Since Canada’s parliament approved the practice of physician-assisted death — known in Canada as medical assistance in dying, or “MAiD” — the number of Canadians opting to die by lethal injection has grown to surpass deaths from Alzheimer’s and diabetes combined, according to The Atlantic. The magazine reports that physician-assisted death now accounts for 1 in 20 deaths in Canada. 

Ewan Goligher is a medical doctor and associate professor of medicine at the University of Toronto. He is also a devout Christian and ruling elder at Christ Church Toronto (PCA), and his theological commitments sometimes conflict with how Canada defines a doctor’s duty. Goligher is the author of “How Should We Then Die? A Christian Response to Physician-Assisted Death.” He spoke with byFaith about being a conscientious objector, maintaining warm working relationships with physicians with whom he disagrees, and helping people value life. This conversation has been edited for length and clarity.

You are a medical doctor, but you’re also a professor. How much time do you spend practicing and treating patients, and how much time do you spend teaching? 

I’m what’s called a “physician scientist,” so about 20% of my time is allocated to looking after patients, which is about 12 weeks a year in the ICU. The rest of my time I run a research program where we’re testing different treatments for respiratory failure in clinical trials, and also investigating mechanisms of lung and breathing muscle injury in patients with respiratory failure. I spend most of my time on research, more than actually looking after patients. But typically, when people are working in the ICU, they don’t do more than 14 or 15 weeks a year anyway, because it’s fairly demanding. My clinical workload is not much less than what would be typical for other ICU doctors. 

What made you want to begin speaking and writing in opposition to medical assistance in dying?

I was not particularly engaged in medical ethics up until 2014 because most ethical controversies or conflicts in medicine hadn’t really touched the area of medicine I was interested in practicing. But as an ICU physician caring for many patients at or near the end of life, when it became apparent that there was rising public support for the legalization of euthanasia, and euthanasia was going to be legalized by the Supreme Court, I started to recognize that I was going to have to grapple with this issue. I anticipated that it was probably going to come up in conversations with patients or families in the intensive care unit.

I happen to be good friends with one of the people who is a nationally prominent advocate of physician-assisted death. We had a very close friendship and differed pretty strongly on this issue. But we ended up writing about it together, and the friendship became the occasion for a lot of dialogue back and forth about the issue with him and with others. I became more and more involved in speaking and writing about the issue, so someone suggested I write a book. Doing so forced me to reflect more broadly on how we as Christians should communicate our moral commitments in a pluralistic society and on the fundamental reasons why we as Christians should oppose assisted death.

Through the whole process, I learned and grew a lot in my theological understanding around issues in medical ethics.

I’m curious about that relationship with the doctor who has been an advocate of medical assistance in death. Are there ways that friendship has impacted your tone and your posture toward this whole subject matter? 

Unquestionably yes, because I know people who support euthanasia and even people who perform it, and I know them personally. I can see that they genuinely believe that they’re acting in the best interests of the patient. For them, they’re motivated by a desire to do good, even if it’s deeply misguided. And when you know people personally and know that they are doing their best to grapple with the problem of suffering in a world where they don’t see meaning in suffering, then you understand that behind the evil action there is a heart that desires to somehow respond to the human predicament. That helps to bring the temperature down a little bit, although as time goes on, I also get more and more grieved by the expansion of the practice. As assisted death in Canada becomes more and more obviously grievous and problematic,it gets harder to maintain a respectful attitude. But it’s much harder to have a harsh tone when you’re dealing with people directly and personally.

Certainly, there’s a place for a very clear, strong, prophetic speech rebuking these practices. But also there needs to be a way to let people come back. If they get involved in this and they’re doing it, how do we give them space to change their minds and repent and come back? Keeping a respectful tone is about trying to create room for that.

Compared to the United States, Canada appears to be less accommodating toward religious objections. Has that been your experience? How do you navigate that? 

In general, Canadian society, despite its purported claim to be a very tolerant society, is much more intolerant of conscientious objection in the context of medical practice. Some of that has to do with the fact that because medicine is publicly funded, many assume that medicine is owned by the state and therefore it’s the Canadian public that decides what’s right for doctors to do. There’s less of a sense of professional autonomy. We can have a whole separate conversation about the right way to organize the relationship between medicine and society, but I think this is part of the explanation for the attitude toward conscientious objection. Canada generally sits further to the left on the political spectrum compared to the United States. 

Another issue is that euthanasia was decided by the Supreme Court of Canada as a matter of charter rights. When issues like assisted death or abortion are legalized through judicial fiat rather than through a legislative process, there is less likely to be space for conscientious objection, because it’s seen as a matter of individual rights. That makes it much harder to stand up and say “no” to something. 

By contrast, in the U.S., when assisted death has been legalized, it often happens through state-level legislative decisions where legislators are able to build in more protection for individual conscience.

Are there ways that your arguments have changed as you have seen such a dramatic uptick in the number of people choosing physician-assisted death?

I wouldn’t say that my arguments have changed substantially. From very early on, I was very focused on the question of the rightness or wrongness of killing itself, whereas many other focused more on the consequences of legalization, and concerns about the slippery slope where it is expanded over time to more and more groups — which is, of course, exactly what we’ve seen. 

There’s very real legitimacy in that argument against euthanasia based on social consequences, but the truth is that if you live in a culture where people who are otherwise wealthy, autonomous, and in control of their lives — not members of more marginalized or vulnerable communities — and those are the people saying, “I want the freedom to have my life ended,” it’s very hard to say, “We can’t do that for you because of theoretical concerns about a slippery slope for others.” That argument is not going to have a lot of traction for them personally. We need to be able to tell that highly empowered person why it’s wrong for them to have assisted death as well. 

We have to get at the root issue, which is a fundamental devaluation of the sacredness of persons, and unless and until we get to the root issue, which is really a gospel issue, we won’t effectively change hearts and minds about assisted death. What you’re seeing, with the rapid rise in assisted death, is the normalization of therapeutic death in a society that sees people as fundamentally disposable. We live in a culture that is genuinely afraid of suffering and doesn’t know how to respond to it, make sense of it, or see how a life with suffering could somehow be worthwhile or significant. 

These are deaths of despair, and they’re not just deaths of people with chronic disability. That’s thankfully pretty rare, although it’s growing. But it’s your friends, your loved ones who just see no point in going through the natural journey toward natural death. And we have to recognize dying is not easy. We can do a great job of caring for people, managing their symptoms and controlling their pain, but even so, there’s real suffering in the dying process. 

There’s a sense that death is genuinely tragic and evil, and if you don’t have the gospel to understand that ultimate victory is possible in the face of suffering, then just having yourself ended in the manner and time of your own choosing makes total sense. And that’s what you see in Canada, and that’s why I felt like I needed to respond to it and write about it. 

I wanted to ask you about your book. You’ve written “How Then Should We Die? A Christian Response to Physician Assistant Death.” Who are you hoping to engage with your book? 

I primarily wrote the book for my Christian brothers and sisters, to give them language to talk to their friends and neighbors about why assisted death is wrong. One of the really hard parts, especially if you’re in healthcare, is to have a kind of elevator pitch to tell people why you’re against this. 

An increasingly important part of being a Christian in contemporary culture is recognizing and responding to the fact that people don’t accept our assumptions about morality. And appealing to book, chapter, and verse in Scripture carries no weight for many of the secular friends and colleagues that we interact with. We need to have ways to explain to people why these things are wrong that genuinely reflect on our fundamental theological understanding of who God is and who man is in God’s sight. Our arguments need to connect with the ideas and truths that our friends and neighbors already have embedded in their hearts by virtue of being made in God’s image. 

The purpose of the book was to try and help people think through, how do I talk about this? How do I understand the issue myself? What are the relevant issues? How do I distinguish between traditionally accepted practices in caring for the dying, like palliative care and withdrawing life support, versus this new practice of euthanasia? I wanted to help Christians cultivate discernment about these questions.

Mainly, I wanted to give people reasons and language to explain why we’re against this, so that they could communicate it effectively to others. That was the main goal of the book. 

Are there ways that you’re teaching practice and your hospital work have been impacted by your position on medically-assisted death? 

Ontario is one of the few jurisdictions in the world that requires objectors to make a referral to a willing practitioner. And as a physician, making a referral makes me responsible and culpable for what happens to the patient in the care of the physician I send them to. Making a referral for euthanasia would make me morally complicit in the act of euthanasia. 

Christian physicians in Ontario and across the country sued the College of Physicians in Ontario to say, “This is a fundamental violation of our charter right of freedom of religion and conscience.” We lost the case and then lost on appeal as well. And so at present there’s not any real legal protection for freedom of conscience around this issue in Ontario. Some physicians have had to change their practice environment. Some have retired early. Some have transitioned away from caring for dying patients because they were getting requests for assisted death and couldn’t live with the choice between the risk of professional discipline and the loss of conscientious integrity. 

Many of us have found ways to navigate this so that we don’t have to make a direct or effective referral. We’re largely dependent on the goodwill of colleagues to be faithful to our consciences. 

But reflecting on these matters has reinforced in my mind the profound value of the patients in my care. As Christians, we have a very high view of the dignity of the patient and a very high view of the value of the human body. These notions have fundamentally shaped how medicine is practiced over many centuries. 

Are there ways that you feel like you’ve been supported by your church? 

I’ve been very grateful for the engagement and concern that the pastors at my PCA church have shown. As Reformed Christians, we have a rich understanding of the relationship between nature and grace, and that moves us to care about these real-world issues. I’ve seen pastors in my church and in other PCA churches care about this issue, speak about it, and educate their congregations about it, and that’s been really encouraging. 

As frail humans, we’re very dependent on others to feel and to remember the true magnitude of our own value. When you’re weak, suffering, disabled, or in decline, if you don’t have people sitting at your side saying in word and deed, “I love you. I’m so glad you’re here,” you’re very inclined to doubt your own value. 

Historically, the medical profession has been a kind of bulwark upholding human value. One of the significant things about the Hippocratic tradition of refusing to be involved in the death of a patient is that in doing so, you are asserting and reminding the patient how much they matter, despite their suffering and disability. 

Tragically, doctors are now saying, “Well, it’s your choice. Nobody’s going to tell you whether you should live or die.” Failing to speak up in support of the patient and remind the patient how much they matter, tacitly invites the patient to choose death. And that’s what we see happening. It’s subtle, but it’s real. 

And this is where churches have a profound role to play. By creating communities where people can see and hear and feel their value through the means of grace and through Christian fellowship and Christian love, we create a powerful bulwark to prevent people from wanting to seek death at the hand of their doctor.