The Munk Debates Podcast - Be it resolved: People have the right to choose how and when to die

Episode Date: November 23, 2021

Everyone who enters the medical field does so altruistically, standing steadfast against the ever present threat of death and disease.  But as any doctor knows, there are limits to what they can do. At a certain point, the goal shifts from curative to palliative care.  At this stage, the goal is no longer to save a life, but to relieve suffering as best as possible.  How to do so, and the point at which suffering becomes worse than death, is highly contested.  A growing movement of doctors, nurses, and ethicists argue that patients should be empowered in the face of this impossible choice.  They argue that just as a patient has a right to choose how to live, they should also choose how and when to die.  They argue it is ethically and morally shortsighted to keep suffering patients alive at all costs, and that euthanisia and physician assisted suicide are a mercy, not a crime.  But others in the field argue that life is far too sacred to place in anyone's hands, doctor or patient.  Even on the brink of death, lives have meaning and must be preserved.  They argue that the oath that doctors take forbid them from making these types of decisions regardless of the state of their patient.  And that those that advocate for physician assisted suicide are doing their patience, and themselves, a massive disservice. Arguing for the motion is Dominic Wilkinson, Dominic Wilkinson is Director of Medical Ethics and Professor of Medical Ethics at the Oxford Uehiro Centre for Practical Ethics, University of Oxford. He is a consultant in newborn intensive care at the John Radcliffe Hospital, Oxford. Arguing against the motion is E. Wesley Ely, American physician and professor of medicine as the Grant W. Liddle Endowed Chair at Vanderbilt University School of Medicine. Dominic Wilkinson: “It's time to be honest and consistent about end of life choice. People have the right to choose how and when to die”. Wes Ely: “If you tell me why you ought to respect a patient's autonomy, I'll tell you why you ought not kill that person”. Sources: CBC, ABC News, CBS Evening News, PBS News Hour The host of the Munk Debates is Rudyard Griffiths - @rudyardg.   Tweet your comments about this episode to @munkdebate or comment on our Facebook page https://www.facebook.com/munkdebates/ To sign up for a weekly email reminder for this podcast, send an email to [e-mail].   To support civil and substantive debate on the big questions of the day, consider becoming a Munk Member at https://munkdebates.com/membershipMembers receive access to our 10+ year library of great debates in HD video, a free Munk Debates book, newsletter and ticketing privileges at our live events. This podcast is a project of the Munk Debates, a Canadian charitable organization dedicated to fostering civil and substantive public dialogue - https://munkdebates.com/ The Munk Debates podcast is produced by Antica, Canada's largest private audio production company - https://www.anticaproductions.com/ Executive Producer: Stuart Coxe, CEO Antica ProductionsSenior Producer: Jacob LewisEditor: Reza DahyaAssociate Producer: Abhi RahejaBecome a Munk Donor ($50 annually) to get 72-hour advanced access to the full length editions of Friday Focus and Munk Dialogues. Go to www.munkdebates.com to sign up. Hosted on Acast. See acast.com/privacy for more information.

There are options, and that's why we need to take this opportunity seriously. There's no way you can prevent global warming unless China is part of the solution. This is not normal male behavior. This is predatory behavior. We don't know how bad this bug is. We don't know what this bug does. All of that was thrown away in those eight minutes and 46 seconds, and that's the moment that I became an abolitionist. Extraordinary claims require extraordinary evidence. Welcome to the Mug Debates on every episode. we provide you with a civil and substantive debate on the big issue of the day to arm you,

the listener, with enough information to make up your own mind. Today's debate, be it resolved. People have the right to choose how and when to die. A landmark Supreme Court hearing began today on whether to allow doctor-assisted suicide. The justices are being asked to consider whether current laws prohibiting assisted suicide violate the rights of terminally ill Canadians to die on their own terms. When Australian academic David Goodall turned 104 years old last month, he had one wish to end his life. This morning, lawmakers in California are preparing to roll out legislation

that would allow terminally ill patients to control their own deaths. Hello, I'm your moderator, Rudyard Griffiths. Every doctor and patient knows there are limits to what modern medicine can do. Most of us, at the end point of our lives, will be the recipients of what's called palliative care. At this stage, in our medical journey, our life journey, the goal is no longer to save us, but to relieve our pain and suffering. How to do so, and at what point the absence of death becomes worse than the inevitable conclusion of every human life is a highly contested debate. A growing movement of doctors, nurses, and ethicists argue that patients should be empowered to make this life-ending choice on their own terms. They argue that just as a patient has a right to choose how they live, they should also be able to choose how and when to die.

They argue it is ethically and morally short-sighted to keep suffering patients alive. euthanasia in the form of physician-assisted suicide is a mercy, not a crime. It may sound shocking, but in Belgium, euthanasia is quite accepted, and it's not just for the terminally ill. Chronically depressed patients like Ava can request it too. And so, on a day and time she's chosen, Ava says goodbye to her family. But others argue that end-of-life decisions are far too important to place in any one person's hands alone, whether that be a doctor or patient. Even on the brink of death, lives have meaning right up to the very end of life.

Providing palliative care in ways that prevents suffering pain and anxiety is what every doctor owes his or her patient. Killing them preemptively through medical intervention is a violation of those very same medical practitioner's most sacred oaths. The surge in medically assisted suicides is supposed, a grave threat to modern medicine as it undermines the ethical bonds that unite patient and doctor in a relationship of trust and mutual care. On this installment of the monk debates, we aim to discover what it means to die with dignity by debating the motion, be it resolved. People have the right to choose how and when to die.

Arguing for the motion is Dominic Wilkinson, the director of medical ethics at the University of Oxford. He's a consultant in newborn intensive care at the John Radcliffe Hospital, Oxford. Arguing against the motion is Eugene Wesley Ely, American ICU physician, the holder of the Grant W. Little Endowed Chair at Vanderbilt University School of Medicine, and the author of the bestseller, Every Deep Drawn Breath. Wes, Dominic, welcome to the Monk Debates. Thank you. It's a pleasure being here. Rudyard. Thanks very much for inviting me to join you. Well, an important resolution today in some ways a timeless debate, but a debate that is at the heart of so many important conversations that we have about our own mortality,

those same conversations that we have about our loved ones within our families. That resolution encapsulated today in our motion, be it resolved, we have the right to choose how and when. to die. So the opportunity to have a substantive conversation with both of you, people who thought kind of long and hard about this issue and have confronted it as physicians, as medical practitioners in some of its most acute and real-life settings is just a privilege indeed for our monk debate community. So here's what we're going to do.

We're going to put a couple of minutes on the clock and turn the program over to you, Dominic, you're arguing again in favor of our motion, be it resolved. We have the right to choose how and when to die. Let's get your opening statement, please. Well, thank you, Rajid. So here are four indisputable facts. First, we will all die. It is a bleak but inescapable reality. Despite all the advances of modern medicine, our biological existence will come to an end. There will come a time. when no medical treatment humanly available can sustainers. Second, patients who are reaching the end of life sometimes endure very considerable suffering. Again, notwithstanding considerable advances in medicine and palliative care, dying patients experience pain.

In a Swedish study out of 160,000 dying patients included in the palliative care register, one quarter, 40,000 patients experienced unreliable. pain in the final week of life. Dying patients also experience nausea, vomiting, breathlessness, fatigue, confusion, anxiety, insomnia, incontinence, constipation, terminal hemorrhage, a whole range of forms of intense distress. Third, how we die matters profoundly to people. Respecting patient values, preferences, choices is a fundamental part of modern medical ethics and palliative than end-of-life care. And many people, the clear majority in countries like the United States, Canada, Western Europe, Australia, New Zealand, wish to have the option of assistance in dying

if they're terminally ill. And finally, even in countries where assistance is illegal, doctors already, every day, make decisions together with patients and families that affect the timing and nature of their death. These decisions are ethically complex. They could, in theory, be abused, but they're nevertheless ethical and lawful. We allow doctors to make them. It's time to be honest and consistent

about end-of-life choice. People have the right to choose how and when to die. Thank you, Dominic. A great opening statement, concise to the point. Now let's go to Wes for the argument against our motion today, be it resolved. we have the right to choose how and when to die. Wes, over to you.

Sure, I would like to first state that we agree on common ground with regard to the idea that we all want to reduce human suffering. This is the core and the cornerstone of the purpose of medicine. It's also important to acknowledge that physicians and all healthcare professionals who come to this argument in favor of physician-assisted suicide and euthanasia, do so with good intentions towards. benevolence and sympathy towards patients. And we have to realize that all of us know these are difficult and stressful conversations. I want to first define what the question actually is. It's not, therefore, does a patient have a right to die of their own choosing? It is, actually, do we as society want to and agree to redefine the fundamental purpose of the millennia-old practice of medicine from a healing art into one in which physicians are arbiters of and organizers of

performing a procedure that ends in the patient's death. And what are the implications of such a decision? The reason this is the actual question is that if you look, for example, just at Canada, who has only had physician-assisted suicide and euthanasia approved for about five years, we've watched that the numbers have gone from 189 in the first year alone to over 2,300 in Ontario, with over 24,000 people having undergone death at the hands of this new law, Physicians, Sissus suicide and euthanasia. However, 99.99% of all of those deaths were by a scheduled lethal injection from physicians, such as, for example, a barbiturate overdose.

So it's really a question of do we want doctors to be carrying out this as a medical, procedure. The question is then, what is my role as a physician? And I believe that if I were to undergo a intentional lethal dose of drug to a patient, that I would actually be abandoning my patient, not providing good for them or being with them, but actually providing a sense of abandonment, an expedient, cost-effective way of approaching their suffering. So what I really want to do is, bring to my patient a true mercy, not a false mercy, but true mercy. And I'll end with a story. I had a patient come to me named Paul, and he said to me, doctor, I have pulmonary fibrosis, I want to die. And I got this nausea in my stomach and said, Paul, I am not going to leave you,

but I will not intentionally bring about your death. I told him, I said, you're the best judge of when you need more medicines for pain, anxiety, and breathing, and all of us will work night and day, to relieve your distress. I'll do anything I can to palliate you, but I will not deliberately end your life. And then I went on to tell him, your disease does not diminish your value as a person. You are of inestimable worth. I put him in touch with a nurse named Christine, and later on, he came back to me, and I said, two things. He said, look, just don't abandon me. And then he said, my illness made me forget that one of the things I do well in life is I see when people are hurting. And he found that Christine was hurting and he had the ability to help her in her life.

So Paul found purpose in his dying days. So in closing, I would say that as a physician, my purpose is to help people find their why to live, just like I did with Paul. And in so doing, he ended up saying, I don't want you to bring about the end of my life anymore. I still have purpose in his dying days, he reached that conclusion. Thank you, Wes. Now an opportunity for rebuttal, so this is a chance for both of you to kind of weigh in on each other's opening statements. So Dominic, let's go to you first.

What do you want to react to from what you've just heard from Wes? So Wes talked about this question about redefining doctors' roles. his concern that in allowing doctors to actively end patients' lives, that they would be abandoning patients, that they would be residing from fundamental goals of medicine. I think we need to, and we will doubtless come back to, some profoundly misleading false dichotomies that occur in debates about assisted dying. And these are these notions that we either choose

to provide palliative care, that we either choose to support patients in finding meaning in their dying days or we actively end their life. But of course, we ought to embrace both of those for every patient like Paul that Wes described who can find meaning despite the severity of their illness and whose symptoms can be relieved

by caring physicians like Wes providing palliative care, there are other pools out there who say, hang on a second, you're telling me I have to stay alive for your sake or for the sake of somebody else. I am in pain. You have tried and failed to relieve my suffering. Why is it that you're requiring me to continue to live? You have in your pocket, in your cabinet, means of relieving my suffering. Why is it that you are forcing me to continue to live? So I think we should avoid these false dichotomies. We should avoid this. This

notions that it's a choice between caring and ending life, there can be situations where actively ending a patient's life respects them as individuals, respects their choice, respects their sense of worth and their dignity. And of course, there will be plenty of other cases where exploring their wishes, providing good palliative care makes it possible for them to enjoy the end of their life in a different way. Thank you, Dominic. So, West, similar opportunity for you, you can react to Dominic's opening statement or what you've just heard now. Now, let me come back to autonomy as a driver of this. I totally agree that we must respect people's autonomy. And that is based on respect for a human being of this incalculable intrinsic worth. But by ending a patient's life,

we destroy a patient's autonomy because we turn a somebody who has that autonomy, into a nobody. And I don't want to be a physician. I can't be a physician and practice my art if I am intentionally converting a someone into a no one, especially when my medical interventions must be aimed towards healing and helping someone with 100% intent. And I don't know what's on the other side of death. It could be that what that person's going to go through after they die is worse than the suffering they're currently experiencing. No one knows the answer to that question. So if I'm going to be an evidence-based physician,

my intent must be to stay on this side of that bright line of reducing human suffering with that tool that I have in my pocket. You know, eroded autonomy also occurs by physician-assisted suicide and euthanasia. There's this beautiful quote by Ben Matlin in the New York Times who had a degenerative neurogenerative disease, and he wrote, truly conceive of the many subtle forces, invariably well-meaning, kind-hearted, and even gentle, yet as persuasive as a tsunami that emerge when your physical autonomy is hopelessly compromised.

So I don't want people who have less of a voice because of their life circumstances, disease like Ben Matlin has, mental disability, poor education or poor cost. These people are less of a voice than the rich and the educated in society. And those are the very people that physicians assisted suicide and euthanasia has been shown to take advantage of in circumstances, for example, in the critical care unit, where we actually know now that from a paper by Kenneth Schenberg in the New England Journal of Medicine that nearly 30% of the deaths in which physicians were involved, that it was an involuntary, decision by the physician without the patient having even requested to have their life ended. And I can't tell you how many times as a doctor I have thought that somebody was going to die, even told family members, I don't think they'll be here at Christmas time. And now, five, ten years later, I'm still getting Christmas cards from that person that I

thought was going to die. So had I exercised that judgment at the time, that person would no longer be here. And in short, if you tell me why you ought to respect a patient's autonomy, I'll tell you why you ought not kill that person. Thank you, Wes. Fascinating debate here, so many different directions to go in. So let's start unpacking this together. And Dominic, let me come to you first, just for a little bit of maybe history and background here. Because Wes talks about, I think, something that's familiar to many listeners, the idea of the Hippocratic Oath, this kind of covenant on the part of doctors to do no harm and this idea of a line that doctors traditionally have not crossed or have crossed with the utmost

reluctance. So I want to hear a little bit more from you, Dominic, about why you feel that now is the time that we can start crossing that line and why, I assume, in your view, doing so doesn't corrode somehow the Hippocratic Oath. It doesn't change that covenant on the part of doctors and the relationship between the doctor and the patient, not just in the individual instance, but in the culture and in the profession. So, I mean, I think there are important elements of the hypocratic oath that we retain that are still part of the modern practice of medicine, I think there are other parts of the Hippocratic oath that we have realized over time were of their time.

So, for example, there were parts of the historic oath that told doctors they should refrain from cutting for stone. That was something that should be the domain of barbers, not of physicians. Now, of course, this would be great news if we told our modern surgeons that they shouldn't be trying to relieve the distress of patients with, with gallbladder stones. But those norms of the time have changed. There are all sorts of ethical norms that we've changed over time. Think of the advances in artificial reproduction. Even 50 years ago, it was unthinkable to be able to do what we can now,

to allow those who are medically infertile, to conceive, to have children. That has transformed in a very significant positive way. So medicine, as it advances, leads us to make choices. At this point in time, medicine can prolong life to very great extent, and that leads to really important ethical choices about when that's the right thing to do and when it's not the right thing to do. Medicine also has the ability to relieve suffering, but that comes with limits.

And recognizing those limits, we now have to fail. the question about whether we ought to offer patients as part of their end of life care, the option of assistance in dying. And there is more than 60 years of experience of doing that in some European countries. Thank you, Dominic. So, Wes, isn't Dominic right that everything has changed? Our mores, our attitudes about death, our own sense of agency and autonomy, me, and maybe more importantly to the concern of many listeners, medical science has advanced in profound ways over the last number of decades to allow for the extension of life. But that extension of life combined with quality of life is a gap that much of modern

medicine seems incapable at this moment of closing. And how would you respond, West, to the listener who just says, look, I'm not. I'm a free autonomous individual in the 21st century. I want to make an end of life choice. My end of life choice is to die. And I want to do that on the timing and schedule with a sense of mental health and wellness in that moment of death when I make that choice precisely because I am an autonomous individual equipped of my own rationality and my own agency. Absolutely. You know, I started with the common ground that we must recognize people's free will, and we must recognize their autonomy.

And so I went back to the question of, should they have the right to die? And I said, absolutely, they should. That's not the question that we're asking here. The question is, should the doctor be the one to do it? And let me get on with this. Because as we established, 99.99%. So basically, all of the cases are a scheduled appointment. with a doctor for euthanasia.

And I didn't say this earlier, but the distinction is that it's not physician-assisted suicide in the outpatient circumstance where the person is taking the pill. PAS is an outpatient situation where I prescribe you a drug and you go home and do it. Okay. That is happening infinitesimally small number of cases. It's basically all a patient coming in Tuesday at 10 a.m. for this intended ending of your life via lethal injection. That's what this is in the world today.

So the question back to the oath is, is this the role of the doctor? And do we in society agree that we will change fundamentally the role of the physician in society to be the person to carry out this medical procedure? But as I said earlier, and if we go back to the oath, the oath is I will neither prescribe nor administer a lethal dose of medicine. Now, where is our common ground? Dominic says, medicine is evolved and the oath should change. I completely agree with that. This is our common ground. Medicine has evolved in beautiful ways. I'm a transplant physician. I'm trained as a lung transplant physician. So I completely embraced the idea that when Danny West comes to me, and he's a

person in my recent book, every deep-drawn breath, he gets a new set of lungs in his life to extend his life. And the oath is a proto oath. Hippocratic oath was a proto oath, meaning it was the beginning. How does the oath evolve? So as the oath is evolved, we have to realize that what wasn't in that oath was the adequacy of palliative care. We know, for example, that 70% of people do not get adequate palliative care. If we spent the amount of attention and time on developing palliative care, that we are spending on PAS and E, we would actually do so much of a better job. So we know, for example, that let me throw out a couple of pieces of information about this autonomy issue and then palliative care.

Autonomy has to have its limits. We want people to have autonomy, but it has to have its limits. For example, what is the reciprocal cost of the autonomy? For example, patients, families and doctors have rates of PTSD and depression at 20% even two years later. So we have to consider the reciprocal cost of the doctor being the one to do this, and then that person undergoes moral injury and the family undergoes moral injury, a story. A family member of a friend of mine had their loved one underwent, their loved one underwent assisted suicide and euthanasia. And that person just sobbed and sobbed with me at a coffee

shop because she was so injured that she was now in therapy. So there are reciprocal costs to autonomy. Hi, Rudyard Griffiths here, your host and moderator. I have a favor to ask you, please consider becoming a monk member. Membership is free and you get access to a series of great benefits, including a 10-plus-year library of some of our best debates, dialogues, and podcasts. You also get a free monthly newsletter featuring the debates that we're watching around the world. And you get a specially curated Friday weekly monk members-only podcast that focuses on the big international event. and trends shaping our world. All of that, again, free at www.w.w.munkdebates.com. I hope you'll consider joining and becoming part of our community. Now, back to our program.

You know, Dominic, death is part of life. And with advancements in palliative care and the extent to which pain as a vital symptom is now understood and broadly socialized within the medical community, what is the objective? What is the objective? objection here? Do you have an ejection? If, in fact, every person in the process of dying could be guaranteed a death that is absent, you know, pain and acute suffering. Because isn't the risk here, Dominic, that as you know, we have a society that is deeply scared of death that doesn't talk about death, that runs from death, and to what extent is the euthanasia movement in some ways dovetailing with the very thing that society wants, which is an avoidance

of death. And shouldn't every person as part of a full life also have a full death, provided that it's hopefully absent of pain, absent of acute suffering? So one of the questions is what counts as a full death? And one of the important issues is whether the notion of a full death should be the one that the physician believes counts as a full death, or whether it ought to be what counts to that individual. There are plenty of physicians like Wes who wouldn't support active euthanasia or assisted dying, but there are at least an equal number who do support that. There are, in fact, a majority of physicians in the United States who support assisted suicide. There are a large number of palliative care physicians in places like Canada, northern Europe, in those parts of the

United States where assisted suicide is lawful. They understand this as an option that they can provide very consistent with their professional role and their obligations. But to follow your question, why isn't palliative care enough? Can't palliative care relieve or dying patients suffering? Well, I quoted the figures from Sweden from the UK. which is widely recognised as a world leader in palliative care. In 2019, there were 126,000 patients at the end of life who were estimated to have suffered from unrelieved pain in that year. And based on those patients who were treated in hospice

and the level of pain relief in the gold-class provision of palliative care in hospices in the UK, even if they were all treated with the sort of excellent palliative care provided in hospices, there would still be 51,000 patients a year in the UK dying in some level of pain. Pain is not the only distressing symptom at the end of life. I mentioned, I listed a number of other very distressing symptoms, some of which arise as a consequence of the medicines used to treat pain. So there are a whole constellation of symptoms. We ought to, of course, offer the very best quality palliative care to patients who are dying.

but some patients nevertheless experience very distressing symptoms. Other patients, regardless of these treatments on offer, say, this is not something that I wish to continue to endure. Why are you making me continue to endure this when I know the end is coming? So, Wes, to push this debate into some particular circumstances that, no doubt our listeners are dealing with other and their families or with loved ones, Do you have a different view, West, of people who have what can only be described as these chronic degenerative illnesses and possibly their ability to access doctor-assisted suicide on the basis that they know that they have an irreversible disease that will lead to a really profound loss of their agency in terms of their ability for mental cognition? and that they will spend, no doubt, many years of the end of their lives in a vegetative state with very little, if any, quality of life due to the incapacitation brought out by dementia Alzheimer's or any one of these cognitive disorders that far too many of us know far too well.

Is that an area or a set of cases where you agree that people have this right to choose how and when? to avoid what is arguably a fairly pointless death, isn't it? Because you're not even conscious of your own self at that point. This question poses an external judgment on the other person about whether their quality of life is adequate or not. And one of the things that the medical literature shows very beautifully is that there is this thing called the quality of life gap between what somebody expects their quality of life to be and what it actually is. And the cancer literature outlines this very beautifully that if somebody has an actual adjusted, expected quality of life, and there's not much of a gap between that expected quality of life and their actual quality of life, they perceive their quality of life as fine.

Many times I have judged that somebody's quality of life should be X, and they only expect it to be why. They're fine with that therapy. I had a great ALS patient. Her name was Jessa, and she had ALS on the ventilator. and the resident outside the room said, what are we doing here? Why is she on a ventilator? This is wrong, bad medicine. And the husband of Jessa walked up, she didn't know he was there, and put his hand on her shoulder and said, look, I agree with you that if it was me with the ALS, I wouldn't want to be on the ventilator, but my wife does. And she says that every day she's alive,

she wants to be with me. So she had a narrow quality of life gap. And one of the things about palliative care that we should really make sure we highlight is that, New England journal papers and multiple investigations have shown that when people get adequate palliative care over half the time, they switch their idea from a decision of wanting to end their life to one of saying, no, I still want to live. So Dominic said the UK. But the other half they don't. Let me say that. Just points to the problem. We've got a great country in the UK that does great palliative care. And I say, well, no, they're all nascent. Because if 50% of people are ending and suffering, we have not done adequate palliative care, period. The whole point of palliative care is to provide enough medicine to relieve the pain.

And not that I will ever promise a patient, I can completely relieve it, but I can do way better than what is happening right now. We are nascent and we have to improve with the way that medicine has improved to keep people alive at the end of life. And then, Rudd, one more thing to answer your question. What are people suffering from? Pain is number 14 on the list for requests for ending their life. It's depression and loneliness. These are epidemic. And these things can be treated by medicines, by loving caregivers, by social workers and hospice workers, where we could put money and time into those circumstances. But it does require money and time. We had a paper in the annals of internal medicine that showed that many people are actually requesting this now.

just for a pure geriatric syndrome, which you said it's some sort of fatal illness. These are not people with a fatal illness. They have a geriatric symptom. They're just growing old and now requesting end of life. So this idea that my bucket list is checked and I should have my life ended is where we have evolved in this circumstance of requesting euthanasia. And there are thousands of people receiving the end of life doses of medicines with intentional end of life because they simply request it without.

having confirmation that they have a lethal illness, that they are actually competent, or that they weren't coerced into that by their family. So we don't have adequate reins on this circumstance in Canada or Benelux. And that's one of the things I really worry about because then it can be applied to people who are vulnerable because of mental illness or lack of education or money. So let's talk about the vulnerability. If the claim, and the claim is thrown around all the time, that assisted dying is going to particularly affect those who are vulnerable. We ought to see higher rates of assisted dying amongst those who fall into those categories. But assisted dying in Oregon and the Netherlands showed no evidence of heightened risk for the elderly,

women, the uninsured, people with low educational status, the poor, physically disabled, chronically ill, minors, people with psychiatric illness or racial or ethnic minorities. repeated studies have shown on the contrast that those who end up accessing a sister dying come from a relatively privileged background. I would disagree with that, and I'll give you two examples. I think that there's a societal example regarding increased suicidality, and there's an individual example at the bedside. In Belgium, we actually, as I said earlier, have documentation in the New England Journal

of Medicine that 27% of the patients who, underwent a physician-involved end of life, did so in an involuntary circumstance. I would argue that all of those patients, that one-third of people who got a doctor choosing to end the life intentionally, that those people were vulnerable because they were in a critically ill circumstance, they were unable to speak for themselves. And it is absolutely the case. And this has not been measured. So it's not in the fact you just stated that poor people, those without family, those are the ones that don't have a voice. So this is a circumstance of vulnerability that is actually playing out right now in the world. The second example is that we have good evidence now when we compare

states in the United States that approved PAS and those that didn't, since euthanasia is still illegal in the United States, we have proof that in the PAS states that there was a rise in suicidality in the general population, uninvolved with PAS. So there are people out there vulnerable to the societal acceptance of suicide. And the fact that if doctors are involved, this must be okay. If doctors think it's okay for their profession to be the one that is actually carrying out a medical procedure intended to in life, that this must be somehow more acceptable than we used to think. and I just think that that's a cheapening of life. I think it's a cost-efficient and expedient way of cheapening life

and allowing people to say, hey, I must not be worth it anymore. So if I have disease, my life, the message I'm getting, like Ben Matlin said in the New York Times, the message I'm getting is, why haven't I taken myself out here because I'm costing society and I can't really provide benefit now because of my disease? I'm not worth staying around for. I think we need to really pay attention to the messages that we give to society. But I think it's a profound mistake to conflate these debates about assisted suicide

with a wider important debates about how we care for those with chronic illness, with disability, with mental illness, who have thoughts of ending their life. In states like Oregon that have had physician-assisted suicide for more than 20 years, the proportion of deaths that follow physician-assisted suicide are tiny. 0.4% of deaths in Oregon follow physician-assisted suicide. Why is it so small? Well, partly because only a relatively small number wish to embrace this choice, a number take the prescription, but then because they have the guarantee that if their suffering reaches that point,

they could end their life, they're then able to enjoy the last part of their life without taking that prescription. So I think the way that we talk about death and dying needs to be much more mature and much more nuanced and we shouldn't throw around these often unsubstantiated accusations about wider valuing of life. This isn't about devaluing the lives of those with chronic illness or disability. On the contrary, it's about respecting individuals' rights to make decisions about the end of their life. Thank you, Dominic. Let's go to closing statements. I'm conscious of our time. This has been a terrific debate. We've, I think, looked at this from the perspective of patients, doctors, families, and society at large. So mission accomplished on all those fronts.

Our motion today that we've been debating is, be it resolved, I have the right. We have have the right to choose how and when to die. Wes, you've been arguing against the motion. What are the final points or arguments that you'd like to leave our listeners with? I think it's important that we diagnose the problem that we're having to face here. And the Greek words, Dia and gignosting apart and no. So we have to be able to discern apart what is going on here that's creating this desire and what are the implications for society.

The question here is not does the patient have autonomy. It's not does the patient have free will? That is not the question. The question is, as a society, are we going to have the physician in charge of providing the lethal injection, which I think 100 percent undermines the trustworthiness of that doctor for the patient? The patient will never know again if the doctor is 100 percent wanting to do help versus harm to them. In addition, I think that we have to focus on human dignity. And dignity is innate to every human being. It must be respected. And there's nothing dignified about creating a somebody into a nobody. It removes the person's autonomy. It ends their own decision making. And it's why I think these euphemisms around the end of life movement,

such as dying with dignity, have been chosen. They're trying to undermine the actual purpose of the word dignity by saying, do you want to die with dignity? Of course I want to die with And who wouldn't want to die with dignity? Well, then let me dive deep with you at the bedside as your physician and show you the respect I have for your life even though you have illness. No matter how much life you have, I will spend the time and show the love to be with you, not feel sorry for you, but to empathize with you and be present with you and not just provide benevolent intent, but actually do good for you by showing you a why to live, lifting

you up. And really, the glory of medicine is when we fully explore the other person and that unique human individual. And I think that what physician-assisted suicide and euthanasia does is it bypasses that glorious connection that we make. It would change me from a physician into merely a technician providing this lethal injection. That's something I simply could never do and would never disrespect the patient by doing. So in summary, I think that good medicine, is palliative care, it's reduction of suffering via the tools

that as Dominic point out I have in my pocket. I can provide you that reduction of suffering and I will stay with you and as I promise Paul, I will never abandon you. I will address your loneliness.

I will find social workers and palliative care doctors, hospice doctors. I will kill your pain but I will not kill you. I will treat you as a somebody, not as a nobody, and never abandon you.

Thank you, Wes. Our debate today, it's been a fulsome one. The motion be it resolved. We have the right to choose how and when to die. Dominic, you've been arguing in favor of the motion. We're going to give you, as per debate convention, the last word in this discussion. So I'm going to finish by quoting one of the judges in the vital Canadian constitutional case that led to change reform in Canada. Laws that prohibit assisted suicide mean that people who are grievously and irredeemably ill cannot seek a physician's assistance in dying and therefore may be condemned to a life of severe and intolerable suffering. A person facing this prospect has two options.

She can take her own life prematurely, often by violent or dangerous means or she can suffer until she dies from natural causes. Assistance in dying is and should be a compassionate and dignified form of care at the end of life. Not every health professional would wish to take part in it. Dr. West has made very clear that he would not choose to, but they don't need to. Only a small proportion of dying patients choose assistance in dying, even in those countries, those states where there is the most experience,

even in those places where there are the most liberal laws on assisted dying. We're never all going to agree about assisted dying. This debate topic is not new. It's been raging for decades. We should accept that and move on. Given that we do not all agree, the logical answer would be to allow people to make decisions about their own lives and deaths.

Some who are terminally ill and provided with palliative care will wish to continue to live, like the case of Paul mentioned by Dr. Wes. But others, even if they're provided with the best palliative care in the world, we'll still desire assistance to end their lives in the way and at the time that they choose. We should respect both choices. People have the right to choose how and when to die. Thank you, Dominic.

And thank you, Wes, for a terrific debate. Folsom, to the point, really has led. me to think down some new lines of inquiry and as you say this is a reoccurring debate. It's one that's not going to go away and you've both approached it with civility and substance and a willingness to engage each other's arguments and ideas. So on behalf of the Monk Debates community, thank you so much for coming on the program. It's my privilege. I appreciate you, Dominic. Thank you for helping me think through it as well. My pleasure. Thanks very much, Wes. I've enjoyed the debate.

Well, that wraps up today's debate. I want to thank our participants for a fascinating, far-reaching conversation on a vital issue of our time. If you have feedback or reflections on what you've just heard, please send us an email to podcast at monkdebates.com. Also, a reminder that if you're enjoying the monk debate podcast, please check out our regular Friday, Monk Members Only program that looks at the big issues and events in the news, hopefully providing you with new context and analysis. about the issues and ideas transforming our world. You can access that podcast free as part of our basic membership, which is also free, and you can do all of that at Triple W. Munk Debates, MUNK, DebateswithanS.com,

forward slash membership. Thank you for lending your time and attention to our effort to bring back the art of public debate, one conversation at a time. I'm your host and moderator, Rudier Griffiths. The Monk Debates are produced by Antica Productions and supported by the Monk Foundation. Jacob Lewis is the producer. Abi Rojasia is the associate producer. The Monk Debates podcast is mixed by Reza Daya and the president of Antica Productions is Stuart Cox.

Be sure to download and subscribe wherever you get your podcasts. And if you like us, feel free to give us a five-star rating. Thank you again for listening.