MAiD in Canada and the Homo Economicus View of Dignity: Inclusive Enough?

Abstract

Both Carter and Bill C-14 provide an interpretation of human dignity linked to and dependent on autonomy. By relating human dignity to autonomy, the Supreme Court of Canada and the Canadian Federal Government seem to support an anthropological view of dignity centered on the idea of the homo economicus. However, this is not the only view of human dignity. The author argues that a better (i.e., more pluralistic and inclusive) anthropological view of human dignity should capture the diversity of persons and the richness of the human life in a more integral way, without excluding those people who do not meet the homo economicus standards. Specifically, the author discusses the Personalist view of human dignity, according to which human dignity is (a) intrinsic to every human being, simply in virtue of their humanity, and therefore (b) not lost when autonomy is gone. The author discusses the Personalist view of human dignity and juxtaposes it against the homo economicus view, to show the inclusiveness of the former and the shortcomings of the latter. By closely examining the Personalist view of human dignity, the author dispels the claims that human dignity can ever be lost and be restored by euthanasia and assisted suicide—claims that stem from both Carter’s and Bill C-14’s interpretations of dignity.

Keywords:

• Carter v Canada
• Bill C-14
• assisted suicide/euthanasia
• MAiD
• autonomy
• human dignity
• homo economicus
• personalism
• mental health disabilities
• suffering

Acknowledgements

This paper was presented at “Navigating Impasses in Bioethics: End of Life, Disability, and Mental Illness’ at the Von Hügel Institute, St Edmund’s College. Cambridge, on December 8, 2017. The author is grateful to Francisco J. Urbina and David A. Jones as well as her co-panelists Elizabeth Schiltz and Trudo Lemmens for the most helpful comments and stimulating discussions. The author am also grateful to Lidia Ripamonti and Philip McCosker for their support and efforts in organizing the event and for making the Von Hügel Institute such a wonderful research community. Thanks also to Mary Clare Enright for her research assistance.

Notes

1 An expert panel of the Council of Canadian Academies has been mandated to evaluate the question of whether mature minors should be included under MAiD’s provision, whether MAiD should be provided on the basis of advance requests, and whether MAiD should be provided for the sole reason of mental illness.

2 Carter and Bill C-14 decriminalized and legalized voluntary euthanasia and assisted suicide for those competent consenting patients whose “death was reasonably foreseeable,” on the premise that they would be incapable of ending their own lives due to a debilitating condition. Although neither Carter nor Bill C-14 explicitly exclude mental health patients from MAiD’s coverage, death is not reasonably foreseeable for most patients suffering solely from mental health conditions, in which the sole source of suffering is psychological.In this connection, there has been a plea for the removal of the “reasonably foreseeable death” clause, so that mental health conditions that are rarely terminal can be included under MAiD.

3 Carter and Bill C-14 decriminalized and legalized voluntary euthanasia and assisted suicide for those competent consenting patients whose “death was reasonably foreseeable”, on the premise that they would be incapable of ending their own lives due to a debilitating condition. Although neither Carter nor Bill C-14 explicitly exclude mental health patients from MAiD’s coverage, death is not reasonably foreseeable for most patients suffering solely from mental health conditions, in which the sole source of suffering is psychological. In this connection, there has been a plea for the removal of the “reasonably foreseeable death” clause, so that mental health conditions that are rarely terminal may be included under MAiD. It is in the context of this debate that the question of advanced consent has been also considered.

4 I am grateful to Sephora Tang for this point.

5 I am grateful to Sephora Tang for this point.

6 If having suicidal thoughts is a typical manifestation of many mental illnesses, would providing assisted suicide (rather than suicide prevention) as “medical treatment” to the suicidal population (solely because they autonomously choose, desire, and competently demand it) be the appropriate psychiatric care?

7 Although O’Neill (2003) challenged this conception of autonomy that equates it with independence and self-determination, she acknowledges that this is the norm in medical ethics. As she put it, “Informed consent in medical ethics is commonly viewed as the key to respecting patient autonomy. (…) Contemporary accounts of autonomy have lost touch with their Kantian origins, in which the links between autonomy and respect for persons are well argued; most reduce autonomy to some form of individual independence, and show little about its ethical importance (O’Neill, 2003, p. 5).

8 In Carter and in Bill C-14, the great importance that autonomy, independence, and self-determination receive is manifested through an emphasis on the requirement of informed consent. However, informed consent requires that patients be fully informed about the nature and consequences of his or her chosen medical intervention, as well as of all the alternative treatments. One deficiency in the Canadian federal legislation (Bill C-14) is that it does not require patients who request MAiD to exhaust reasonable treatment possibilities, compared with legislation in the Netherlands which requires that both the patient and the physician come to a conclusion that there is “no reasonable alternative” (Regional Euthanasia Review Committees RTE Code of Practice. The Hague. April 2015. http://www.camapcanada.ca/NetherlandsGuidelines.pdf. Accessed September 21, 2017.).As Chan and Somerville put it: “While the Court required that informed consent to physician-assisted death was essential, this is not possible unless all reasonable alternatives to the proposed “treatment” are offered. This means fully adequate palliative care must be available before a patient’s consent to assisted death would be valid” (B Chan, M Somerville, Converting the “Right to Life” to the “Right to Physician-Assisted Suicide and Euthanasia’: an analysis of Carter v. Canada (Attorney General), Supreme Court of Canada, in Medical Law Review, 0, 0, April 19^th, 2016, 1-33, p. 32). See also Trudo Lemmens, 2016, p.282, who make the same point.

9 See, for example, M Sheehan, Can broad consent be informed consent?, in Public Health Ethics. 2011 Nov 1;4(3):226-35; and Onora O’Neill, Some limits of informed consent, in J Med Ethics, 2003, 29, 4-7.

10 Although Schiltz (2018) did not discuss assumed consent directly, she explains this same rationality that leads to assumed consent for the disabled. Schiltz argued that the common social perception is that it is irrational for a nondisabled person to end his or her life, but rational for a disabled person to do so. As she puts it: “the practice of assisted suicide reflects a discriminatory belief that life with a disability is not worth living. If a person without a disability decides to commit suicide, society considers that an irrational choice that should not be respected; society intervenes to prevent the free exercise of that choice. However, if a person with a disability makes the same choice, it is seen as entirely rational and something that should be supported. This reflects a fundamental bias about the quality of life with a disability” (Schiltz, 2018, p. 10). On how the oppressive influences of the environment—particularly the ableist ideology—contributing to the disabled’s loss of hope leading to suicidal ideation, see Ho (2014).

11 “An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy” (Carter v. Canada, 2015, paragraph 66).

12 Although Iris M. Young does not employ the term homo economicus, she traces the origins of the contemporary oppression and its dominant figure (i.e., White male, able-bodied, rational, autonomous, independent, competitive, high-achiever oppressor) back the Enlightenment. The White male archetype that Young describes correlates to the homo economicus model.

13 As Margaret S. Archer (2005) put it: “This was the model of man which was eagerly seized upon by social contract theories in politics, Utilitarians in ethics and social policy, and liberals in political economy. […] in the hands of Rational Choice theorists, he [homo economicus] bids to conquer social science in general” (p. 263).

14 Erik Krag (2014)made a similar point when he points out today’s disproportionate emphasis on independence and achievement and the misleading harmful social messages that this obsession sends into defining those who are do not meet the standards of independence and achievement as worthless and burdensome.

15 “The main federal laws which protect people with disabilities from discrimination include the Canadian Charter of Rights and Freedoms and the Canadian Human Rights Act” (see https://www.canada.ca/en/canadian-heritage/services/rights-people-disabilities.html).

16 As Veritas Splendor puts it: “the natural law [i.e., fundamental human rights] expresses the dignity of the human person and lays the foundation for his fundamental [human] rights and duties, it is universal in its precepts and its authority extends to all mankind. This universality [emphasis added] does not ignore the individuality of human beings, nor is it opposed to the absolute uniqueness of each person” (Veritas Splendor, #51).