 Welcome. Good evening and welcome to the Shulik School of Law. We're delighted that you're able to join us this evening for the inaugural Sir Graham Day Ethics Morality and Law Lecture. I'm gonna get started with a few words about Sir Graham Day, who is right here, and then a few words about the format for tonight's event before handing it off. So Sir Graham Day, he is a business executive, lawyer, and corporate director. He was chair and CEO of British Shipbuilders from 1983 to 86, chair and CEO of the Rover Group from 86 until 91. He has served as chair of British Aerospace, Power Gen, and Cadbury Shwepps. Sir Graham has been knighted by the Queen and inducted into the Canadian Business Hall of Fame, and he has been appointed a member of the Order of Nova Scotia and officer of the Order of Canada. Closer to home, I would note that he is now counsel to Stuart McKelvie, and he calls hand sport Nova Scotia home. His many Dalhousie connections include the fact that he graduated from this very law school in 1959, was chancellor of Dalhousie from 1994 to 2001. He taught in our business school, and he holds an honorary degree from Dal. He does however tear himself away from Nova Scotia at least once a year when he heads on down south to Florida to pursue his passion for baseball by watching the Blue Jays spring training. Sir Graham Day is well recognized for his thoughtful advice, his careful counsel, and his generosity, and that brings us to tonight and the inaugural Sir Graham Day Ethics Morality and the Law lecture. This series honors the Sir Graham Day spirit. It is designed to advance our understanding of ethics within the legal profession and in society as a whole, and so we turn our attention to a topic that is squarely at the intersection of ethics, morality, and the law, assisted dying. But first a quick word about format. This evening we're delighted to be collaborating with the CBC radio show Ideas with Paul Kennedy. They will be recording throughout and will use that recording along with other interviews conducted around tonight's lecture to produce a show that will be aired in the new year. And even more significant for all of us who are here now, Paul Kennedy, who is well known to all of you fans of Ideas, will be hosting tonight. Paul will do the honors of introducing Peter Singer. Peter will speak for 30 to 45 minutes and then we'll have lots of time for discussion. Paul will moderate that discussion period. We'll have microphones available as you see here and here so that when Paul opens up the floor you'll be able to ask your questions directly to Peter. Speaking to the overflow room, if you are in the overflow room, there aren't microphones there obviously, you can pop over and ask your question and then we'll have to send you popping back because we are super overcrowded in here right now. But you don't feel you can't come and ask a question. If you are asking questions, given the number of people who are here tonight, we would request that you keep your questions as succinct as possible. It's not an opportunity for speeches, but rather an opportunity to ask Peter Singer something burning in your mind. A quick note now, please everyone, check your phones. Check that your phones are off. This is recording that will destroy the recordings and also more importantly actually it will break the feel of the evening. So please turn those, please turn those off. With that done without further ado, turn you over to Paul Kennedy. Thanks Jocelyn. Can I say from the get-go that it's always a great pleasure for me to come to Halifax, even when the city throws the kind of weather that many Canadians consider to be quintessentially Haligonian like it has this evening. And I think it's also an indication of how interested you all are in Peter Singer that you've come out in such weather. This is a special evening for other reasons as well. It begins a partnership between the Shulik School of Law and ideas that I hope will continue for some time. First dates are always sort of difficult and tricky and hard to predict where the relationship might go. But from the turnout tonight and the obvious interest in this topic, I think I can predict a very successful relationship for I hope what will be a very, very long time. The third reason I'm very excited to be here today is because Peter Singer will be introducing this, he'll be inaugurating this lecture series and that's obviously something that brought out a large crowd. Peter Singer is a very special man. I met him only this afternoon for the first time. I don't think there are any other living philosophers who have received death sentences for the things that they've written and the philosophies they espouse and that's true of Peter Singer. Given the topic of this evening's lecture, that could be considered somewhat ironic but I think you will enjoy and find this very stimulating as it goes along here. Professor Singer is an antipodian professor. He holds very distinguished chairs at two of the most prestigious universities on the planet that would be Princeton and Melbourne. He's the author or the editor of more than 40 books and I'll just mention three that are really important, Animal Liberation, Practical Ethics and then the third one which is quite significantly connected to the topic of tonight's lecture, Rethinking Life and Death. As I said, I had the opportunity of speaking with him this afternoon. First time I met him, that will be part of the eventual ideas program which will be assembled with parts of this lecture and parts of that conversation. I learned during that conversation this afternoon that you are about to hear a very stimulating, very exciting, very challenging and I think very brilliant lecture. Please welcome Peter Skitter. Thank you very much for that welcome. I want to thank Jocelyn and everyone connected with this lecture for having invited me here. It's an honor to give the inaugural Sir Graham Day lecture and it's particularly significant I think to be here in Canada talking about this topic at a time when the whole nation is making important decisions in this area. This is I think a particular part of a broader ethical shift in our thinking about life and death and that's a really important change, a historical change and I'd like to say a little bit about that before I get to the more specific questions of assisted death that we'll focus on for the majority of what I'm going to say. But just to put it in context, we're coming out of a 2000 year history in which essentially the dominant ideas about life and death have come from the religious teachings associated with Christianity and those teachings have been that life is sacrosanct. We talk about the doctrine of the sanctity of human life and that it is always wrong intentionally to take the life of an innocent human being. Now I'm not saying of course that that ethic has actually been honored and fulfilled in every respect, it clearly hasn't, but it's nevertheless been the official position and it's on that basis that our ethics was formed and essentially lasted well into the 20th century. Part of that ethic I suppose was the idea that the decisions about when someone dies are not decisions for us to take, they are decisions for God to take. I suppose the religious view was, it was sometimes said for example that to end one's own life was to be like a soldier in an army deserting your post, the image being that we're all part of God's army in the world and it's only up to the commander in chief to tell us when it's time to leave our post and when it's not. And associated with that were a number of other specifically religious doctrines. One of course was the idea that we are made in the image of God and this makes us special and particularly precious. And another is the idea that we have immortal souls, so that you would think in a way that would make death less significant rather than more significant. The idea that it's simply as people say a passing into a different realm and indeed a more important and of course eternal realm. But in fact it seemed that that made the decision more momentous, made more hang upon it and made people feel that it was not a decision for them to take. So that after all according to Christian teaching it was the standing that you were in, whether you're in a state of grace or not at the time of death or some specific Catholic views, whether you had had confession and received absolution and so on, that would determine your immortal fate. So if you think of it in those terms, to make that decision becomes more significant because you might have acted and killed somebody when they were not in a state of grace and then they will roast in hell forever, whereas if only they had lived a little longer they would have seen the error of their ways, they would have repented and they would have had eternal salvation. So these religious reasons I think gave a particular weight to decisions about when to die and emphasis the prohibition on taking innocent human life. But there's one other thing that I want to point out about that though I'm not going to go into it in any depth now and that is that this doctrine draws a very sharp distinction between human beings and other species, non-human animals essentially. Because we alone are made in the image of God, we alone have immortal souls. And so these strictures about the wrongness of taking human life are specifically for human life. They do not apply to non-human animals and of course the practice is simply to kill them when convenient basically including if you want to eat them or if you find them to be pests or a nuisance or even for sport, for amusement. So their lives may be taken very lightly but the lives of humans of course as I've said cannot and this does not depend on ideas that we are rational, more rational than they are or that we are autonomous beings and they are not. These are things that did come later in western philosophy so you could say they're present in the ethics of Immanuel Kant at the end of the 18th century certainly there's an emphasis there on our rationality and autonomy and the idea that therefore humans alone are ends in themselves and animals are merely a means to our end. But clearly you know you find that in the Christian teachings beforehand and it is based much more on these particular religious doctrines of us being made in the image of God and having immortal souls and so on and the animals not and therefore even when humans did not were not rational manifestly not rational or autonomous and none of us were born rational or autonomous and others unfortunately because of irreversible mental disabilities brain damage or something that sort may never become rational or autonomous nevertheless it was every human life that is supposed to be sacrosanct and superior to that of all of the non-human animals. So we're seeing interesting shifts across all of this area now we're seeing I think clearly a reevaluation of our attitudes to animals in various ways and a questioning of the sharpness of the divide in ethics between humans and non-human animals. We're also seeing a reevaluation of questions about the sanctity of human life one of the reasons for that is the advance of medical technology. Medical technology has made it possible for us to keep human beings alive where previously they would have died and in some cases that has led us to ask whether it is indeed worth doing that. The most dramatic of these cases was the development of the respirator sometimes also called a ventilator which can keep somebody breathing keep the heart beating keep the blood flowing even when the brain has irreversibly ceased to function. So when respirators began to be used in the 1950s it was found of course that they were very valuable for somebody who was in a temporary state where they might have stopped breathing and the heart might have stopped beating and they might have died but they had good prospects of recovery. But sometimes it turned out that people did not have good prospects of recovery that their brain was irreversibly damaged indeed irreversibly had stopped functioning and that this could be demonstrated by various clinical tests and yet the respirator could keep the hearts beating and the bodies functioning. So doctors then said well what are we going to do now are we going to fill up our intensive care wards with patients who have no hope of any recovery of consciousness whatsoever but whose hearts are beating breathing bodies are still warm and that question hung around for a little while no one did very much to it about it until Dr. Christian Barnard in South Africa performed the world's first heart transplant and that led people to realize that these people whose brains were no longer functioning could in fact be used to save the lives of other people who had prospects of longer survival. Christian Barnard's first patients didn't survive very long but it was clearly a new technique that offered promise of longer term survival. So what happened from that time on and we can be fairly clearly documented in the files at Harvard University Harvard Medical School set up a committee to examine the definition of death and recommended that these patients whose brains had stopped functioning should be considered dead and then you simultaneously solved the problem of keeping them in your wards you don't have to keep dead patients in your wards and you opened up a source of organs for transplantation. Now you couldn't just have said let's use the hearts of these living patients to help other patients who will otherwise die because the other patients have better prospects because that would have directly challenged the idea that you were killing an innocent human being. You can't say no I'm not killing them I'm just cutting out their heart and giving it to someone else. So that was why that problem was essentially solved by a redefinition of death. It was not a scientific discovery that when your brain is ceased to function you're dead. It was a decision that we are going to call these people dead and that will have very useful consequences. Now of course there was a value underlying that and I think the value is a sad one and that is that the lives of these patients were really of no further use to them because they could never recover consciousness and they were taking up resources and their hearts could be useful to other patients. But as I said couldn't be presented that way but gradually other medical technologies did force us to consider this question. So then we had patients who were clearly not brain dead but who were in a persistent vegetative state the famous case of Karen Ann Quinlan in New Jersey in the 70s and we had decisions then we said well we don't have an obligation to keep them alive to use extraordinary means of life support to put them on a respirator and so we've had a debate about that but I think clearly underlying that debate although I know that there are people who would not accept this interpretation of it underlying that debate is a judgment that the life of someone in a persistent vegetative state is not really worth preserving once you've reached the conclusion that they have no hope of recovery of consciousness. So we started to reevaluate this question and I would say that began a movement from questions about the sanctity of life to questions about the quality of life and the question is there a minimal quality that somebody has to have for their life to be worth preserving. Now these are fairly baseline cases obviously either if your brain is irreversibly cease to function altogether or if you've irreversibly lost the capacity for consciousness as in a persistent vegetative state you can't be consulted you might have written a living will beforehand you could consult that but most people don't some of the Karen Ann Quinlan was a young woman who certainly had not written a living will there and so you couldn't consult the wishes so essentially you had to make a judgment for those patients and I think it's it's those judgments in those cases also in the case of of infants newborns born with severe disabilities sometimes for example infants born very extremely premature have massive bleeding in the brain brain hemorrhages and the prognosis is very poor that they will have a life that is meaningful and doctors will then go to patients and parents sorry and say so what would you have us do we could we could continue to treat your child there's a reasonable chance that he will come through and we will be able to discharge him and send him home with you and he may live for many years but he's unlikely ever to be able to live independently perhaps unlikely ever to be able even to feed himself perhaps this will depend on the severity of the bleeding and we can get images of that perhaps unlikely even to be responsive to you his parents and very often parents will say well if that's the what we're expecting then I think it's better not to continue to try to keep my child alive to let the child die so again I think we're really making a quality of life judgment when we do that one forced upon us by the technology that we have which earlier generations never had to make because people with those sorts of injuries would in any case have died rapidly and I think they rain they raise a lot of quite difficult issues about how you make those judgments who should be involved in the judgments what kind of quality of life is is sufficient and we may have a little time to discuss some of those questions but they've also provided the context for decisions that I think are now being made in a number of countries in a number of jurisdictions and also as I was saying here in Canada for what is really an easier ethical decision to make and that is cases where people are competent to make their own decisions about their own lives and to express a wish about whether they think the quality of their life is adequate or not for continuing so these are cases obviously of assisted dying sometimes physician assisted suicide where a physician writes a prescription on request from the patient which the patient can take to end his or her life sometimes voluntary use in Asia where a doctor can give a lethal injection to a patient and these are questions which have been coming up now for for quite some time and I think it's very understandable that they do because we have different things coming together on the one hand we have the line of thought that I was talking about before that says there are qualities of life that are not worth living there is the erosion as I said of the idea of the sanctity that all human life is sacrosanct that it's always wrong intentionally to take an innocent human life and that may have something to do with the loosening of religious bonds and the decline at least in many countries of the influence of religious teachings and we have that coming together with a strong idea of individual autonomy and more specifically in this case the autonomy of patients so I want to talk a little bit about autonomy for a moment it's it's in a way a separate tradition from specifically the medical one we can perhaps best trace it back to John Stuart Mills famous essay on liberty in which he wrote that the purpose of the essay that he was writing was to put forward the principle that the state should not intervene with the individual for the individual's own good whether physical or moral but that the only justification for the state to interfere with the individual was to prevent harm to others now I think that's a powerful principle in a liberal state in a state which sees limits on what governments ought to be doing I think over the years we've come to see it not as an absolute principle that there are cases where the state may be justified in interfering with individuals for example where otherwise they would be careless about things that are important and I think the prime example of that which pretty much we all accept I imagine many of you drove here I suppose you fastened your seatbelts when you did so and I think I take it that here as in most jurisdictions there is a law requiring you to do that perhaps a law that is not very often enforced but nevertheless you can be penalized and be fine if you don't do that why do we have that that's clearly an example of paternalism I think it's very difficult to defend on that that you would be harming others some people might say well you have a national health service so you would be imposing costs on others if you're injured the state has to fix you up well I think you know if you were serious about avoiding restrictions on liberty you could get people to go to the police station to sign a document that they waive the right to treatment or perhaps that they will pay a small extra insurance premium to cover their treatment and then they don't have to wear a seatbelt but we don't we don't really bother to make that allowance because we think this is a trivial infringement of liberty and we also think that it's something where people generally are not the best guardians of their own interests because we're not good at doing things which will reduce cases that reduce risks which are already quite small make them much smaller maybe even eliminate those risks even when the costs of doing so are quite small and even when the benefits of doing so in the rare cases where the risk occurs the benefits would be great so I would not oppose that type of legislation on million liberal grounds but I do think there are many other cases where we've regarded this principle as an important one it was initially I think important in the movement to decriminalize sexual relations between people of the same sex or in the way the laws were actually cast generally it was between between men and there was certainly a time if I think about the text that I studied when I was an undergraduate when the assumption was that this was immoral conduct but nevertheless liberals defended the idea that it should not be criminal conduct on the grounds that the state should not be enforcing morality Herbert Hart wrote a famous essay on this law liberty and morality the state should not be enforcing morality and if people wanted to do what was immoral as long as they were consenting adults and it didn't harm anyone else the state should allow them to do it I think today most people would say it's not in any way immoral conduct at all so we don't really even have to worry about this question of enforcing morality but it was significant at the time but now I think we have these this other case which can certainly we can see the change in laws that we're talking about on the basis of respect for individual autonomy and a rejection of the state's justification for interfering with acts again really between consenting adults but in this case an adult patient and his or her doctor so we can say if an adult patient of San mind decides that he or she does not wish to live longer then and the doctor is willing to provide assistance in dying should the state interfere with that at all so that's the autonomy case for changing the law to allow assistance in dying or voluntary euthanasia some people are not comfortable with that because they think well people may be just in a temporary state and this is after all a very irreversible decision that you're making people may be in a temporary state in which they're unhappy with their life so an example is often put up is somebody perhaps a very young person perhaps even a teenager has had an unhappy breakup to their love relationship and they're they're very unhappy now and they think without that person I don't want to go on my life is not worth living well we we wouldn't want if that person would go to a doctor and say help me end my life we wouldn't want the doctor to say okay fine we would want to say well you know wait a minute think about this you know I've known lots of cases like this it's not a unique experience and you will recover you will start to feel that life is worth living again so I think we could reasonably introduce some other conditions on this rather than the pure autonomy criterion we could say well there has to be some kind of objective underlying condition which we believe is not likely to change in the near future to justify the physician in helping you with this situation and the most obvious such condition of course is that the patient is terminally ill that the doctor or perhaps after calling in a colleague doctors determine that the patient does not have long to live and is not going to recover from the condition which is causing the quality of life to be one that is unacceptable to the patient so when that's the case then I think you can be confident that the patient is not making a mistake there's no temporary condition from which the patient will recover so you have a combination of the principle of autonomy and the idea that the quality of life has sunk to a level that is not acceptable and who better to judge that than the patient provided as I say that the patient is of sad mind competent not suffering from a merely temporary and treatable depression so that's the kind of thought I believe that has those two streams of thought have come together to lead in some jurisdictions to the legalization of physician assistance in dying either as in as generally in Europe in the Netherlands in Belgium in Luxembourg either where doctors can give a patient a lethal injection voluntary euthanasia or as in the United States in the jurisdictions of Oregon and Washington and now more recently Vermont and by a judicial decision in Montana or by a physician writing a prescription that on request of the patient and again under certain conditions after consulting another colleague determining the patient's condition is terminal and so on that will that the patient can take and that will end the patient's life so this is a movement I think is is clearly spreading as I say the most recent example in is Vermont and I should mention also Switzerland which has also physician assisted dying in a way the exception to the European model because the other European nations that have this allow voluntary euthanasia Switzerland does not so it's spreading it seems to be spreading and of course Canada is really now at the next country at the crux of this issue for two separate reasons that are happening more or less simultaneously the case of Carter versus Canada which occurred in British Columbia in which a patient Gloria Taylor asked for physician assistants in dying claiming that the prohibition of this was denying her rights under the Charter and I'm not going to speak about that being in a Canadian law school and being neither a lawyer nor Canadian but what I can say is that I've read the judgment of judge judge Lynn Smith in this case and she reviewed the evidence with extreme thoroughness I mean there was a real procession of international experts brought into the courtroom to provide evidence because in the judge's view the case depended on whether it was necessary to have this prohibition of physician assisted suicide in order to protect vulnerable populations from being exploited so if it could be shown so I'm sure a very brief summary of the judge's reasoning but if it could be shown that there was a less restrictive prohibitry regime one that would allow the plaintiff in this case to have the assistance of a physician to end her life that nevertheless protected vulnerable patients that would be what the get what what the government ought to do and anything above and beyond that would be a violation of the plaintiff's rights so that was why all that evidence was necessary and I think it's reads well as a summary of the evidence and the judge's verdict that indeed it showed that there were other regimes in the world including the Netherlands and Belgium and Oregon that had such systems and that indeed the vulnerable were protected and that there was no evidence of systematic abuse or as is often said of a slippery slope where once you legalize physician assisted suicide or voluntary euthanasia you find that the killing spreads and it was certainly suggested when the Netherlands was the first country to to go down this path so it was certainly suggested when voluntary euthanasia began to be openly practiced in the Netherlands that that this would broaden and indeed that would broaden people often referred to to the Nazi Holocaust as being at the bottom of the slippery slope so it wasn't just that would broaden in small ways as to what counted as an incurable condition or an intolerable condition because the Netherlands never required that the condition be terminal but just that it should be incurable and for the patient intolerable and that this would lead to the killing of people who were a burden on the state or were considered undesirable in in some other way well we have now a lot of experience of legalized voluntary euthanasia or physician assisted suicide we have as I say in the Netherlands began to be openly practiced not you could say fully legalized but after court decisions there were public announcements from the prosecutor's office that doctors who carried out voluntary euthanasia on the patient's request would not be prosecuted if they complied with a set of conditions that had been agreed to by the Royal Dutch Medical Association so so it was openly practiced from the early 1980s so we have more than 30 years of experience there it was legalized in Oregon physician assisted suicide was legalized in Oregon 17 years ago so we have 17 years of experience there and we have shorter periods in Belgium and Washington and Switzerland so I think we now have good evidence that there is no real slippery slope that there is no danger of this kind of wide expansion certainly in the Netherlands there've been further discussions of boundaries of people who are very old and just say they're tired of life although they have no real medical condition in a strict sense should such people be helped that that's a debate that is going on in in the Netherlands and I think it's a reasonable thing to debate in Belgium there being debates about the age at which you can express a competent wish to die and the law was changed quite recently to allow minors to also request voluntary euthanasia depending exactly on the age of the minor the the younger ones must have their parents consent to that but otherwise I think you can be regarded as as competent I think perhaps at 16 so you know again where doctors have said that there is a terminal or incurable condition so I'm not saying that there hasn't been further discussion about possible extensions but I am saying that what you might regard as an uncontrolled or dangerous slippery slope leading to abuse does not seem to have happened so for the reasons that I've given I think that this is a welcome development and I think we are now at the stage where we are seeing other jurisdictions moving forward as we saw in the United States with Vermont there's a lot of debate in a number of other countries about this question and I think that the other thing I should mention of course is that is that here so you sure you're aware that Quebec legislature has has voted to legalize a voluntary euthanasia for citizens of Quebec there's a question as to whether that is compatible with the federal criminal code and that no doubt will also be decided in the Supreme Court as will the final verdict on the British Columbia case I mentioned the Carter versus Canada case so there are there are different ways in which Canada is going to make important decisions on this and that I'm sure will have a further influence on other countries it will would clearly have an effect on the United States particularly those states which are if you like a little more like Canada than some others I think you're rather unlike for example states in the deep South which I don't see as legalizing voluntary euthanasia or physician assisted suicide for some time but you're probably well you are more like the states in the Northwest which have already legalized this Oregon and Washington and Montana perhaps but other states I think in in the Northeast as well would move to do so would be influenced to do so if Canada would decide and my own native country of Australia I think as another Commonwealth nation in the same political tradition as Canada we've debated this over the years in fact briefly we had voluntary euthanasia legalized in the Northern Territory but the Northern Territory is not an autonomous state I'm not sure whether you have the same system here that you have provinces that can legislate for themselves but you have territories I know you have territories well which can be overruled by the federal parliament so that was the case with the Northern Territory so the Northern Territory is that was overruled by a conservative dominated federal parliament and it didn't last long but there are moves in various states to legalize voluntary euthanasia or physician assistance in dying and in fact the leading newspaper in Victoria the state that has Melbourne as the capital where I go for several months each year is currently having a editorial campaign with reports of cases of the kind that you're familiar with urging that but physician assistance in dying should be legalized in Victoria so I think that this is a pivotal moment I think that Canada's decisions on this are going to be watched by the rest of the world and I think also of course that they are part of this longer trend that I gestured at briefly at the beginning of a shift in our ethics which is I see as overall clearly a positive development because it takes a more both an approach that respects autonomy more and that is more humane that that gives more regard to the suffering that people go through and rather than leaving them with that suffering or with that poor quality of life allows them to say when they've had enough so I'll leave it at that thank you and I look forward to the questions and discussion thank you Peter Skinner as justly mentioned there will be questions there's time for well approximately 35 minutes of questions and there's already a questioner at this microphone keep your as Kimo just learn also mentioned please keep your questions brief so that there will be a chance for more people views on assisted dying in the mental illness context rather than physical illness so I think that I think that that's a very good question but it's a broad one because there's all kinds of mental illness there are mental illnesses in which people are delusion and don't really understand what's going on and they may think that they're dying when they're not dying or that they're very ill when they're not dying and there are mental illnesses in which people are suffering greatly and I suppose the most common example of that would be depression and even if we just focus on cases of depression which the most significant ones for this topic I believe some depressions respond to treatment some people with depression respond to some treatments but not to others and very sadly there are some people with depression who don't respond to any treatment so clearly if a patient who is depressed says that their condition is so bad that they want to end their life the first question any physician should ask is if they're not familiar with the patient is well what have you tried for what sort of treatment of your depression have you tried and if there are possibly helpful treatments that the patient has not tried then I think that the doctor's responsibility is to urge the patient to try those treatments but if treatments have been tried the depression has been very prolonged you know this could be 20 years or more and the patient is persists persists in the view that that the depression is causing suffering such that life is not worth living and I believe that that can that can happen I think the depression is a greatly underestimated cause of suffering I think they can come a point where a doctor can say look I think you're competent to make this decision you've tried everything there's no real prospect of the condition changing no particular likelihood of that anyway your judgment is that you think it's not worth hanging on for the perhaps slim chance of it changing and so I could I could defend the idea that when all of those things have been tried over over a significantly long period a doctor could help a patient to die thank you very much for a really interesting talk I have a question where they you see a connection between the abortion debates and assisted dying because I think there's a very interesting parallel and so far that virtually all the countries mentioned allow abortion but when you look at the prospect of life you would have to admit that in many cases there would be the possibility of a long life and so on while when there are people that say I want to die we want to interfere with that right yes that's a that's an interesting question so there are a variety of connections clearly one connection is that on the standard Christian views that I outlined at the beginning of my talk it's wrong to take an innocent human life if you regard the fetus as an innocent human being then you're going to be opposed to abortion and you're going to be opposed to volunteers in Asia if you don't regard the fetus as qualifying as an innocent human being then you have a different situation where you could be opposed to volunteers in Asia but not opposed to abortion another another difference between it that you could argue is from the John Stuart Mills liberal principle that I mentioned that says the state should not interfere with acts that don't harm others you could say we should legalize voluntary use in Asia because that's an act between consenting adults doesn't have others but it doesn't follow that we should legalize abortion if you think that the fetus can't as another so you have to decide some people say you have to decide when life begins I think that's the wrong way to put the abortion controversy I'm perfectly prepared to say life begins at conception you know in a biological sense that just seems to me to be factually true and the anti-abortion people make that point over and over again but the point that they don't grasp is that to say that there is a life here even to say that there's a human life here is not to say that there was a being with a right to life that that's a separate question and that as I said might depend on the characteristics or qualities that a being has to have which the embryo or early fetus I think clearly doesn't have because it's not even a sentient being so there's a whole lot of those sorts of different connections with the issue and different ways in which people can go but I will just mention that last night in New York I was taking part in a debate about this topic for an organization called IQ squared you can find it online at IQ2USA.org and one of the my opponents in the bait was Baroness Elora Finlay from the House of Lords in Britain who is opposed to voluntary euthanasia but is a po is but is pro-choice on on the abortion issue so you do you do get people to go different ways take a question from this side okay hello so my question is more on what about the I guess would be manipulation of the individual who may be not actually who may be saying they want to have this issue of voluntary euthanasia or assisted dying but it may be through either the primary care in the person delivering primary care or manipulating them into like elder abuse or something like that causing issues of people saying that they want to die when they don't want to be a burden or something like that yeah so I wouldn't say that that's impossible or out of the question I think it's would be very rare that the primary care physician would would seek to do that and the provision that a second physician be consulted I provide I think provides some safeguard and if there are family around then the idea of consulting family provides a further safeguard to that issue but I just I also want to pick up on one thing you said that people may be thinking that they're a burden to others or the family once your quality of life has fallen to a point where it's it's not great maybe it's not intolerable but it's not great and you realize that you don't have anything better to look forward to so you might well be in a situation in which the fact that you are a burden to your family is the tipping point and I don't think that's at all unreasonable after all parents do lots of things for their children to make sure they have their children have a good life they might for example if they're immigrant parents they might work long hours in a very unpleasant factory atmosphere perhaps an unhealthy factory atmosphere in order to earn enough money you've heard people say this you know why did I do this they say to their daughter or son I did this so you won't have to do it so they're making big sacrifices for their children and we think that's perfectly reasonable and then let's say somebody is much older or sick and don't see much prospect of recovery and they need to be cared for and they see that one of their children unfortunately it's usually a daughter is spending an enormous load of time looking after them perhaps giving up her career or sacrificing some of her career prospects in order to do that and they may well feel that this is not what they want it's not that they've been manipulated but that they are a burden to the daughter who is looking after them who's the carer and it's just not worth it it's just not worth it to them for the quality that they're getting out of life anymore so I don't think it's you know I don't think we should just say whenever anybody says I'm a burden on my family we should say oh well that's a bad reason for asking for assistance in dying and now we won't give it to you because that's been a factor you know I'm not saying that people can't be manipulated at all but I'm just saying that's not in itself proof of manipulation thanks professor every wonderful talk so my question was pretty first in that it's about a gray area perhaps and and in regards to what if one faces prospect of a good life but only after a period of really intense treatment so for instance let me give two two possibilities two cases where this might come up one is a person who's diagnosed with cancer perhaps has got a good prospects and 80% survival rate but only after you go through chemotherapy that's a very elongated process and if did that patient were to say I wish to end my life would a doctor be responsible as a doctor if they were to assist them and let's say they do encourage them to you know to go with the treatment nonetheless the patient says no no I cannot have this kind of suffering another case might be a burn victim who faces a prospect of you know intense suffering while they're recovering but perhaps after the recovery can live a very fulfilling life and in those cases would you support doctors to suicide or what do you say does it more analogous to the Jilder lover who is temporarily extremely depressed but do you know if they can go through it will at the end of the day perhaps find your life very fulfilling right okay they're interesting cases and again it's always good to have a little bit more context how long has the person had after the cancer diagnosis to think about whether they want the chemotherapy whether that's worth going through are they still in the shock of the first diagnosis and not really adjusted to that the burn victim is usually a more acute case of course they've just had the burn and they're in great pain I think in those cases we can justify asking people or requiring people to wait to have some time to think about that decision now with the burn victim you would hope that you could relieve the pain even if you make them unconscious in order to do so in order to have that treatment one of the interesting things though is that say in the chemotherapy case really pretty much everybody would agree including the opponents that I was debating with last night in New York that the patient has a right to refuse the treatment patient and that's where you know that autonomy tradition has been so strong in the medical area in so far as giving patients a right to refuse treatment so if the patient says I don't want chemo every doctor would say and you know they could be sued if they didn't okay you don't have to have chemo and then the patient is presumably going to die from the cancer and again the good doctor should say well given that you've exercised your right to refuse treatment and that you're dying from the cancer my job is to make you as comfortable as possible if you like your palliative care physician should then be coming in and saying I'm not trying to cure you I realize that you've rejected that but I want to make you as comfortable as possible so that's that's an option now you could say if that's the patient's right to refuse chemo and then have palliative care what's is there a real difference between saying and if the patient says but I want to die now I don't want to wait for the two minute development kill me is there a difference and I think really the answer is no and so if the patient says given that I have the right to refuse chemo and I'll die from the cancer I want to die now again if the patient is that enough time to think about that decision and it's clearly a considered decision I would accept that request back to the side my question is in a case where a patient asks for euthanasia but his or her family is completely against it would you say that there should be equal consideration given to the subsequent increase in suffering for the family as a risk to the decrease in suffering for the patient as a result of the euthanasia so if the whole thing boils down to just an absolute value decreasing suffering don't they sort of compare well I guess what you're pointing to is that my underlying position is one in which I think that suffering is something that is intrinsically bad and ought to be reduced just as happiness or enjoyment is something that is good we ought to seek to increase so at a theoretical level I have to agree with you that all suffering counts and the suffering of the family counts I'm not sure how you would be able to estimate that the suffering of the family is going to be as great as the suffering of the person who wants to die because it may be in fact that what the family are doing is putting themselves in a position where after their family member dies they can say to themselves well it was not my doing it was not my decision I'm not responsible for it I did everything I could to make sure that the family member continued to live so I don't have to feel guilty about that and particularly people with with certain ethical views might feel guilty and perhaps therefore their opposition is in a sense putting themselves in that position and and they they will quite rapidly get over that once the family member dies so I think that's that's a possible view I also think the other thing that you have to think about is is the larger picture for others not just for this particular case but but what's saying to other patients if they are not able to make an autonomous decision if they are subject to the expressed wishes of their family it gives the family a control over them at a moment that is really in some way private that is really in some way their own you know most intimate most most personal decision nobody else is in there experiencing what they're experiencing and I think the idea that you have control over that is is important in fact I'll just mention here one thing that I didn't mention when talking about the knowledge that we have of what happens in places like Oregon and Washington where doctors where patients can get prescriptions by which they can end their life in about a third of the cases where a doctor agrees to a prescription and issues the prescription the prescription is never used so the point there is that the patients want to be in control they want to know that if things get worse they can end their life and just having the medicine there in the closet is enough so I think that's part of the reason why it's really important for patients to feel that they're in control actually since this line is longer we'll take another question from the site the beginning of your lecture after speaking about autonomy you stated that there are other conditions beside autonomy that can be introduced to play safeguards and there are three that you mentioned the patient being terminally ill them not having long to live and this all causing the patient to have a quality of life that is not acceptable then my question fees off of actually the first question that was asked with respect to depression so there you stated that in that case you can see a case where the depressed person has received multiple different kinds of treatment maybe every kind of treatment out there and none of it has worked and in that case perhaps you would support them asking for assisted suicide this seems to then take away that criteria of them not having long to live because the idea is a depressed person so I'm assuming that you're not a standing by that being a needed requirement and if one takes that away that sounds more like bill 52 from Quebec where all you really need is terminally ill and quality of life being poor so my question is what about cases like pulmonary fibrosis it's really easy to talk about really severe cases of depression really severe cases of cancer and one can see those perhaps easily or more easily than others fitting into this criterion but pulmonary fibrosis I don't know if you're familiar with it I think you should say more about it I'm sure that the audience is I'm not fully familiar with it and I'm sure that members other people in the audience are not so when someone has smoked for a while or for a long time this damages their lung tissues and this is irreversible they eventually start having breathing problems and so there are certain treatments you can give them that puts band-aid on the issue but essentially it's irreversible damage and over time it will lead to them potentially dying from this damage to the lung so one could imagine a person especially if we're leaving it up to the patient to decide what is an acceptable quality of life for them to say say at the age of 28 that this is not acceptable quality for me and so I wish to get assisted in suicide would you stand by that well it's a very good question and you've laid out the fact that I've said different things which don't all apply in all cases and therefore you have to make decisions which ones are critical and there are differences there in different jurisdictions so in Oregon and Washington and Vermont there has to be terminal illness I understand the Quebec legislation and they refer to as a six months the Quebec legislation does talk about a fanta vie but doesn't give a date for it right whereas in the Netherlands and Belgium and I think Luxembourg as well an incurable condition that the patient finds unbearable is sufficient it doesn't have to be terminal or at the end of life but it has to be incurable so you know a clear case that would be different would be a young person who suffered quadriplegia and after some time trying to adjust to it decides that life is not worth living in the Netherlands they could be given voluntary in Asia in Oregon and Washington and Vermont they and I take it in Quebec they they couldn't so in this case that you described I think if the patient's persistent judgment not just you know what he said on one bad day but persistent judgment over time was that the condition was was so bad that it was intolerable could not tolerate continuing to live that would be a case where you could accept that that judgment now it might be that you would say from observing the patient that look I can't see why this is so intolerable I don't you know essentially you don't believe you and that there's a problem then when when the doctor just doesn't accept the patient's judgment because I think normally you would say the doctor the patient is the one in the best position to judge but the doctor might suspect that something odd is going on the doctor might for example then consult a psychiatrist to try to see whether patient whether has some mental problems that's causing him to ask for death even though he doesn't seem to be in such a bad way so I think there are other things you could do but but in the end if there's nothing like that and the patient remains committed to that view I think again the doctor could accept that thank you back to the side hi I'd like to say that I think like advanced tech medical technology has advantages and disadvantages and everybody every person has their own unique biochemistry and how it affects their their recovery yet how does it what's the difference between a person that is able to function on level to decide their own death which is also they can be considered suicide and yet in society you're always trying to prevent suicide to a person that sits there and say hey an individual to say hey to decide a person's life that's unable to function and how does that morally acceptable to decide the value of their life just by a mere hallucination of God as as as a structure of society so I think we you know you've introduced point about the way in which we try to prevent suicide in general and that's a good point which I'd like to take the opportunity to say a little bit about because as I said we the debate last night in New York was on the topic legalized assisted suicide and once that debate got publicized both I and my colleague here on the side arguing for that got calls from people in the movement supporting physician assisted dying saying you should not have agreed to debate on those terms you should have insisted that the proposal was legalized physician assistance in dying or something of that sort because suicide has these negative connotations because when we think about suicide we think about somebody who is in a temporary state where they take their life perhaps it's the lovesick teenager I mentioned before perhaps it's somebody who's in a temporary depression that hasn't sought treatment for the depression and could be helped perhaps it's somebody just feels very alone and abandoned and we have set up these lifeline services to help people like that and obviously I think you know that's true these are cases of people ending their lives or trying to end their lives who have not and not in a state where they're giving it careful thought and rational consideration and are reaching those decisions in ill-considered ways and and that's a tragedy when they die when they could have been helped so it's reasonable to to say that's not what we're talking about and some people on my general side of the debate would say therefore let's not use the word suicide I take a different approach and perhaps it's because I'm a philosopher and I think that it's better to face issues rather than to try to brush them under the carpet by using softer terminology so I would say it is suicide but we should accept that some suicides are rational and morally justifiable fully defensible and nothing to be ashamed of and so we have to draw a sharp distinction between the kind of suicides I mentioned before and the ones where really this was the best option for the person in the circumstances in which they were now some people want to say oh but they were dying anyway you know they didn't decide to end their life they were dying anyway when where you're talking about a terminal case that's that's true but still the timing of your death is your choice there you know we're all going to die at some point so the decision to die earlier than you need to I would see as reasonable to describe as as suicide but clearly sometimes rational and sometimes not and just one end the clock here and also two eyes on the line so we'll call closure after the four people who are now in line so these will be the last four questions hi I've been thinking a lot about the kind of the issue of animal euthanasia in connection with this and thinking about how animals have a moral patient status and I was thinking if a person is in a state of significant pain and they might possibly be a moral agent there might might be able to regain their agent status after a certain amount of time or something like that that but it's indeterminate whether they will for sure do you think it would be permissible for the family members then to decide while they're in this patient but not agent state to euthanize them I wasn't quite clear than the way you started we're talking about a human or an animal human yes because in the case of animals they do have if because they're in a moral patient state right their owners will be able to say that they can be euthanized if they're in a lot of pain somebody else has to make that decision for them yeah but in the case you're talking about the patient at the moment is not a moral agent can't take the decision for themselves but if they're treated they will again be in that situation yes yeah okay so normally I would think then that they ought to be treated because they can't make the decision now but they will be able to make it later so if they're treated and they recover to the point where they can make the decision and they decide that the quality of life after recovery is not adequate they should then be able to end their life but to make it the decision for them if you know I'm assuming that they've not had a living will or some similar declaration to describe what they want done in their circumstance for the decision to be made for them I think you know when they're going to have the opportunity of reaching a decision would be wrong okay thank you back to the side so I'm not an expert in this and I'll accept what you presented in terms of the evidence saying that it's not going to lead to a slippery slope I wonder though is it possible that there could be mistakes that are made certainly the systems that are in place are not perfect and there may be some mistakes that are made where people are euthanized who do not want to die question I wonder is is it worth permitting that system to exist and and having those people be killed to alleviate the suffering of the people who do wish to die so I mean firstly I agree with you that mistakes can be made in any human institution no matter how much carefully you try and and regulated mistakes can be made that's true you referred specifically the mistake of somebody being euthanized who does not want to die if somebody being killed we should say you does not want to die I think under the regulatory systems that exist that's not a very likely mistake if indeed it happens I know there's been a pretty careful study of the Oregon situation in which I about 700 people I think have used Oregon legislation to die I don't think any case has been found of somebody who you know clearly did not want to die at the time because after all they both they have to request the for the prescription they then has to be a waiting period I don't remember exactly I think maybe nine days or something like that maybe 14 days they have to repeat the request they have to see a second physician who agrees that they want that then they have then they get the prescription then the prescription has to be filled then they have to take the substance so for them to take it when they don't want to die I think is you pretty much can exclude the kinds of mistakes that can be made and that have been pointed out by opponents of legalization is mistakes in prognosis so it it can happen that two doctors say that a patient is terminally ill but the patient in fact maybe they say they would agree under the Oregon law the patient is not likely to live longer than six months but there have been cases in Oregon of patients who have lived longer than six months they've had the prescription press but they didn't use it as I said and some of them have lived a year or two so undoubtedly doctors can make a mistake there and somebody could think I've got less than six months to live it's not worth it but if they knew that they had two years or perhaps in some cases they would have longer than that perhaps the mistake was a more serious mistake yeah yeah there could be there could be those kinds of mistakes so then as I think you hinted at in your question there is a sort of balancing act I mean we have let's say just take the Oregon case so we've had 700 or something people who have used the act to die therefore didn't suffer when they didn't want to suffer didn't have the kind of undignified death that they didn't want to have plus the others who got the prescriptions but didn't use it another couple of hundred and then perhaps let's say we've had one patient who died earlier than they need to it could have had some years but we don't know exactly what quality of life they would have had maybe some of them would have really recovered so how do you balance that out I think that's that's a serious question I think if you can make the mistakes extremely rare if you really can have good requirements for high level of confidence in the diagnosis then you can say that the amount of suffering relieved and the amount of autonomy granted to patients in these in the last stage of life could at way a very rare case of somebody who could have lived longer and had a reasonable quality of life for some further time thank you hi there I really enjoyed in your talk how you started from the beginning of viewing life as sacrosanct and how the intentional taking of life was always wrong and how we've now shifted to where we look to the quality of life instead but I think that in not accepting that autonomy alone is a valid reason to pursue suicide and in attaching these other conditions such as being terminally ill or being in an incurable state that we are acknowledging in some way that it is inappropriate for someone to take their own life based on their own personal choice so how much weight do you give to the argument that life is is sacrosanct in some way and that and do you think that we should still consider this as an important consideration in this debate I would not use the word sacrosanct to describe the value that I would place on on life that seems to me to be too absolute a term that suggests and as I said it suffers from this problem of having to say something about why all human life is in this way and non-human animal life is not I mean I would rather see this as being on a continuum there is value in life if it meets a certain minimal quality that there's value in the lives of non-human animals perhaps you know they're also degrees with different species and the kinds of richness of life and types of fulfillment and enjoyment that they can have that there's a continuum and that for normal humans maybe they're at one end of that continuum so I would certainly be happy to say that there is value in in life that has some significant positive qualities I would put it that way and that's why I would not allow completely unrestrained reign for autonomy in these decisions I would because I think people do make mistakes I mean the seat belt example is is one minor example where people make mistakes where we've been able to reduce the road toll by requiring people to wear seat belts and I think pretty much everybody agrees that's a good outcome but also even in these other cases people can make mistakes and can if they live can come to say that it's a good thing that they were not allowed to exercise their unfettered autonomy thank you last question so I was wondering if you could maybe reflect a little bit on or if you had any thoughts on whether the methods used to achieve the end make a difference I think you mentioned that in some places it would be a prescription that was given and in some places it is possible to request and receive a lethal injection and I was wondering if you could talk about whether there are any important differences or implications to those two things yeah it's an interesting question and I think it reflects something about the underlying political ideology of the culture so it's in the United States really there's just no debate about legalizing voluntary euthanasia about legal making it legal for doctors to give lethal injections to patients there aren't really organizations campaigning for that in the way that there are organizations campaigning for physician assisted suicide and they've been these votes and referendum and I think that's because of this view in the United States of the importance of individual liberty you know something that comes with the Declaration of Independence and the Bill of Rights and so on that these are rights which are reserved to the citizens and that the state does not have rights that are not explicitly bestowed on it through the Constitution so that's why the idea of you know patient autonomy here the patient can take this substance by themselves whereas for the doctor to give a lethal injection is just contrary to the law relating to murder and there's no movement to change that law in that respect in the United States now the Dutch and Belgian for example have never seen it that way they've basically seen them as equivalent that and perhaps that's because they they have them they don't have this restricted view of the state so you know you see obviously that in other areas the the huge outcry about Obamacare which I'm sure you in Canada you know I think of as curiosity in a way but I mean but if you were there watching the news media you know the idea that this is this is legislating socialism socialized medicine all of these terms that were being used were obviously with very negative connotations that the state should not be running medicine in some way should not be controlling medicine so you don't have that the Europeans generally don't have that and that's why they're more prepared to say yes you know it doesn't really make much difference whether death comes because you've drunk or taken a substance or because the doctor's giving you an injection and because you know there's one clear disadvantage of the prescription method and that is if you've got a cancer that means that your digestive system is no longer functioning you can't be helped by a prescription because the cancer may be blocking the esophagus so you can swallow it it's not going to get to your stomach if you're just going to vomit it up again it's not going to kill you there's nothing that the Oregon law can do for you in those circumstances but the Dutch and Belgian law can and it's interesting I think that Quebec has gone for a voluntary euthanasia rather than just for physician assisted suicide and I guess that perhaps relates to the fact that Quebec has stronger ties to Europe than other parts of Canada I don't know whether you know other people can tell me whether it would be more more likely that other provinces in Canada that legislated for this if they did would legislate for physician assisted suicide rather than for voluntary euthanasia. Can I ask a quick follow-up question to that? Is there so you mentioned that many of the prescriptions that are written don't get filled I'm wondering if there's a parallel that one could look to in terms of lethal injection so are there ever because there's an issue of control there that's taken out so there is a parallel and it's called talking to your doctor so in a country in which it is legal for the doctor to help you and to carry out voluntary euthanasia as you get sick as you know if you're diagnosed with a incurable illness or condition or terminal condition you talk to your doctor and you say so doctor if I've decided I've had enough will you help me will you give me that lethal injection and of course in the Netherlands not every doctor will say yes some doctors will say you know no it's contrary to my conscience or my religious belief I could not do that for you but you have the opportunity to find another doctor just as with abortion right not every doctor will carry out an abortion and we should not compel doctors to carry out abortions if it's contrary to their conscience but they should tell you that that's the reason that they're not doing it and that if you want to find another doctor you may do so so yes I think in the Netherlands that law gives reassurance to everyone more or less that they know they can openly talk to their doctor whereas in a jurisdiction where that's not legal in many cases if you try and talk to your doctor about it they'll say I can't discuss that with you I would be committing a crime now there's a few brave doctors who will say quietly you know yes I will help you when necessary although use some language coded language which indicates that they would would do that but it's clearly much easier to have their conversation where you're not asking the doctor to commit a criminal thank you for your questions just before Jocelyn closes the evening I would like you to thank Peter Skinner join me in thanking Peter Skinner for giving wonderful inaugural lecture just before we wrap then I would like to thank Sir Graham Day for making this marvelous event possible I'd like to also thank the CBC ideas crew Paul Kennedy Mary Link and Greg Kelly this was an incredible first date I hope we see much more of you and finally to all of you in here and all of the others over in the overflow room thanks for coming out tonight Peter thank you for a spectacular evening