m publishing shortly for Cardus, which is an Ottawa-based think tank. They also have a great journal in America called Comment. They didn’t pay me to say that, but I just, I’m a huge fan of them. And I think the readers of Plough would probably appreciate them.

So in 2016, MAID in Canada as a percentage of total deaths was around 0.5 percent of total deaths in 2016. In 2022, it’s already over 4 percent.

This is such a rapid growth rate. It is very difficult to … I’ll give you just a short example. Health Canada, by law, they have to publish a report on, administrative costs related to what’s described in Canada as MAID, medical assistance in dying, which again, is almost always euthanasia, where it’s a physician who is administrating the life-ending medication to the patient.

So by law, they have to publish this report on administrative costs. Well, how do you estimate administrative costs? Well, it depends on how many cases of MAID exist. So in December of 2022 they published a report saying that their estimate was that Canada was only going to reach 4 percent of total deaths. That MAID is going to cost 4 percent of total deaths in 2033, right? In eleven years. But Canada ended up reaching that target within the end of that year, right? So this is just how dramatic the rate of growth is.

You know, in California, California started at a much slower rate, but in 2022, the number of deaths from assisted suicide in California increased by 63 percent. The reason for that increase was that in 2021, California restricted many of the safeguards that were deemed to be barriers of access. One of the more important safeguards is that assisted suicide in California used to have minimum waiting days before you would qualify. And before, I believe it was ten days. Well, they reduced that to two days. So you lost, again, eight days of waiting periods. And unsurprisingly, you’ve seen a dramatic increase.

But every jurisdiction has seen continued growth, right? So, for instance, again, just to give an example, Netherlands decriminalized, effectively decriminalized assisted suicide in like the 1980s, 1990s. That’s when they stopped really prosecuting the vast majority of physicians for “mercy killing.”

You know, they only legalized it in the early 2000s, right? It took over two decades for deaths in the Netherlands to pass more than 4 percent of total deaths. That only happened in 2016 in the Netherlands. Belgium, by the way, which is another, which is the neighboring country to the Netherlands, obviously.

And they’ve also legalized euthanasia relatively early on. Also, I believe in 2003, Belgium never passed 3 percent of total deaths to be euthanasia. Canada managed to do it, you know, managed to do it in just the span of like seven years. All of this to say is that you’ve seen this dramatic growth rate in the number of deaths from euthanasia and assisted suicide everywhere. And you’ve seen this dramatic increase happen in a very short amount of years. Right. All of these tipping points, right, are extremely recent.

And it’s worth emphasizing, again, that the history of euthanasia, right, like the origin of the term euthanasia did not mean mercy killing. The origin of the term euthanasia as coined by Francis Bacon was the idea that physicians should be at the place of death. Right. That it’s not a medical failing for a physician to be at the deathbed of a patient when the patient dies. Right. Prior to that, it looked kind of bad if you’re a physician and your patient dies. Right. The term euthanasia as a good death did not mean mercy killing. Instead, you only … and this is a great book by Ian Dowbiggin, who’s a medical historian from the University of Prince Edward Island. And he actually wrote the book on the history of euthanasia and assisted suicide. So what he says is that the actual origin of the term euthanasia to mean mercy killing comes out from an esoteric journal article by an esoteric author in the 1920s.

And the reason I also think he wrote the book on it is that he has done a tremendous amount of research on showing how the origins of euthanasia and the origins of eugenics were all the same organizations. They were the same people, right. The vast majority of the original members of the Voluntary Euthanasia Society, which was in the United Kingdom or the Euthanasia Society of America, – you can probably guess which country that is – were eugenicists. And in fact, after he published his book, which relied heavily on the archives of the Euthanasia Society of America, which is Compassion and Choices, right? The largest and as they say, oldest assisted suicide organization after he published his book and they held their own archives. Right. Those archives were destroyed.

Now, he doesn’t know if it was by accident or if it was by intent. But they were still destroyed. And what’s remarkable as well is that if you look at the history of assisted suicide, if you go into Compassion and Choices’ website or you read NPR’s articles on Compassion and Choices or even in academic journals that are not published by Ian Dowbiggin, the history of Compassion and Choices always starts in 1980. That’s on their website – that they start in 1980.

But the reality is that there’s an entire history of eugenics and euthanasia in this country that long predated that. And the conversation we had in the beginning, about these different organizations sharing how-to guides on how to commit suicide, this is Compassion and Choices who were sharing that. Right. They were activists in this regard as well.

And the truth of the matter is that if you look at prosecution, the criminal prosecutions over people who are pressuring others to die by suicide, you only see this if you know, if the person who dies is able bodied, typically young. Like you look at the sodium nitrate cases, which for Kenneth Law – whether it was he was doing for commercial reasons or ideological reasons, again, is an ongoing lawsuit. But he was selling this, you know, selling different suicide methods online. The fact that he was prosecuted, I would argue, and I think you see this through, you know, this is what Compassion and Choices themselves in the archives mentioned. That the people who are prosecuted only happen if the people who die are not people who are disabled.

[Susannah Black Roberts: Just a little housekeeping: don’t forget to subscribe to this podcast on iTunes! We’ll be back with the rest of my conversation with Sasha and Rosemarie after the break.]

Susannah Black Roberts: So it seems to me that one of the things that you’re describing here is a real kind of slow, quick and then slow and then quick again change in culture. And the change in culture that, you know, allowed people to embrace eugenics at the end of the nineteenth century and the beginning of the twentieth was kind of rapidly papered over after obviously Nazism made eugenics kind of taboo.

And then it was kind of reinvented beginning in the ’70s and the new euthanasia/eugenics movement, which involves things like polygenic risk score selection for embryos, if you’re trying to like get the right kind of kid, which involves, you know, aborting Down syndrome babies and which involves kind of tidying away life unworthy of life, or whether that’s, you know, encouraging people to do that through a kind of heavy-handed “This is for your own good, dear” approach or whether it’s through, you know, an even more sinister kind of pressure.

It’s a very rapid change with a kind of lacuna in the middle that that is the middle of the twentieth century where all of this lack of reverence for life was kind of packed into Nazism, and then we thought that we weren’t like that.

I wonder if you, Rosemarie, if you wanted to comment on that perception and also maybe on this piece that you’ve sent around for us by Dhananjay Jagannathan on reverence for human life, because it seems like we’re trying to, there’s like two different cultures going on here. There’s like a present-day culture of scientific, essentially, you know, utilitarian, sort of a tidying impulse toward eugenics and toward euthanasia, which has no kind of concept of what reverence for life might mean or that suffering might not be the worst thing in the world. And then an entirely different culture, which is existing alongside it, which has ideas like there’s something about human life that we ought to have reverence for. And they’re almost two different civilizations existing in parallel to each other.

Does that ring a bell to you, Rosemarie?

Rosemarie Garland-Thomson: While Sasha has Excel sheets, which I think are very helpful, I don’t have an Excel sheet to my name because I am an academic humanist. So what I have in front of me is a lot of treatises by philosophers and historians of the past. So I’d like to introduce into the conversation the kind of history that you’re referring to here, Susannah. And that would be what we think of as the history of modernity along with the history of eugenics. So to back up a bit, eugenics, which is a word that startles these days, was science from the late nineteenth century into, and this is important, the first four decades of the twentieth century. So sometimes we hear eugenics talked about as a pseudoscience, but in fact, it’s really important to understand in terms of history and the development of thought and the development of nation states, liberal nation states, and the development of consumer capitalist democratic orders, that eugenics was science. Eugenics was the prevailing way of thinking about social organization and political processes dedicated to the idea of improving society. This was the progressive era and progress was unquestioned at that time. It was imagined that people could be improved. And it was imagined that that was exactly what we ought to be doing in eugenics. That is the science of improving people by what we think of as selective breeding or controlling reproduction and genetics would be a way to produce an ideal, a fair, a moral society.

And as with so many human enterprises, where we thought what could possibly go wrong with improving humanity, everything went wrong. And it was the implementation of the premise of eliminating the unfit and increasing people understood as fit that got carried out through the Nazi regime and the Holocaust and gave us a new way of thinking about progress and about ethics and morality, and certainly about medical science.

And so what we have is a really complicated situation where the ideas of making humans better and making human society better has had to change in important ways, and it’s the civil and human rights movements of the mid-twentieth century that came after World War II. And after what we think of as a Holocaust that made us understand that the rise of science and medicalization and the rise of individualism and the importance of autonomy and freedom were complicated issues that we have to think through. So I think a good place to start is to think about an organization that I quite admire, and that is an organization that some of my close friends and disability activists or people with disabilities belong to and that’s it’s an organization called Not Dead Yet. And of course, it takes its name from the Monty Python skit “Not Dead Yet” where one of the actors – I don’t remember who – goes around saying, when the cart is coming around to pick up the dead, he keeps saying “well I’m not dead yet, I’m not dead yet.” And of course, this organization shows you that people with disabilities actually have quite a sense of humor, but it’s a single advocacy organization that discourages and critiques what is sometimes called physician assisted suicide or medical aid in dying because it argues, and I think this is right, that these medical practices or these social practices or these legal practices discriminate against people with disabilities and are applied unfairly to people with disabilities. So it really does invoke the idea of equality that is so important in a liberal democracy in order to object to MAID and on the basis of its unequal application to people with disabilities.

So that’s a good place to start, but there’s lots more to say.

Susannah Black Roberts: It seems to me that there is that – through the sort of historical churning of all these arguments, we’re getting to a point of, like, alright so obviously coercive eugenics and euthanasia are bad, and we can see that and we can critique something like the Canadian regime. I think Dhananjay Jagannathan in his original piece for the Bulwark talked about this, because the idea that you can have a human society where the people who are paying for your medical care, and the kind of great and the good of your society are saying, “It’s totally fine for you to kill yourself. I mean, I don’t need you here. Of course it’s your own choice. But it’s just, we just want you to know it’s totally fine if you wanted to make that choice.”

Like, the fantasy that that’s not coercive or that we are the kinds of creatures that that wouldn’t make a difference to is ridiculous. Obviously that is pressuring people to kill themselves, because we’re human creatures and we’re social creatures and that’s like how you convince them to kill themselves.

Even if so, you know, so the civil rights and human rights era, post–World War II taught us that individual agency and the individual person is important, even in the face of, like, you can’t smoosh someone out in order to improve society so we know that now. However, if there was a genuinely non-coercive means of asking someone, hey, do you want to kill yourself?

It seems like we’re at a spot – and this is actually Dhananjay’s second essay, which you sent around – we’re at a spot where we have to ask ourselves, is there something in fact wrong with killing people? Is there a reverence that we need to have for our own lives that would prevent us from making that choice, even if it were a totally free choice?

And that’s the kind of like cultural question, which kind of, you know, there’s nothing in materialism or in contemporary utilitarian culture that has any room for that idea that there is in human life something which we have to have, that we ought to have reverence for, even if it’s the case that it’s our own lives.

So that’s kind of an aspect of the two different cultures that I feel like are living aside each other.

Rosemarie Garland-Thomson: Yeah, let me let me use this as an opportunity to talk a little bit about the challenge in modern liberal orders of how to balance the freedoms that are the basis of liberal societies, or the autonomy – that’s the term that is often used. But I like the word freedom, actually. The freedoms that liberal orders bestow on their residents and citizens and the common good.

And in bioethics, we talk about balancing treatments and actions that cause harm with the same treatments and actions that cause benefit. We have, I think, a very parallel situation here when we think about, as I said, the balance between freedoms or autonomy and the common good. So there are always going to be limits on freedom that have to do with the common good. And the example of euthanasia or medical aid in dying is a perfect one in this regard.

For example, on the one hand, liberty interests or freedom or autonomy would say that self-determination and the ownership of our bodies is a very important principle ethically, morally, and politically in modern liberal social orders.

It was the self-determination and ownership of your own body that was the main argument used in the anti-slavery movement, that said a person can’t own another person because you own yourself, you own your own body. And so that argument was a very useful one in achieving something that was important for the United States and the world at that time.

Right now, the question of euthanasia or medical aid in dying is one of autonomy and self-determination. Everyone should have the right to determine what happens to them. On the other hand, there are other people involved. There are other issues. There is a common good that is involved here. And this is, I think, what is invoked nicely by Dhananjay’s argument. And that is, what kind of harms exist to individuals and to the social order, the moral order in general, when we think that we own our own bodies enough that we can determine what happens.

Whether or not they are killed and what kinds of harms might come and to ignore what kinds of harms might come by that very exercise of autonomy and freedom that is medical aid in dying. In other words, there are other people involved. For example, there’s a tremendous amount of moral distress that can be caused to healthcare workers who are required to cooperate in these medical treatments, such as euthanasia, medical aid in dying or abortion or other kinds of life ending practices. Because, of course, medical people take a vow to do no harm and that vow to do no harm is a more important vow than the vow to do good. So medical and moral distress on the part of healthcare workers is a harm that comes from the exercise of freedom or autonomy that is part of what we assume to be the justification for medical aid in dying or euthanasia. So it gets very complicated very fast and philosophers, of course, have much to say about this.

We can imagine a conversation between someone like Immanuel Kant who said that no person should be used as a means to another end, that all people are ends in themselves. And Singer, who is a utilitarian philosopher, who has advocated repeatedly for parents’ right to euthanize or to kill their disabled newborn if they in fact decide that they don’t want that disabled newborn to be a member of their family. And this is the provocation that Singer keeps bringing forward over and over and over again. So there are large and important conversations about the, as I said, the balance between freedom and individual choice and what might be the common good and MAID. And this increase in MAID, this expansion that Sasha has described so effectively, I think is one of the best examples of this. And of course, what we need to do as a public in this liberal democratic order that we live in is have as many public conversations as we possibly can have to influence policy and practice. And this podcast is one of those conversations. So thank you very much for that.

Alexander Raikin: Well, thank you. Yeah, I just wanted to jump in just to mention as well. Obviously, it’s not just Singer, right? Who is so fanatically in favor of what is at its heart involuntary euthanasia, right? You can call it the Groningen protocol, which is what Dutch physicians use, which Dutch physicians say Groningen protocol is it sounds a lot better than infanticide. But they have different criteria for the euthanasia of newborn disabled children.

This is my pet peeve, which is if you look at the history of euthanasia and eugenics, you see very quickly that despite the name or the public arguments that you see in favor of voluntary euthanasia involuntary euthanasia is just the next door over. Right. So, you know, the first state to debate the legalization of voluntary euthanasia was Ohio in 1906. The following year, they debated involuntary euthanasia. You’ve seen this all across the board, right? The British Voluntary Euthanasia Society. They were as they were introducing their legislation, their bills to legalize voluntary euthanasia. They were discussing the expansion to children who have congenital disabilities in Canada as well. So, right now involuntary euthanasia is not allowed. It is forbidden by law. However, you have the Quebec medical college, for instance, advocating for the expansion of the Groningen protocol to Canada. You also have and I wrote this for a cover essay for National Review some months ago, I had conversations that came out, the Canadian association of MAID assessors and providers were openly discussing and laughing about sedating a patient to make sure that the patient would not be able to resist their euthanasia.

Obviously, I have no further evidence that this was actually confirmed besides the physician sharing that they did so, but this is a very real concern. And this also has the sort of rubric that Rosemarie did such an excellent job at describing the different tensions, philosophical tensions that we have around the discussion over voluntary and involuntary euthanasia. So, one of the issues that I find just so perplexing. Just to give a random example, you have entire literature now in journals like the Journal of Homosexuality about queering suicide.

There’s a University of Ottowa professor, Alexandre Baril, who published a book that was titled Undoing Suicidism: A Trans, Queer, Crip Approach to Rethinking (Assisted) Suicide, where he essentially advocates that suicide and assisted suicide is valid, partly on the basis that trans people, queer people, disabled people are far more likely to commit suicide and it’s the stigma of suicidism which is preventing them from being able to.

You know what? Derek Humphrey and other activists versus the suicide mentioned, in fact, the formative activists for assisted suicide in the United States. What he described as self-deliverance. So you have this ongoing push to expand suicide and expand assisted suicide and expand euthanasia to people who are the most vulnerable. And for me, personally, as part of all the research that I’m doing – for me, that’s just the hardest part to understand. Right? Every single group that has the highest percentage of suicide cases, they’re the ones who are targeted by this legislation and by different legislative efforts. So, in Canada right now, the government of Canada is spending millions of dollars to push MAID to indigenous people.

And you have criticisms from the indigenous disability council about this saying that they feel targeted. They describe it as MAID grooming. They want help to live. They want help with having more support and accessibility at the same time as we’re discussing as well. So forgive me if I’m ranting for a bit, but it’s also really important to stress that Canada’s public health care system, while in theory universal in practice is very much not.

And in Canada, there has been a tremendous decline in the quality of health care over the last several years as MAID has been legalized and then expanded. This is not me saying this. This is the head of the Canadian Medical Association who last summer said Canada’s health care system is undergoing a collapse.

This was the federal minister of health who said that Canada’s health care system is undergoing a sickness. You have an almost doubling in wait times to access basic medical services in Canada, according to the Fraser Institute, and you have this massive expansion in euthanasia at the same time as this decline in health care services and at the same time, it should be mentioned that the baby boomers are in the process of retiring. Right. So you have all of these articles just going through in the 1960s and 1970s, 1980s about this ongoing, you know, about this sort of boomer wash that’s going to happen with massive retirement and increase in health care costs because of chronic illnesses, et cetera, et cetera. And the need for assisted suicide as an outlet for that. These aren’t just like esoteric activists who are saying this, but this is this also includes people like Derek Humphrey, he is the one who founded the Hemlock Society, of which Jack Kevorkian was a member. He was the one who more than anyone else pushed assisted suicide into the mainstream. And he, in one of his books, describes how assisted suicide is going to be normalized, not for any autonomy arguments, but for financial reasons.

Rosemarie Garland-Thomson: So things we’ve talked about the limits of freedom and autonomy and the conflict between freedoms and the common good as well as the benefit of harms and balances in these societies that we live in today. But there’s one other element of the MAID debate and situation that I really want us to get a chance to talk about. And that is the concept of suffering. So all of the conceptualizations, as well as the language of the actual laws about made and what we call in the United States, physician assisted suicide sometimes, are premised on the rationale that someone using these medical treatments would use them on the basis of relieving unbearable suffering.

And there’s a good and important history of suffering that has to do with Peter Singer, for sure, that I think we’re going to want to look at quite carefully. You may recall that utilitarianism in the nineteenth century was in some sense based on the idea of increasing pleasure, the utilitarian idea of increasing pleasure for human beings in their lives and reducing suffering. That suffering began to be understood as something that was negative rather than something that was inevitable for human beings and in some sense made them stronger and better and more human. And that suffering was something that should be eliminated from human experience.

And it was a relatively new idea in the late eighteenth and early nineteenth and mid-nineteenth century. And it plays a very important part, as I suggested, in the logic of euthanasia and in the logic of a lot of medical treatment. The question about suffering is what makes it unbearable? What is suffering? How do we measure suffering? Elaine Scarry wrote a book a long time ago about pain in which she said the problem with pain is that it’s unmeasurable and it’s also uncommunicable to other people. It’s a subjective thing that one experiences that can’t be made clear to other people. And so evaluating someone else’s suffering or even being able to decide for ourselves what kind of suffering is bearable and unbearable is an enormous, let me just say, moral liability. It comes to a concept that will structure medical treatments that determine whether people live or die.

Flannery O’Connor, the novelist who was herself a woman with a significant disability, she had Lupus and Lupus caused her to die early in her life, and she was a Catholic writer – and this is very important as well. And she felt that suffering was part of the human condition. She was also very worried that the minute policymakers, if you will, started applying sympathy to what they imagined as other people’s suffering, rather than using first principle arguments, which she often did, she said rather famously that sympathy soon enough would lead to the gas chambers.

And she’s exactly right in terms of the history of eugenics and the history of the Holocaust in the sense that the Holocaust in general and certainly the euthanasia program, the eugenic euthanasia program, which killed thousands and thousands of people understood as ill or with medical conditions or having disabilities or being indigent or understood as life unworthy of life: Those people were killed under the concept of what Hitler’s personal physician called mercy deaths.

And so this concept of abating human suffering, making it go away through the merciful killing of others, is something that I think we need to look at very carefully because it’s the same logic along with the logic of freedom and autonomy and self-determination that come together to justify the practice of MAID and physician assisted suicide in the Western world.

Susannah Black Roberts: Yeah, I think that’s a really excellent point. So there’s two things I’d like to say. One is that in Dhananjay’s second piece, he discusses the idea of like, all right, let’s look at mercy. Is mercy the kind of thing that it is claimed to be here? And he points out that actually, originally mercy is thought to be like, it’s the mitigation of a punishment that’s due. So it’s not a question of being nice and alleviating suffering. And that’s what mercy is. Mercy is, if you are due a punishment, if you’ve done wrong, I’m going to show you mercy and not exact that punishment or that debt from you. And that’s a quite different model.

The other thing to say is that like, if you do take that utilitarian vision to its logical conclusion, what you get is what’s today called the Efilism movement. So it’s EFIL, which is life backwards. They’ve got a whole bunch of Reddits and so on. And it’s basically the contemporary anti natalist movement. They’re negative utilitarians, which means that they think that suffering is basically the only negative in the world. And that positive experience does not really, it does not reckon in their calculus. So basically, their purpose is to eliminate all suffering from the world. And what they want to do is convince everyone not to have children. Because then there will be no suffering in the world, there will be no human suffering. They don’t think that it would be good to do this right now because we can’t yet eliminate all animal life and animal suffering also concerns them. So, you know, this is a rather large movement of primarily people in Silicon Valley, but not only there, who genuinely think that ideally there would be no suffering because there would be no experience. And that is what they’re aiming at. And that is the end logic of negative utilitarianism of the kind that, you know, in its kind of nice form, seeks to off you when you’re ill, and to be merciful to you in that way. And I think the slippery, totally inevitable slip away from a bodily autonomy limited euthanasia to involuntary euthanasia.

You know, it’s your, you sort of have to ask yourself like, well, how can that happen if our whole focus is on personal choice and bodily autonomy, how could we then go to, well, maybe we can kill these children. And I think it just has to do with, you know, the, the hypothesis of, you know, absolutely voluntary suicide. And that’d be OK. That hypothesis is a person may kill himself because people are the kinds of things that one may innocently kill.

And if that’s true, then, then there’s no real reason to not kill other people. Like if the kinds of things that people are, are the kinds of things that one may innocently kill, which has to be the case for euthanasia, voluntary euthanasia to be OK morally, then why not kill other people? And that really seems to be kind of where the rubber hits the road for me.

Rosemarie Garland-Thomson: Yes. In human history, we can observe that great evils or great harm often comes from very small beginnings, very small steps. Leo Alexander, who was one of the lawyers in the Nuremberg Doctors’ Trial, observed that from small steps, the great Holocaust was built. And I think that we as human beings can be quite humbled, and also vigilant about thinking through and watching for these very small steps that can lead to great harms. And this is, I think, what you’re talking about. So the idea that we want to mitigate suffering seems like a swell idea to start with, just like improving all of humanity seems like a really swell idea to start with.

And there’s always been a kind of “what could go wrong” naiveté, I think, in human aspiration that gets mixed along the way with hubris and naiveté and what we sometimes call now the thin veneer of civilization.

And very quickly, we as human beings can do great harm to one another. I think one important philosopher for us to pay some attention to here is Hannah Arendt, who, of course, she is a Jew who studies with Heidegger and witnesses really the rise of Nazism and the Holocaust. And she writes in her book The Human Condition, which is published, I think, in the 1960s, although she writes it a bit earlier than that.

She basically concludes that looking at human civilization and looking at the human condition, that life is the highest good. And I think we can put that conclusion up against this rather startling development that you’re talking about of Efilism, the anti-natalist movement. By thinking about the pro-natalism of Hannah Arendt, who I think has led the way in the claims, the ethical claims, that life is the highest good and that pro-natalism is an important impulse in human communities.

Susannah Black Roberts: Yeah, Jennifer Banks’s book, Natality, is sort of a key read here. She sort of teased out a lot of Hannah Arendt’s pro-natalist or natalist vision.

Rosemarie Garland-Thomson: But there’s a fantastic book entitled Heidegger’s Children. If you look at a lot of the sort of, I mean, all of the Jewish students of Heidegger, whether it’s Leon Kass, Hans Jonas, or Hannah Arendt, that all of them have the sort of pro-natalism and pro-life dimension to their writings. Right?

But the sort of beauty, the validity of his sort of philosophy is the idea that we can’t go back. Right? It’s the idea that technology is a modern rupture. And I also just wanted to mention that, you know, just when you were talking about Efilism, I was thinking of a quote from G. K. Chesterton, where he describes eugenics as terrorism by tenth rate professors. And I think there is a lot of, there’s additional validity in that when you look at, well, let’s just reverse life and call it a philosophy.

But, you know, I do, just to get a little bit, this is a serious conversation, but if we go back to sort of the Nazi example, actually, let’s go back to G. K. Chesterton. He also, in another one of his essays, he describes how the origin of euthanasia is that first you consider yourself a nuisance and then you consider other people a nuisance, and therefore their lives are not worth living.

But I honestly think the Nazi example is the sort of inverse of that. Right? We talked about Karl Brandt and, you know, Hitler’s personal physician, and we talked about the euthanasia program in Nazi Germany. But it’s worth pointing out that it only started on September 1, 1939. Right? It was a wartime measures act. And the reason why it was a wartime measures act was because two of the first bills that the Nazi Party in 1933, right after they seized control of the Reichstag, two of the first bills that they introduced were a sterilization bill and a voluntary euthanasia bill. The sterilization bill came into effect, despite opposition from the Catholic Church – the Protestant churches more or less supported it. But the euthanasia bill did not pass. It was introduced, but it was amended, essentially, it was amended away because of opposition by the Catholic Church and the Protestant churches. And in many ways, if you actually read the wording of that legislation in that voluntary euthanasia bill of 1933, in many ways, it had more safeguards than exist in our voluntary euthanasia programs in countries like Canada or the Netherlands.

In the proposed Nazi euthanasia bill, it required a review board, right, which doesn’t exist in any country now. It required three physicians, two of them being the review. It required that all other medical treatments be tried first. You do not see those requirements in any jurisdiction, right? So, look, it’s one thing to say Hitler was a vegan, therefore veganism is bad. But I think it’s a completely different thing to look at. Well, what does it tell us if we’re following moral philosophy or moral policy, excuse me, that was first advocated by the Nazi Party? And this was the prelude. And the opposition by the public in Nazi Germany of 1933 forced the Nazi regime to kick the euthanasia program to the outbreak of the war when they can do it more quietly.

Yeah, so I just think it’s deeply disturbing. And there is much more, it’s just deeply disturbing. It keeps me up at night, for lack of better terms.

Susannah Black Roberts: Rosemarie, do you have any last sort of words?

Rosemarie Garland-Thomson: Yes, I’d like to emphasize the connection between MAID and the project of justice and equality that is so characteristic of the best work of liberal democratic orders in the twentieth and twenty-first centuries. And to say that in terms of disability bioethics or the ethics of medical treatment and scientific treatment in terms of disability is that these issues are fundamental to all of us, not just to what we imagine as the designated group. People with disabilities is really all of us because all of us will become disabled over a lifetime, because all of us have people with disabilities in our families and in our communities. And so to imagine that people with disabilities are a distinct group, that the larger “we” don’t need to consider very much because it’s far away from our experience if we identify as non-disabled people is a mistake. It’s a mistake for us as individuals and it’s a mistake for the society more broadly. So I want to call for some solidarity here at a time when there’s much I think conflict and much polarization, that word is a little bit old these days, around politics and around identity groups and to suggest that disability solidarity is human solidarity and would invite the audience and the larger community to consider that.

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