When Health Care Becomes Homicide

Introduction

What do a 27-year-old autistic woman, a 51-year-old woman with chemical sensitivities, and a hearing-impaired 61-year-old man hospitalized for a risk of suicide have in common? All of them were loved. None of them were dying. And all of them were Canadians killed by doctors.1 From the time when Canada decriminalized “medical assistance in dying” (MAID) in 2016 until the end of 2022, MAID had claimed 44,958 Canadian lives.2 These numbers represent not mere statistics, but people with stories, families, and souls. As Canadian ethicist Daryl Pullman notes, their deaths “are in point of fact, homicides.”3 So a truer term for MAID is SHAM: “sanctioned homicide actualized medically.”4 Stripping SHAM of its euphemisms clarifies that SHAM is not simply a political issue but a life-and-death matter bearing earthly and eternal consequences.

These consequences do not only impact Canadians. According to the World Federation of Right to Die Societies, “Assisted dying . . . in some form is legal in the Netherlands, Belgium, Canada, Colombia, Luxembourg, New Zealand, Switzerland, Spain, Germany, Austria, all the six states in Australia” and 11 jurisdictions in the US.5 Multiple additional American states are considering SHAM,6 even as American legal scholars call for expanding current laws.7 How can Christians evaluate and respond to these issues from an informed biblical perspective?

Scripture does, however, reveal alternative end-of-life approaches far more conducive to societal flourishing.

To answer, the following discussion argues that SHAM accords neither with prudent public policy nor with biblical Christianity because SHAM facilitates unjustifiable social harms and contradicts God’s Word. Scripture does, however, reveal alternative end-of-life approaches far more conducive to societal flourishing. Part One clarifies what SHAM is and is not. Part Two contrasts biblical and secular worldviews relevant to SHAM. Part Three traces the development of public policy theory and practice surrounding SHAM, highlighting lessons from Canada. Part Four critically evaluates arguments for SHAM. Finally, Part Five suggests biblical alternatives to SHAM, concluding with recommendations for public policy and Christian engagement.

Part One: What SHAM Is and Is Not

In SHAM, a health care worker intentionally ends or helps to end a human individual’s life. Two forms of SHAM are euthanasia and physician-assisted suicide (PAS).8 In euthanasia, a medical worker personally kills another human. In PAS, a health care practitioner prescribes lethal drugs for a person to self-administer. Typically, these acts of killing occur under two conditions. First, the person being killed must exhibit an irremediable medical issue that is considered either fatal or sufficiently “grievous.” Second, the person (or their proxy decision-maker) must request the killing. However, as the cases of the three Canadians mentioned above illustrate, the first condition is not always met. Neither is the second, as evidenced by statistics from the Netherlands reporting that in 2021, 517 patients were killed without an explicit request.9

Importantly, SHAM is not the refusal or withdrawal of futile or excessively burdensome medical treatment.10 Some scholars argue that withdrawing life-sustaining treatment from dying patients is “passive euthanasia.”11 By this argument, treatment withdrawal and SHAM both involve a doctor initiating a chain of events that results in the patient’s death; therefore, both acts are morally equal. However, other scholars note that these acts not only involve different causes of death (for instance, lethal injection vs. terminal illness), but also, vitally, the relevant parties’ intentions are not necessarily the same.12 If the patient or doctor intended death in both cases, then the moral implications may be comparable. But a dying person who would prefer living yet recognizes the futility of further treatment or who requests enough painkillers to die comfortably (even if this shortens life) is not aiming to die.13 SHAM, in contrast, always aims to kill. And as biblical and modern laws that distinguish murder from manslaughter show, intentions matter.14

Part Two: Evaluating SHAM from Biblical vs. Secular Worldview Perspectives

Having established what SHAM is (and is not), we can survey how biblical principles inform ethical evaluations of SHAM. Genesis reveals that God created humans in his image as embodied beings designed for relationships. Although God created a “very good” world, sin corrupted creation, causing suffering and death.15 But God sent his Son Jesus as the sacrifice to bear sin’s death penalty for those who trust in him. Rising again, Jesus defeated death, which 1 Corinthians 15:26 calls “the last enemy.” Christians face this defeated foe with hope, knowing that death leads us home to Christ (2 Corinthians 5:8) and that God will establish a new creation with no death, pain, or mourning (Revelation 21:4). Meanwhile, despite their fallenness, humans retain inherent value as God’s image-bearing creatures, whom other humans must not kill (or even curse).16 As creatures rather than self-creators, humans possess limited rights over their own bodies, which belong to God (1 Corinthians 6:19–20). God alone has the absolute authority to bequeath or withdraw the gift of life.17 Correspondingly, theologian David VanDrunen notes that the Bible never depicts suicide positively, but instead portrays a righteous man named Job rejecting a suicidal course despite yearning for death.18 God’s Word calls us to lovingly care for those who, like Job, suffer in our fallen world. But following God’s commands about caring does not permit breaking God’s commands about killing. Ultimately, God’s Word directs us to view life as a gift and death as a defeated foe to neither suicidally pursue nor futilely avoid at all costs.19

Rather, secularism assumes humans are self-aware animals who can control their bodies’ fates in line with their psychological values.

A secular view, in contrast, does not see humans as created image bearers who are morally accountable to God. Rather, secularism assumes humans are self-aware animals who can control their bodies’ fates in line with their psychological values. This division between external facts and internal values is possible, as Christian author Nancy Pearcey argues, because evolutionary views do not see humans as body-soul unities designed for specific purposes.20 This thinking lets humans function as self-creators whose choices matter more than their bodies. Devaluing embodiment this way, as legal scholar O. Carter Snead points out, means failing to perceive humans as dependent beings embedded in relationships from fertilization.21 Snead notes that the resulting mindset, expressive individualism, sees humans as volitional islands seeking to make choices that shape reality in line with their values. This mindset, which deifies willful individuals, coronates autonomy as the highest good. People who cannot express autonomous choices are treated as objects expendable for the benefit of humans who can. Snead and Pearcey describe how such thinking underlies abortion, the destruction of embryos for assisted reproduction, and SHAM. In the latter case, secular views affirm SHAM by depicting people as isolated, self-possessed machines with rights to “turn themselves off” should their inner values so direct.22 Thus, debates about SHAM are not just political disagreements but worldview conflicts hinging on questions of humanity’s meaning.

Part Three: A Brief History of SHAM, from Ancient Greece to Contemporary Canada23

These worldview considerations help explain how the “right to die” narrative fits the thinking of today’s post-Christian nations. But the story of euthanasia in Western medicine begins much earlier, in pre-Christian Greece.24 Christian ethicist Nigel Cameron explained, “The taking of poison was the commonest means of suicide in ancient Greece, and the physician (who apparently often acted as his own pharmacist) was asked to assist.”25 In response, the Hippocratic oath forbade physicians from administering or suggesting lethal drugs, even upon request. Cameron notes that Hippocratic medicine, with its high regard for life, gained popularity through Christianity’s rise.

Fast forward to 1859. That year, Charles Darwin published On the Origin of Species, popularizing evolution.26 Drawing from Darwinian concepts, an English teacher known as Samuel Williams kindled the modern euthanasia controversy in 1870 by penning an essay that defended “mercy killing.”27 Then in 1883, Darwin’s cousin Francis Galton launched the term eugenics to describe the “science” of improving humanity by promoting or preventing births of infants with favorable or unfavorable traits, respectively.28 Both euthanasia and eugenics operate on the premise that certain lives are not worth living. This view accords with Social Darwinism, which presumes humanity should control its own evolution by favoring the lives of the “fit” at the expense of the “unfit.” Accordingly, influential Social Darwinists—including biologist Ernst Haeckel, Unitarian humanist Charles Francis Potter, theosophist Annie Besant, and Planned Parenthood founder Margaret Sanger—fanned flames of support for euthanasia and eugenics.29

The most infamous Social Darwinian campaign began in 1933, when the National Socialist German Worker’s Party (the Nazis) enacted laws promoting eugenics, as other nations had done.30 In the late 1930s, Adolf Hitler called for “extending the rights” of incurably ill patients by allowing “mercy killing.”31 The Nazis soon launched the “Aktion T-4” involuntary euthanasia program targeting disabled persons.32 To garner support for Aktion T-4, the Nazis released a film that promoted a “right to die” by telling the story of a physician killing his wife, who sought euthanasia for multiple sclerosis.33 Ultimately, Germany’s euthanasia campaign was, in the words of Nigel Cameron, the “signal point of departure” from Western Hippocratism.34

While euthanasia fell from favor after WWII, public opinion shifted again around 1969. That year, Dutch psychiatrist Jan Hendrik van den Berg released his book Medical Power and Medical Ethics promoting euthanasia to relieve suffering.35 Support for SHAM began rising in the Netherlands, with Dutch law enabling SHAM in 1985 and then further legislating SHAM in 2002.36 Though SHAM remained punishable in the Dutch criminal code, doctors would not be prosecuted if patients sought death for illnesses causing incurable, unbearable suffering.37

Meanwhile, other jurisdictions began legislating various forms of SHAM, with early instances including Oregon’s allowance of PAS in 1997 and Belgium’s legalization of euthanasia in 2002.38 The question of PAS had already reached the Canadian Supreme Court in 1990, when Sue Rodriguez, a woman with terminal amyotrophic lateral sclerosis (ALS) sought SHAM.39 Arguing in line with a secular worldview, Rodriguez asked, “If I cannot give consent to my own death, whose body is this? Who owns my life?”40 The Court ruled against Rodriguez by one vote; however, a doctor fulfilled Rodriguez’s wishes without prosecution in 1994.41

These tremors gave way to a seismic Supreme Court decision in Carter vs. Canada (2015), altering Canada’s medical landscape with a fissure that would only expand.42 The case involved a woman named Gloria Taylor, who had ALS, and a woman named Lee Carter, who had taken her mother to Switzerland for SHAM.43 When Taylor and Carter challenged Canada’s SHAM prohibition, the Court concluded that this prohibition violated Canadians’ Charter rights to “life, liberty and security of the person.”44 University of Toronto law professor Trudo Lemmens notes, “The Supreme Court’s Carter decision did not create an unrestricted constitutional right to physician-ending-of-life but only invited parliament to legalize some form of ‘physician assisted dying.’”45 The Court acknowledged the objection that legislating SHAM may lead societies down a “slippery slope” toward coercing (or forcing) vulnerable people to die.46 However, the Court concluded that safeguards could prevent this slope by ensuring that only competent, uncoerced adults with incurable, terminal illnesses could request SHAM.47

In response, Canada’s Parliament passed Bill C-14 enabling SHAM in 2016.48 This bill permitted competent adults (age 18 or older) to voluntarily request SHAM due to a “grievous, irremediable medical condition” characterized by advanced decline, intolerable suffering, and a reasonably foreseeable natural death.49 But in 2021, an amendment known as Bill C-7 erased the “foreseeable natural death” requirement, offering SHAM to patients who are not dying.50 Bill C-7 also called for extending SHAM to patients with mental rather than physical illnesses, though this extension has been delayed to 2027.51 Other voices sought SHAM for minors, with Quebec’s College of Physicians controversially advocating that parents should be able to euthanize infants with severe deformities and poor prognoses.52 Relatedly, a survey of 1,000 Canadians indicated that nearly a third of respondents would support SHAM for homelessness and poverty.53 In fact, 1 in 5 respondents agreed that SHAM “should always be allowed, regardless of who requests it.”54

Even as “access” to SHAM is expanding, protections for conscientious objectors are declining.

Even as “access” to SHAM is expanding, protections for conscientious objectors are declining. Quebec’s courts have ruled that all palliative care centers must provide SHAM, with no religious exceptions for faith-based institutions.55 Meanwhile, Canadian SHAM rates have soared, passing Belgium and the Netherlands.56 All these realities cast a backward shadow on the Supreme Court’s optimism that safeguards would prevent a downward spiral. Yet these results logically flow from the Court’s pro-SHAM arguments—and the worldview behind them.

Part Four: Evaluating and Responding to Arguments for SHAM

What were these arguments? In answer, a primary theme in the reasoning behind Carter vs. Canada was expressive individualism. The Court agreed that the “right to ‘decide one’s own fate’ entitles adults to direct the course of their own medical care,” with the concept of care being reimagined to encompass homicide.57 Similarly, the Canadian Government forwarded Bill C-14 on the belief that this legislation “would enable [patients] to make a fundamentally personal decision concerning their bodily integrity, autonomy, and dignity, which could also help prevent them from ending their lives prematurely by providing reassurance that they will have access to medical assistance in dying at a time when they may be unable to end their own life without assistance.”58 These statements illustrate how arguments for SHAM commonly appeal to (1) the “compassionate” relief of suffering; (2) radical autonomy, expressed as the “right” to control one’s own life and death; and (3) the avoidance of “undignified” dependence on others. These three reasons further comprise an overall appeal to (4) a concern for “quality of life.”

How well do these arguments reflect the reasons Canadians cited for requesting SHAM? The latest government report stated, “In 2022, the most commonly cited source of suffering by individuals requesting MAID was the loss of ability to engage in meaningful activities (86.3%), followed by loss of ability to perform activities of daily living (81.9%) and inadequate control of pain, or concern about controlling pain (59.2%).”59 Loss of dignity placed fourth at 53.1%, with the fifth reason being the actual or prospective “inadequate control of symptoms other than pain” (47.4%). Fear of “being a burden on family, friends, or caregivers” ranked next at 35.3%, followed by “loss of control of bodily functions” (30.2%) and isolation or loneliness (17.1%). Loss of control, autonomy, or independence ranked fourth-last at 4.3%. Fear, anxiety, and emotional or existential suffering placed at 3.3%. Just 1.8% of patients cited losing quality of life, second-last only to a category labeled “other” 0.7%. Ultimately, some of the top arguments for legalizing SHAM correspond to some of the least-cited factors for choosing SHAM.60

These statistics underscore the pain, disappointment, and anxiety that patients experience. Does the best response to such suffering entail terminating the pain by terminating the patient? From a biblical view, the answer is no. Scriptural principles not only preclude the act of SHAM itself, as Part Two discussed, but also provide the answers to pro-SHAM arguments. Regarding compassion, Vandrunen notes that if patients are not believers, SHAM is the least compassionate solution. If they are believers, they need “the comfort and encouragement of the gospel,” not the assent that their lives are no longer worth living.61 Regarding autonomy, the truth that we are created, embodied, relational beings dependent on God and others contradicts the narrative of humans as isolated wills with absolute rights over their own fates.62 Regarding the fear of losing dignity, a biblical view helps us recognize that love displaces fear (1 John 4:18), that depending on others is a natural, human way of receiving love, and that our dignity inheres in our value as God’s image bearers.63 Even under undignified circumstances, this dignity cannot be erased. And regarding quality of life, Job’s account reminds us that even when our lives seem like photographs drained of color, our Creator sees a different picture. By trusting him as Job did, we lean on God’s infinite understanding rather than on our own painfully limited perspectives.

God’s Word also responds to the fear of “being a burden.” As interdependent, embodied beings in a fallen world, all of us were born as burdens on our families, continue burdening others to various degrees throughout life, and will become burdensome again. Bearing burdens and being a burden is part of loving and being loved. It is part of being human.64 To address another human’s burden by killing the human rather than sharing the burden is not only to miss the mark of love (Galatians 6:2) but also to dehumanize ourselves and others. God’s Word points us toward a much different vision of humanity—one far more conducive to societal flourishing than the secular vision, as the practical consequences of pro-SHAM arguments illustrate.

Bearing burdens and being a burden is part of loving and being loved. It is part of being human.

Christian and secular authors have both called attention to these consequences, which include (1) expanding society’s acceptance of killing as a means of problem-solving, (2) harming vulnerable populations, and (3) damaging the medical profession.65 The first consequence, which accompanies ever-widening “access” to SHAM, can occur both for logical and practical reasons. Various ethicists have described how the logical reasons flow from arguments about autonomy, compassion, and the “right to die.”66 Specifically, if a right to die exists, why should it only apply to patients who meet certain criteria? If autonomy matters more than life, then people should be free to choose death regardless of how they are (or are not) suffering. And if relieving suffering matters more than life, then doctors should be able to kill suffering patients even without express consent. Either way, “access” to death must expand as a matter of justice.67

Practical factors may facilitate this expansion, as SHAM can save governments millions of dollars and help meet demands for transplant organs. In Canada, a 2020 report by the Parliamentary Budget Officer estimated that the “net reduction in health care costs under Bill C-14” had totaled 86.9 million dollars.68 Canada also leads globally in rates of post-euthanasia organ donation.69 Even without such utilitarian considerations, assisted death policies that seek to prevent abuses by establishing safeguards face feasibility issues.70 For instance, ensuring that patients are truly competent and uncoerced is hardly straightforward given the significant percentage of patients whose requests for death coincide with depression and anxieties about “being a burden.”71 Illustrating such problems, a study of Belgium’s increasing euthanasia usage noted, “Several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such.”72 Canadian scholars have likewise observed that standards once touted as “safeguards” are now called “barriers to access” of “care.”73 Meanwhile, as other authors noted, “Because [SHAM] has normalized killing as a solution to suffering, other options seem less tenable, available, or economically feasible,” leaving society in a precarious state.74

A second and third set of consequences illustrate this state. The second is SHAM’s role in harming vulnerable populations. In Canada, although Bill C-14 originally emphasized “protecting vulnerable persons from being induced, in moments of weakness, to end their lives,” this theory has not translated into practice.75 Meanwhile in the US, research indicates that insurers can unduly influence patients to choose death.76 Similarly, various authors have argued that SHAM discriminates against people with disabilities by implying their deaths would be valuable and by withholding suicide prevention efforts available to others.77 As Christian ethicist Gilbert Meilaender points out, normalizing SHAM additionally pressures people to become “considerate heroes” who do not stay alive using up resources; thus, euthanasia policies that tout “more freedom” for patients may in practice lead to less freedom.78 Along such lines, some pro-SHAM ethicists have already argued that patients who excessively burden their loved ones may have a duty to die.79 SHAM has also been linked to increases in suicide rates overall.80

The third set of consequences surrounds how SHAM impacts the medical profession. Nigel Cameron notes that prioritizing relief of suffering above the sanctity of human life turns medicine into a power play against the vulnerable.81 This outcome results because people with a voice can define “suffering” in ways that devalue the voiceless (including a patient’s own future self). Commentators including Cameron contend that SHAM goes against medicine by redefining “health care” to promote killing rather than caring.82 Before SHAM, the mentality underlying health care said, “We see you are hurting. Let us offer you the best care we can to help you live as well as possible given the circumstances.” The new mentality says, “We see you are hurting. Have you thought about taking your life? In fact, let us take it for you.”

Part 5: Recommendations

Regarding end-of-life issues, what would public policies informed by a biblical worldview look like? Fundamentally, homicide would not be considered part of health care. The practical effects of SHAM suggest that no gap should exist between ethics and law on these matters, meaning that prohibiting SHAM is the most appropriate policy. In lieu of SHAM, governments and churches should encourage an ethic of sharing one another’s burdens as embodied creatures in a fallen world. One way to accomplish this goal is to promote excellent palliative care, disability support, and pain management.83 Patients need to know that today’s medical technologies enable advanced pain control, helping to alleviate concerns for intolerable suffering. Patients’ cited rates of loneliness, emotional distress, and other nonphysical suffering also point to the need for spiritual care, with chaplains, pastors, and churches playing essential roles. By living out a biblical view that affirms all image bearers’ dignity and expresses love for “the least of these” (Matthew 25:40), Christians can counter concerns about losing dignity or “being a burden.” Policymakers can assist these outcomes by allocating resources to palliative care, pain control, spiritual care, and disability support. Promoting better at-home care—for instance, by providing education, resources, and tax benefits to caregivers—will also help foster a mentality of burden-sharing rather than killing.

Conclusion

Ultimately, a biblical worldview directs individuals and societies toward far healthier approaches to end-of-life practices than do pro-SHAM secular arguments.

Ultimately, a biblical worldview directs individuals and societies toward far healthier approaches to end-of-life practices than do pro-SHAM secular arguments. Where a secular view sees humans as isolated machines with the right to self-destruct at will, God’s Word portrays humans as interdependent embodied souls with indelible dignity. Various nations have departed from this high view of life by legislating SHAM, with Canada offering an especially sobering case study. The reasoning behind Bill C-14 highlights common pro-SHAM arguments, including autonomy, relief of suffering, and concerns about the loss of dignity or quality of life. But the logical results and practical consequences of such arguments illustrate that SHAM coincides with unjustifiable harms. In response, policymakers and individual Christians must reject the idea of homicide as health care and instead promote strong palliative care, spiritual care, pain control, disability support, and aid for caregivers. These goals will implicitly acknowledge what everyone—from 27-year-olds with autism to 61-year-olds with hearing loss—shares in common: we are all created in God’s image, imbued with priceless value, and entrusted with the gift of life.