Introduction

On February 6, 2015, the Supreme Court of Canada (SCC) through a unanimous 9-0 ruling, struck down provisions in Canada’s criminal code against assisted suicide (Carter v. Canada [Attorney General]) ⁽¹⁾. In doing so, the highest court in the land overturned a 1993 decision which upheld prohibitions against physician-assisted suicide claiming that, over that 22-year period, the legal and factual matrix had changed (Rodríguez vs. British Columbia [Attorney General]). The Supreme Court, however, ignored the fact that during that timeframe, nine separate legislative attempts were made in Parliament to change the law in order to allow assisted suicide and euthanasia, and every attempt failed. Six times Parliament voted, and every time Parliament voted against changes to the law. The principal concern was that assisted suicide would present great risks to the most vulnerable. In 2011 and again in 2012, Parliament voted nearly unanimously to implement national antisuicide measures, stressing prevention for vulnerable Canadians who might be induced intentionally to end their lives because of psychological or social pressures.

Responding to the Supreme Court’s assertion that apparently so much had drastically changed in 22 years, the Catholic Civil Rights League (CCRL) ⁽²⁾ of Canada, a lay group that intervenes in court challenges «in support of law and policy compatible with a Catholic understanding of human nature and the common good» stated that, with the Court’s decision, Canada had entered into a state of «suicide relativism» (2015). Suicide relativism is defined as the view that the moral character of an act of suicide, or a person’s intentional ending of his or her life, can vary depending on the reasons used to justify it. Typically advocates of assisted suicide distinguish this practice as ethically justifiable «rational» suicide from other instances of suicide.

In Canada, this state of suicide relativism amplified as, on June 17, 2016, Royal Assent was given to Bill C-14 enshrining in Canadian law the practice of what is contentiously named «Medical Assistance in Dying (MAID)». This is a name which ought to be rejected because of its confounding ambiguity. Palliative care, which does not take a patient’s life or hasten a patient’s death, is also assistance in dying. It is true assistance whereby physicians and healthcare professionals alleviate pain and reduce suffering without being complicit in taking a human life, in accordance with the Hippocratic tradition of medicine.

As assisted suicide and euthanasia regimes have become ever more ubiquitous in Canada and around the world, the concept of suicide relativism slowly prevails. This affects both the two chief stakeholders in so-called Medical Assistance in Dying (MAID): Firstly, there are physicians and healthcare professionals who object to intentionally ending the life of a patient or being compelled to refer a patient to colleagues who are willing to do so. These physicians and healthcare professionals have varying degrees of recognition for protection of conscience depending on the jurisdiction in which they practise. Secondly, there are the vulnerable persons themselves, the patients who find themselves as potential candidates for assisted suicide or euthanasia. What will guide their decision-making process? If they are seeking spiritual care at the end of life, they too will be affected by suicide relativism.

This paper outlines how suicide relativism has created uncertainty that has affected physicians and healthcare professionals, including healthcare administrators, as they endeavour to discharge their duties amidst the assisted suicide and euthanasia regime in Canada. This is done, in part, by also addressing how patients who are considering or opting for assisted suicide or euthanasia themselves are affected by suicide relativism as they seek spiritual care. For instance, if they are Catholics, they might seek Catholic pastoral care which potentially includes confession, extreme unction, a Catholic funeral and rite of burial.

This paper will discuss the situation Canada, without providing exhaustive coverage of current practices in place in every region of this country. The issues raised, however, could apply to anywhere in the world. Also, while focusing primarily on Catholic theology and pastoral care, the moral questions raised in this paper are potentially relevant to theologians and spiritual care providers in other religious traditions.

This brief paper will compare the two most widely known responses of Catholic bishops in Canada to the moral question of pastoral care for patients considering assisted suicide or euthanasia. These are: Guidelines for the Celebration of the Sacraments with Persons & Families Considering or Opting for Death by Assisted Suicide or Euthanasia, released on September 14, 2016 by the Catholic Bishops of Alberta and the Northwest Territories (2016) and A Pastoral Reflection on Medical Assistance in Dying released initially on November 27, 2016 (2016) and then slightly revised and rereleased on January 25, 2018 by the Atlantic Episcopal Assembly, 2018 ⁽³⁾. These two documents present opposing directives.

Guidelines for the Celebration of the Sacraments with Persons and Families Considering or Opting for Death by Assisted Suicide or Euthanasia, by the Catholic Bishops of Alberta and the Northwest Territories is a 32-page guide, a vademecum for priests and parishes (2016). It is made very clear in the first sentence of the introduction that although, «death by assisted suicide and euthanasia has been made legal in Canada... These grievous affronts to the dignity of human life from beginning to natural end are never morally justified. The legal permission now granted to these practices does not change the moral law» (2016, p. 2).

The document draw on Catholic moral teaching on this issue, such as Evangelium Vitae (1995) ⁽⁴⁾:

Euthanasia «is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person». Since suicide, objectively speaking, is a gravely immoral act, it follows that «to concur with the intention of another person to commit suicide and to help in carrying it out through so-called ‘assisted suicide’, means to co-operate in, and at times to be the actual perpetrator of, an injustice which can never be excused» (nn.65-66).

Regarding confession, or the sacrament of reconciliation or penance, priests are implored to enter into charitable dialogue with patients considering assisted suicide or euthanasia so that they truly understand how it is a grave moral mistake, and why. They are instructed to proceed with absolution if the patient is at least open to prayerfully discerning that it is gravely morally wrong and that they are open to turning away from that option and to rescinding an already made request for death. Otherwise: they are not open at least to prayerfully considering the rescinding of their request -now that they know it is a grave sin- they would be choosing to do something gravely wrong, that is to say, deciding to remain in a situation of sin rather than seek to amend their life. In this case, the minister would need to delay absolution to a later time when the person may be properly disposed (The Catholic Bishops of Alberta and the Northwest Territories, 2016, p. 6).

Regarding extreme unction, or anointing of the sick, which is usually celebrated after confession, it is urged that priests celebrate this sacrament generously as canon law speaks only of a few circumstances in which it would not be celebrated. One of these circumstances though, is the obstinate persistence in grave sin without contrition and repentance. The refusal to repent, show contrition and to turn away from assisted suicide or euthanasia is an obvious example of such obstinate persistence. According to the document:

The request for euthanasia or assisted suicide is in direct contradiction to the baptismal call of the dying believer to proclaim at all times, especially at the approach of death, that «it is no longer I who live but Christ who lives in me» (Gal. 2: 20). The self-surrendering obedience to the will of the Father in union with Christ is obviously absent from an act which is «gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator» (CCC, 2277). At play may well be an «error of judgment into which one can fall», but it remains impossible to change the nature of this murderous act, which must always be forbidden and excluded» (CCC, 2277). The priest must bear in mind «that he is at once both judge and healer, and that he is constituted by God as a minister of both divine justice and divine mercy, so that he may contribute to the honour of God and the salvation of souls» (Canon 978, 1) (1985) ⁽⁵⁾. This implies the duty to implore the sick person with gentle firmness to turn away from this determination in repentance and trust. If the person, however, remains obstinate, the Anointing cannot be celebrated (The Catholic Bishops of Alberta and the Northwest Territories, 2016, pp. 8-9).

Regarding funerals, this document affirms the Church, as a «generous mother» (p. 10) that offers funerals for sinners. It also considers that family members themselves might have been opposed to the death of their loved one via assisted suicide or euthanasia. Unless the deceased person was notorious for obstinate and persistent sin and scandal, for example, as an advocate or promoter of assisted suicide and euthanasia or if the family wished to use a funeral as a means of justifying and further promoting euthanasia or assisted suicide, a church funeral would be granted. Because burial of the dead is a corporal work of mercy, along with prayers at the graveside and perhaps at the funeral home, the rite of Christian burial would remain an option even when a funeral proper would be gently denied.

A Pastoral Reflection on Medical Assistance in Dying, by the Atlantic Episcopal Assembly (2016; 2018) ⁽⁶, ⁷⁾, differs greatly in both scope and in tone when compared to the earlier release from the bishops in Alberta and the Northwest territories. It is only threeand-a-half pages long, and it offers little practical advice to priests in how they might discern various scenarios vis-à-vis patients opting for assisted suicide and euthanasia. Instead, this episcopal reflection offers an approach that is rooted in the notion of accompaniment stating that, «the example of Jesus shows us that pastoral care takes place in the midst of difficult situations, and that it involves listening closely to those who are suffering and accompanying them on the journey of their life situation» (p. 1).

As a reference point for this emphasis, the Atlantic bishops cite Pope Francis and his emphasis on the «art of accompaniment» (p. 2). The document quotes Pope Francis in Evangelii Gaudium, «the gospel tells us to correct others and to help them to grow on the basis of a recognition of the objective evil of their actions (cf. Mt 18: 15) but without making judgements about their responsibility and culpability» (Mt 7: 1; Lk 6: 37) (Evangelii Gaudium n. 172) (2013) ⁽⁸⁾. The Atlantic bishops assert that Pope Francis, «also calls us to practice this ‘art of accompaniment’, removing our ‘sandals’ before the sacred ground of the other (Ex 3: 5) (Atlantic Episcopal Assembly, 2018, p. 2) ⁽¹⁾.

There are also references to the Catholic Church’s post Vatican II understanding of suicide:

…the Catechism [of the Catholic Church] also notes that «grave psychological disturbances, anguish, or grave fear of hardship, suffering, or torture can diminish the responsibility of the one committing suicide» (CCC, no. 2282) ⁽⁹⁾. Such circumstances can sometimes lead persons to so grave a feeling of desperation and hopelessness that they can no longer see the value in continuing to live, thus diminishing the responsibility for their actions (p. 2).

Regarding the provision of the sacraments, there is an acknowledgement that some patients will be «resolutely determined» (p. 3) to make a «determined choice» (p. 3) for assisted suicide or euthanasia, rendering it impossible for them to be celebrated, yet the overall call is for a robust pastoral approach rooted in accompaniment:

In the pastoral care of those who are contemplating euthanasia or assisted suicide, we must remember that the purpose of pastoral care is to communicate the compassion of Christ, His healing love, His mercy and the sacredness of life even in weakness. (p. 3)

Again, there is another reference to the Catechism regarding suicide:

In the accompaniment of a person in an end of life situation, these are the dispositions to be discerned. It is helpful to keep in mind what the Catechism also states, specifically about suicide, that «we should not despair of the eternal salvation of persons who have taken their own lives. By ways known to Him alone, God can provide the opportunity for salutary repentance (p. 3).

Critique of this document and of the Atlantic Episcopal Assembly’s approach was swift and blunt. Fr. Raymond J. de Souza wrote an opinion piece titled, Atlantic bishops’ reflection on assisted suicide fails in its approach (2016) ⁽¹⁰⁾, and Douglas Farrow wrote an essay in First Things with separate titles for the online and print formats, respectively, Discernment of Situation (2017) ⁽¹¹⁾ and To Hell with Accompaniment (2017) ⁽¹²⁾.

The concern in this paper is the concept of suicide relativism. From the Supreme Court of Canada to the court of public opinion and even within episcopal assemblies of Canadian bishops, there are enough variations of opinions regarding assisted suicide and euthanasia. This can sometimes lead to dealing with this issue morally by incorporating relativism.

On moral relativism, St. John Paul II stated in Veritatis Splendor (no. 32) (1993) ⁽¹³⁾:

As is immediately evident, the crisis of truth is not unconnected with this development. Once the idea of a universal truth about the good, knowable by human reason, is lost, inevitably the notion of conscience also changes. Conscience is no longer considered in its primordial reality as an act of a person’s intelligence, the function of which is to apply the universal knowledge of the good in a specific situation and thus to express a judgment about the right conduct to be chosen here and now. Instead, there is a tendency to grant to the individual conscience the prerogative of independently determining the criteria of good and evil and then acting accordingly. Such an outlook is quite congenial to an individualist ethic, wherein each individual is faced with his own truth, different from the truth of others. Taken to its extreme consequences, this individualism leads to a denial of the very idea of human nature.

Again (Veritatis Splendor, no. 80):

…the Church teaches that «there exist acts which per se and in themselves, independently of circumstances, are always seriously wrong by reason of their object». The Second Vatican Council itself, in discussing the respect due to the human person, gives a number of examples of such acts: «Whatever is hostile to life itself, such as any kind of homicide, genocide, abortion, euthanasia and voluntary suicide; whatever violates the integrity of the human person... all these and the like are a disgrace, and so long as they infect human civilization they contaminate those who inflict them more than those who suffer injustice, and they are a negation of the honour due to the Creator».

In his well-known homily, His Eminence Joseph Cardinal Ratzinger, then Dean of the College of Cardinals, at the Mass Pro eligendo Romano Pontifice (2005), which opened the conclave after the death of John Paul II, stated:

Today, having a clear faith based on the Creed of the Church is often labeled as fundamentalism. Whereas relativism, that is, letting oneself be «tossed here and there, carried about by every wind of doctrine», seems the only attitude that can cope with modern times. We are building a dictatorship of relativism that does not recognize anything as definitive and whose ultimate goal consists solely of one’s own ego and desires.

The nature of assisted suicide and euthanasia itself contains an individualism that is rooted in a denial of the very idea of human nature (Veritatis Splendor, 32) (1993), as understood by two millennia of Catholic thought and centuries of Hippocratic medicine. A sense of personal autonomy and a profound notion of patient autonomy under suicide relativism has grown, in a very short period, to the extent that the rights of physicians and healthcare workers to exercise conscientious objection have been curtailed in some jurisdictions in Canada.

In Ontario, for example, to be licensed to practicise medicine under the College of Physicians and Surgeons (CPSO), physicians are obliged to «facilitate» a patient’s request for assisted suicide or euthanasia, such as by providing an «effective referral» to a colleague who is willing to engage in MAID if they themselves will not do this. Such a referral, however, compromises the moral integrity of physicians who hold that assisted suicide and euthanasia are moral evils because facilitating a patient’s access to MAID is material cooperation with a practice that is wrong for anyone to engage in. The judgment of the Ontario Court of Appeal that upheld the CPSO’s policy went as far as to suggest that physicians could «abandon their practice area» if they did not wish to be prosecuted for heeding their moral conscience. The court acknowledged that requiring physicians either to provide effective referrals for MAID or change their area of practice does infringe on freedom of religion for those who oppose this practice on religious grounds but, in this case, the Court ruled that such a policy was justified to promote equal access of all to a legal health service (Christian Medical and Dental Society (CMDS) v. College of Physicians and Surgeons of Ontario (CPSO), para. 79) ⁽¹⁴⁾.

Among Canadian bioethicists also, there is support for this perspective. For example, bioethicist Udo Schuklenk has publicly expressed his view that, in Canada, «Medical schools, pharmacy schools should go out of their way to basically eliminate applicants who they know already will not provide these services» (Browne, 2019) ⁽¹⁵⁾. Another bioethicist and legal scholar, Jocelyn Downie, has stated that «Governments and health authorities have failed to insist that faith-influenced, publicly funded institutions permit MAID within their walls» (Lord and Quon, 2019).

Thus, what I have been calling suicide relativism pervades in Canada from the highest legal authorities in the country to many advocates within the bioethics community. This relativism, however, seems not to be logically consistent or just. In the name of advancing freedom for some individuals to decide whether they will request medical assistance to kill themselves or have themselves killed, based on their personal views that this is ethically justified, the freedom of other individuals not to be complicit in these decisions has been restricted.

Although the Catholic bishops of Canada are united in their view that assisted suicide and euthanasia, objectively, is a moral evil, they are divided on the pastoral response to Catholics who both request assisted suicide or euthanasia and spiritual care at their chosen end of life. Regrettably, in my view, this moral ambiguity results in unclarity regarding the moral status of assisted suicide and euthanasia and serves to advance what I have called suicide relativism among some Catholic lay persons also.