In April 2021, a biopsy showed that my throat cancer was back. I had finished eight weeks of radiation in September 2020, but my tumour, resilient and militant, was growing again. I met with my surgeon in a small room at the cancer centre. It was still COVID time, and my wife Kathi had to be on speakerphone.
Surgeon: “I’ll review your options. First, there is palliative care.”
Me, silently: “What? Palliative care intends to comfort the patient but not to cure her. Why are we talking about this?”
When I tell this story, the surgeon’s directness shocks listeners. But he knew us well. I’m a psychologist, Kathi is a psychiatrist, and, like the surgeon, we’re all medical school professors. He knew my wife and I had read the biopsy report and knew we would understand it. Kathi and I hadn’t come to the meeting looking for consolation; we wanted to talk about what the surgeon wanted to talk about: “What can we do?”
This derailed me. Then I grasped that he had offered to refer me to a service—the acronym is MAID—that would either help me kill myself (suicide) or do it for me (euthanasia). A pause. Then,
Me: “That’s not an option for religious reasons.”
Surgeon, kindly: “I understand. I mentioned these options first because we do not have much to offer regarding treatment.”
You can treat cancer in three ways. Radiation burns the tumour out, but we’d tried that, and it failed. The second way is to treat cancer with chemotherapy or immunotherapy. The surgeon did not believe these would work. Finally, you can cut the tumour out surgically. Unfortunately, my tumour is at the base of my tongue, so surgery would likely kill my tongue, and I could lose the ability to speak or eat. I told the surgeon I understood that but would do it if I could be with my family and continue my research.
A second opinion from a leading Canadian throat-cancer surgeon confirmed that my tumour was inoperable.
“I know this is difficult to hear.”
“Months, not years.”
The surgeon was correct that for recurrent head and neck cancers like mine, most patients live just a few months regardless of treatment. But for a small fraction of patients like me, pembrolizumab—a novel, preposterously expensive immunotherapeutic drug—sometimes extends life. After almost two years of pembrolizumab treatment, the tumour’s still here. But so am I.
And I am still trying to understand why he offered to help me die. And how Christians should respond to MAID.
Here is the legal context. In the 2015 Carter v. Canada decision, the Canadian Supreme Court held that Canadians had a right to medical assistance in dying in specified circumstances. The criteria that qualify you for MAID have been spelled out in a series of laws passed by Parliament in response to Carter. Canadian law says that you have a right to MAID if you are (1) a competent, consenting adult who (2) has a grievous and irremediable illness that (3) causes enduring and intolerable physical or psychological suffering that cannot be alleviated under conditions you consider acceptable, and that (4) you must be in an advanced state of irreversible decline in capability. The law does not require that a person’s natural death be imminent.
Some readers may oppose MAID because they believe that there are no circumstances that justify killing. But really, no circumstances? The 1549 Book of Common Prayer renders the sixth commandment as “thou shalt doe no murdre.” “Murdre” matters here because it recognizes exceptions, cases where we can justifiably kill—for example, in self-defence. Are there cases where MAID is justified? Physicians tell me there are patients in constant, unendurable pain, whom they cannot help, and who want to die. In these dire cases, a physician’s duty to relieve suffering conflicts with her duty to preserve life. She must choose which duty takes priority. I believe that for a patient in extremis, and as a last resort, MAID is not murder.
MAID deaths in Canada have increased from 1,018 in 2016 to 10,064 in 2021, an almost tenfold increase in six years. The growth is steep and follows a straight line, with no sign of slowing. Twice as many Canadians died by MAID in 2021 than all suicides combined. Designing and evaluating suicide-prevention programs are parts of my professional work; I cannot get these numbers out of my head.
MAID deaths in Canada have increased from 1,018 in 2016 to 10,064 in 2021, an almost tenfold increase in six years.
Journalists also report cases of persons offered MAID who could not obtain other medical care that might have reduced their suffering. Likewise, there’s a report of a patient who sought MAID because he could not get adequate housing. If this happens, it matters. In 1999, the ethicist Judith Jarvis Thomson published a defence of physician-assisted suicide. She argued that patients’ right to liberty entitles them to MAID, and her paper attacked those arguments that distinguish between a doctor letting someone die (by disconnecting a respirator) and killing them (by injecting a drug). Thompson noted, however, that “even if these are bad arguments, there may be others that are better. Many people oppose the legalizing of physician-assisted suicide on the ground that (as they think) there is no way of constraining the practice so as to provide adequate protections for the poor and the weak. They may be right, and if they are, then all bets are off.”
All bets are off if a patient seeks MAID because he cannot get needed medical care, food, or housing. The choice to die quickly and painlessly versus slowly in agony benefits the patient only if no better alternatives exist. That patient isn’t at liberty; he’s being coerced. And when MAID occurs through coercion by circumstance, MAID becomes murder (call it “murder by system”).
However, are marginalized persons dying by MAID because they are not adequately protected? No, according to evidence presented to the Canadian Senate panel that recently reviewed MAID. So far, the uptake in MAID has occurred primarily among affluent Canadians, people who supposedly have sufficient access to good mental health and palliative care. From this, MAID advocates have concluded that we must work harder to make MAID accessible to the marginalized. The senate panel did not notice that if MAID is currently offered primarily to the well-off, we have no evidence about what will happen when MAID becomes available to the “poor and weak.”
Journalists have also reported on patients who received offers of MAID when they had not expressed a desire to die, including Canadian Forces veterans seeking treatment. My case was likewise an unsolicited offer. I had never told the surgeon—or anyone else—that I could not endure my suffering. Moreover, at no point in our conversation did he ask about my suffering.
Why, then, did the surgeon do it? One reason is that he believed—incorrectly, in hindsight—that palliative care and MAID were the only beneficial options. Put another way, he presented the standard treatment options for incurable cancer, deleting the ones he believed futile. I am a medical school professor, and I’ve helped teach a course on the doctor-patient relationship. We train medical students to list all the treatments that would benefit them. It’s the patient’s body, and patients should decide what happens to it. What shocked me was that MAID was on the standard list rather than a last resort for a patient in extremis when all other options have been tried and failed.
The Canadian Association of MAID Assessors and Providers sees things differently. Their concern is that many Canadians do not yet have access to MAID. To remedy that, they believe MAID should be a standard option for patients like me.
I work at a children’s hospital just a few hundred metres from the cancer centre. Our hospital screens every adolescent admitted to the hospital for suicide risk, not just those about whom we have a prior reason for concern. We screen every person because a youth suicide is an unacceptable outcome. Thankfully, it’s a rare event.
Suicide rates among adults, however, are twice those for youths. When considering adults with cancer, you need to double the risk again. It has been known for decades that cancer patients have a high risk of being depressed, and depression is also a risk factor for suicide. One of the highest-risk groups is oropharyngeal cancer patients—my specific diagnosis. Think about everything you need to do with your throat, then imagine that every swallow or cough led to a stabbing pain projecting through your head and neck.
Moreover, it’s not just that having cancer increases your risk of suicide; simply being told you have cancer can have health consequences. The Swedes keep meticulous health records, and the researchers studied six million Swedes in fifteen years of national data. They found that the risk of cardiovascular death—heart attacks or strokes—was more than five times higher during the week following the diagnosis compared to a matched sample of undiagnosed Swedes. Being told that you have cancer doesn’t suddenly clog your arteries. Instead, the trauma of receiving the diagnosis precipitated a cardiovascular crisis among people already at risk of a heart attack.
Since my diagnosis, I have had scores of visits to cancer clinics. No one has screened me for suicide risk. No one has evaluated my mental health. However, the system found the time to offer me MAID.
However, the most striking health effect of getting a diagnosis was that the risk of suicide was an astounding 12.6 times higher during the week following diagnosis. The acute health risk from learning you have cancer declines over time. Nevertheless, the relative risk of cardiovascular crisis or suicide was three times higher over the first year following the diagnosis. I haven’t found a study on what happens when a patient who, like me, already has a diagnosis and then receives a terminal prognosis. Still, it’s reasonable to assume that receiving a terminal prognosis could be traumatic in the way a cancer diagnosis can be. If so, giving someone a terminal prognosis and offering MAID during the same appointment, as the surgeon did in his meeting with me, could be like throwing a match on a puddle of gasoline.
The upshot is that many cancer patients suffer from depression and that, as a group, we are at high suicide risk. You might imagine that if a patient was depressed or suicidal, surely a physician or nurse would notice. Unfortunately, decades of study of depression and suicide has shown that patients rarely volunteer this information. If clinicians do not ask, they will not find out. So, you would think that cancer physicians and nurses would follow protocols for suicide prevention in their routine care, as we do at the children’s hospital. You would expect mental health care to be well-integrated with cancer care in every cancer centre. But you would be wrong. Since my diagnosis, I have had scores of visits to cancer clinics. No one has screened me for suicide risk. No one has evaluated my mental health. However, the system found the time to offer me MAID. There will be no patients with untreated depression in your centre so long as you do not look for them.
Given the evidence, why aren’t mental health care and suicide prevention integral to cancer care? A psychiatrist colleague believes that the problem is how oncologists think: “If they can’t see a mental health problem on a CT scan, they don’t think it’s real.” Medical subspecialists are frequently chided for focusing on a single organ or disease when they should “take care of the whole person.”
Well, yes and no. Cancer doctors and nurses are highly trained in the skills needed to combat cancer. There are too few of them, given the number of cancer patients. When I was first diagnosed and received a recommendation for radiation therapy, I looked up the number of radiation oncologists in the province and the number of new radiation patients yearly. It was clear that each of these physicians had an overwhelming caseload. They do not have time to treat the patients on their caseload if they spend time inexpertly practicing psychiatry. Mental health problems should be treated by people who know how to do that.
But Canada doesn’t have enough mental health clinicians to care for all the cancer patients with unrecognized depression. Waiting times to get mental health services are measured in months and vary depending on where you live. In Ontario, psychiatrists are concentrated in Toronto and Ottawa. But the province is bigger than Texas, and there are few psychiatrists anywhere else. While getting my immunotherapy treatment, I once spoke to an oncology nurse about depression and cancer. “No one seems to ask patients about depression, but as a psychologist, when I look at faces in this chemotherapy unit . . .” “I know,” she said, but it was clear that she thought this was an unsolvable problem. Why should she ask her patients about depression if it would take months for them to be seen by a mental health specialist? The claim that cancer patients at the end of life have adequate access to mental health care doesn’t withstand scrutiny.
Similar concerns apply to the belief that cancer patients have adequate access to palliative care at the end of life. A report from the Canadian Institute for Health Information concluded that “estimates suggest that up to 89% of people who die might have benefited from palliative care. However, a substantial proportion of Canadians were neither identified as having palliative needs, nor as having received palliative care in their last year of life.” A 2015 report found that there were only 275 physicians specializing in palliative care in Ontario, of whom 145 only worked part time, and 96 percent of whom were in the cities. That’s about two full-time equivalent palliative care physicians for each 1,000 annual provincial deaths. It is not credible that we have enough palliative care clinicians to care for all cancer patients at the end of life.
So how should Christians respond? Beginning in the fourth century, Christians established institutions to care for their neighbours in body and soul. Modern hospitals and public health care systems descend from these institutions. Today most of these systems are secular. But the church’s voice must be heard on how the health-care system is run.
What does it mean to care for the body? Christians hold diverse views on whether MAID is licit; some will reject my claim that it can be justified in extreme, last-resort cases. But surely we all agree that MAID should never occur when a patient might benefit from mental health or palliative care. Neither should it occur because a patient cannot obtain the necessities of life. The moral case for expanding MAID rests on the polite fiction that the Canadian health system delivers adequate mental health and palliative care to the population. It has not in the past, does not in the present, and will not in the future without significant reorganization and investments of resources. This is profoundly unjust. If we acknowledge these unpleasant facts, the church should actively resist the expansion of MAID, particularly to marginalized populations.
The church’s engagement matters because we’re on a slippery slope. What pulls you down a physical slippery slope is gravity. What’s the analogue of gravity here? The Canadian health-care system has never had enough doctors or nurses (or ICU beds, long-term-care facilities, geriatric specialists, or . . . the list goes on). Today, 19 percent of Canadians are sixty-five or older; in 2035, it will be 25 percent. There will be increasing numbers of very sick, costly patients. Provinces will face hard fiscal choices, and the health-care system will be drawn toward what’s efficient. Care systems that deliver integrated oncological, palliative, and mental health care are challenging to establish and expensive to run. MAID is inexpensive, completely effective, and easily delivered. If we do not resist it, the system will, as if pulled by gravity, increasingly provide suicide and euthanasia instead of healing for the poor, elderly, and severely ill.
MAID is inexpensive, completely effective, and easily delivered. If we do not resist it, the system will, as if pulled by gravity, increasingly provide suicide and euthanasia instead of healing for the poor, elderly, and severely ill.
However, our concerns are deeper than MAID eligibility rules. Like a star shell, the increase in medically assisted deaths illuminates an ocean of suffering and despair. In 2021, more than ten thousand Canadians gave up the last months and years of their lives. If we changed the law about MAID but did nothing else, the suffering and despair of the ten thousand would be untouched. Compassion and justice require that Christians work to ensure universal access to better care for the dying. More restrictive MAID eligibility rules will not get anyone access to mental health or palliative care. It will not put hope in anyone’s heart.
What about care for the soul? Christians can fight despair among those at the end of life by testifying to our hopes.
I was shocked that my surgeon presented suicide and euthanasia as standard treatments for the terminally ill. And that so many of my colleagues and neighbours seem to think this view makes sense. Reading accounts of people who want to die “with dignity,” it’s clear that many, by no means all, view the loss of capability and the onset of dependence as indignities. They no longer wish to live if they cannot retain their abilities and independence. This view seems natural because it coheres perfectly with our competitive, meritocratic culture.
But we’ve lost the plot. The deepest tragedy is that so many Canadians have volunteered to end their lives. Many of us are afflicted by a distorted view of the value of life. Before I became ill, I valued my life as a means of accomplishing good things. To that end, I was devoted to cultivating my capabilities to get things done. That’s a dangerous path, even if you aim to get things done to benefit others. I have been formed since youth to focus my effort on cultivating my skills and to prize excellence. I judged my capabilities by comparing myself to others; what other standard was there? If I was less capable than others, I experienced that as dishonour. I collected achievements as evidence of merit. It was a pitiless Red Queen’s race: I had to run as fast as possible to maintain my rank in the scientific world. The instrumental goal—becoming more capable—replaced the intrinsic goal of serving children and families afflicted by mental illness as the focus of my life.
But when cancer came, my capabilities began to decline. When your capability diminishes, there’s a risk that you will devalue your own life. If you judge yourself on ability and your condition is terminal, what is there to hope for?
Christians have answers for all of this. We have faith in God’s promise that he will remake the world and resurrect the dead at the end of time. This means everything, but ironically, it’s not entirely on point. Notice that faith in the far future does not attribute value to the time between now and my death. The hours of suffering remain pointless. So why not hasten the process and end life painlessly now? The traditional answer is that my life belongs to God, and I have no right to destroy it. Maybe so, but again, it doesn’t redeem the time you have left. Suppose that you saw me by the side of the road, and I’ve totalled my car. “Get rid of it,” you say, “and get something better.” “I would, but my uncle holds the title, and he won’t let me.” Apparently, I am just hanging around to follow an arbitrary rule.
What is there to hope for when there is no prospect of a cure? The opportunity to love God and your neighbour, and to be loved by God and your neighbour.
Recall, however, that the climactic beats of the Gospel stories are the discourses of a man at the end of his life, foreseeing his imminent betrayal, capture, torture, abandonment, and execution. Whatever they signified, his powers to work miracles will get him nothing tomorrow. Yet in that night of terror, he spoke to his disciples about friendship and love, and—astonishingly—joy. Jesus said,
Abide in me, and I in you. As the branch cannot bear fruit by itself, unless it abides in the vine, neither can you, unless you abide in me. I am the vine; you are the branches. Whoever abides in me and I in him, he it is that bears much fruit. . . . Abide in my love. If you keep my commandments, you will abide in my love. . . . These things I have spoken to you, that my joy may be in you, and that your joy may be full.
This is my commandment, that you love one another as I have loved you. . . . I have called you friends, for all that I have heard from my Father I have made known to you. (John 15:4–12 ESV)
What is there to hope for when there is no prospect of a cure? The opportunity to love God and your neighbour, and to be loved by God and your neighbour. We can hope to grasp how we are joined to each other in and through God. With God’s grace, we can give ourselves entirely to this way of life.
Recently, while I was studying John 15, I received the Holy Eucharist, and we sang Henry Lyte’s 1847 hymn “Abide with me.”
In death, in life, O Lord, abide with me.
I wept. And as I described in issue 22 of Mockingbird Magazine, cancer has allowed me to witness love.
One dark evening, I walked through a hospital parking lot. Ahead of me was a pickup truck. A man in the passenger seat was vomiting into a bag held by a woman, presumably his wife. His complexion was freshly poured concrete; he vomited repeatedly. Whatever journey they’d taken, they’d arrived at chemotherapy. His wife closed the bag and gave him a fresh one; this wasn’t their first time. She could never have been so beautiful at her wedding as she was that night, with bags of vomit, delivering on the marital promise that matters.
Martin Luther wrote, “It is not enough for anyone, and it has no benefit to know God in glory and majesty unless that person knows Him in the humility and shame of the cross.” It’s the way of freedom, reached through the hard road of giving up illusions about capability.
Therefore, I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more than food, and the body more than clothes? Look at the birds of the air; they do not sow or reap or store away in barns, and yet your heavenly Father feeds them. Are you not much more valuable than they? Can any one of you by worrying add a single hour to your life?
And why do you worry about clothes? See how the flowers of the field grow. They do not labor or spin. . . . But seek first his kingdom and his righteousness, and all these things will be given to you as well. Therefore do not worry about tomorrow, for tomorrow will worry about itself. (Matthew 6:25–34 NIV)
This hope is the possibility of joy within suffering. Søren Kierkegaard urged us to learn joy from the lily of the field and the bird of the air:
Their instruction in joy, . . . expressed by their lives, is quite briefly as follows: There is a today . . . and there is no worry, absolutely none, about tomorrow or the day after tomorrow. This is not foolishness on the part of the lily and bird, but is the joy of silence and obedience. For when you keep silent in the solemn silence of nature, then tomorrow does not exist, and when you obey as a creature obeys, then there exists no tomorrow, that unfortunate day that is the invention of garrulousness and disobedience. But when, owing to silence and obedience, tomorrow does not exist, then, in the silence and obedience, today is, it is—and then the joy is, as it is in the lily and the bird. What is joy, or what is it to be joyful? It is truly to be present to oneself; . . . to be today, truly to be today. [And] the more you are entirely present to yourself in being today, the less does tomorrow, the day of misfortune, exist for you. Joy is the present time, with the entire emphasis falling on the present time.
I regret my answer to the surgeon’s offer of MAID. I said I had religious reasons not to take my life. I should have responded like the bird of the air: “No, I want this moment to live, serve, and love.”