A New Case for Medical-Aid-In-Dying? 

Just over thirty years ago, Oregon became the first state to allow physicians to intentionally seek death as part of healthcare. At the time, discussions of Jack Kevorkian were all the rage, along with his slogan, “dying is not a crime.” However, questions about expanding assisted suicide and euthanasia are not merely a thing of the past. Recently, The Economist and The New York Times have each run in-depth articles sympathetic to euthanasia, and the states of Illinois and New York have legalized assisted suicide. 

After Oregon’s 1994 “Death with Dignity” law took effect, the Jesuit moral theologian James Keenan published an important article, “The Case for Physician-Assisted Suicide?” in which he asked what the representative case would be for physician-assisted suicide (PAS)—or as it goes by now, “medical aid in dying” (MAiD). In the article, Keenan asked whether the standard rhetorical example is actually a representative case that reflects the typical MAiD patient, and if not, what that means. He presented the familiar case of “Uncle Louis,” which I might summarize as: Uncle Louis is very old and has lived a full life. He is dying of a debilitating, incurable cancer that has no good pain management. Uncle Louis has had a conversation about MAiD with his long-time physician with whom he has a good relationship. They have tried everything else and as a last resort Uncle Louis (autonomously and freely) decides that he would like “medical aid in dying.” Why should we not affirm Uncle Louis’s choice to die early and on his own terms in order to avoid pain and preserve his “sense of self?” Why should he be left to suffer? 

Keenan’s conclusion is clear: Uncle Louis is not the representative case. Rather, he argued thirty years ago, the more probable average case was that of Mary X—a woman who had a progressive chronic condition, who feared dependence on her family and others, and who was depressed. Mary probably did not have proper medical coverage or access to counseling and thought MAiD was her only option. Mary’s case, Keenan starkly observes, “demonstrates not the lack of autonomy (autonomy is, after all, only for those with power), but rather the inequities in our country … Proponents for the case of Uncle Louis … are only interested in the autonomous person … [Ultimately,] the law that Uncle Louis wants invalidated is the same law that keeps the more common Mary X from being marginalized to death.” 

Throughout the last thirty years, however, those who have argued that euthanasia and assisted suicide are always wrong and a public danger have been met with charges of being uncaring and promises that the implementation of such programs would be responsible, regulated, data-driven, and equitable. Indeed, after thirty years, we can ask whether Keenan was right when he argued that the more likely case once euthanasia is implemented would be a vulnerable Mary X rather than an autonomous Uncle Louis. Did the regulations bring about the intended results?  

Current MAiD Law Worldwide

Presently, at least eleven countries and thirteen U.S. states (and one federal city) allow for some form of MAiD. Belgium, Canada, Colombia, Ecuador, Luxembourg, the Netherlands, New Zealand, Portugal, Switzerland, Spain, and some parts of Australia all allow euthanasia by law. In America, California, Colorado, Delaware, Hawaii, Illinois, Montana, Maine, New Jersey, New Mexico, New York, Oregon, Vermont, and Washington, as well as Washington, DC, all allow assisted suicide.  

There is great variety here. Some places, like Oregon, require a terminal diagnosis of six months or less to live. By contrast, the Netherlands and Belgium allow for euthanasia even if one does not have a terminal illness. Indeed, these latter two also allow people with enduring psychiatric disorders or mental illnesses to request euthanasia. Canada allows euthanasia for those with terminal and non-terminal diagnoses and is set to allow those with mental illnesses to be euthanized in 2027. The Netherlands permits neonates (under age one) who have severe medical conditions to also be euthanized according to their parents’ wishes. 

Moreover, although it is the custom in America to distinguish “physician assisted suicide” (as indirectly facilitating the patient’s death by an intentionally lethal prescription) and “euthanasia” (as direct medical “mercy” killing), this is not the universal practice in Western medicine and law. Neither the Netherlands nor Belgium, for instance, criminally distinguishes between euthanasia and assisted suicide. Indeed, in both practices the healthcare professional confirms and facilitates the patient’s choice to die. Therefore, though I will distinguish euthanasia and assisted suicide precisely in my examples, I will intellectually treat them as “of a piece” and under the larger umbrella of “MAiD” throughout the article. 

More specifically, I will view euthanasia as “any action or omission that of itself or by intention causes death in order to bring all suffering to an end.” Thus, for example, willfully denying or omitting food and water is just as much an act of euthanasia as administering a great amount of anesthesia to suppress breathing. Both acts directly and purposefully introduce (whether by act or omission) a new pathology—dehydration and apnea, respectively—with the aim that the patient would die so that they need not suffer. Euthanasia, then, is what is called in the natural law tradition “an intrinsically evil act.” It is always wrong as an action or choice, regardless of one’s final ultimate intention or goal (e.g., that the intended death may relieve pain or eliminate dependence and thereby end suffering). Apart from any further consideration of ultimate intention, euthanasia and assisted suicide are actions that directly and purposely seek to kill the patient for the “crime” of being ill or sick. They necessarily contradict our human dignity and cannot be ordered to the love of God and neighbor, including and especially the sick and suffering. 

Uncle Louis and the Real Case for MAiD 

Thirty years ago, Keenan argued that this Uncle Louis case was fundamentally misleading or erroneous. Following a structure similar to Keenan’s and updating his argument, I will show that several decades later this common rhetorical case still continues to misrepresent reality and mislead, in fact, in even more ways than Keenan originally thought. 

The first misleading aspect of the Uncle Louis case is that in those countries that have fully implemented a euthanasia regime and for which we have good data, the typical candidate for euthanasia is not necessarily a man. Indeed, in many cases it is as likely or at times more likely to be a woman. In Canada, in 2023, women were nearly just as likely to seek euthanasia as men and so too in the Netherlands. In fact, in 2021, slightly more women than men were “patients” of MAiD in the Netherlands. Moreover, in Canada, for those who sought euthanasia without a terminal illness, nearly three out of five of them were women, and this is a continuing year-over-year trend in the country.  

Similar figures are also found in the Netherlands, where around 70 to 75 percent of people who seek euthanasia for persistent psychological issues (from anorexia and depression up to schizophrenia) are women. Moreover, this trend is unlikely to reverse. Canada, which already allows euthanasia for those who are not terminally ill, will expand MAiD in 2027 to include those whose sole condition is mental illness, i.e., those very categories that already disproportionately affect women.  

Second, the Uncle Louis case is misleading because we can in fact regulate just about any pain. We may not be able to keep a patient totally lucid, but we can manage the pain. The real concern is about adequately responding to the patient. Many studies have shown that there are racial disparities as well as disparities between men and women regarding pain management. Furthermore, recent research in the Journal of Clinical Oncology found that as a reaction to the opioid epidemic and opioid addiction, significantly fewer opioid prescriptions are being filled for terminally ill cancer patients. For such patients, between 2007 and 2017, the number of long-acting opioid prescriptions fell by 50 percent. Most concern about pain “management” is really about “mismanagement” and, well, one does not have to kill the patient to manage pain better.  

Third, the Uncle Louis case is misleading insofar as, in reality, pain relief is not a major factor for people seeking MAiD. In Canada, for instance, the top reason for seeking euthanasia in 2024 was a fear of losing autonomy: no fewer than 95 percent of all MAiD patients worry about loss of meaningful activity and 85 percent also fear the loss of ability to perform daily living activities. This is not an isolated event. In Oregon, which only allows assisted suicide for those given a terminal diagnosis of six months or less to live, “pain” and “fear of pain” are not even among the top five reasons people seek MAiD. Rather, between 1998 and 2023, people’s top concerns are (in order) a fear of losing autonomy, fear of losing the ability to enjoy daily activities, fear of losing a sense of dignity, fear of being a burden on the family, and a worry about losing control of bodily functions. “Fear of pain” is not the concern driving the desire for MAiD. 

The fourth misleading aspect of the Uncle Louis case is connected to the previous point: MAiD is not usually requested coolly and rationally with a clear head but out of a state of depression, distress, and a fear of dependence and the loss of autonomy. This is evident in the figures just cited. Most likely, many such persons who have been given a terminal diagnosis are suffering from grief and depression, hence their requests to die. This picture is further confirmed by the fact that the Netherlands has permitted euthanasia in non-terminal cases like depression and persistent anorexia resulting from childhood abuse, autism and intellectual disabilities, and “prolonged grief disorder” after a woman’s husband died. Spain similarly permits such cases. The Dutch and the Spanish are not the only ones to allow for euthanasia and assisted suicide in those not dying but who are depressed or suffering some psychological condition. Belgium, too, allows this. As mentioned before, Canada is set to follow their examples in 2027.  

Such people who cry out for death from depression or because of suffering from previous abuse or some other condition should not be told that their desire for death is rational, whereas other healthy patients’ requests would “rightly” be rejected. Euthanizing such vulnerable patients inherently makes a judgment on the value of their lives. Moreover, it forces them to try to justify their continued existence to a society that idolizes autonomy. Our suffering does not reduce our dignity. It is precisely the patients who fear being a burden and losing autonomy that palliative care and counselling are designed to help.  

A fifth misleading aspect of Uncle Louis’s case is that, in reality, it is unlikely that MAiD patients will have the same personal freedom and autonomy as Uncle Louis did. Moreover, their ability for “free autonomous choice” may be severely diminished. In fact, when given a prognosis of less than six months to live, up to 90 percent of patients have been found to have impaired judgment in the short term on at least one of four legal standards (even though physicians regularly assess them as “unimpaired”). Requests for medically assisted suicide by these patients would not be a fully free or autonomous decision. Moreover, euthanasia is often nonvoluntary or at least less than “fully” voluntary. For instance, since 2005, the Netherlands has permitted the “Groningen Protocol,” which allows for euthanizing neonatal infants with the consent of the parents as standard hospital care in certain cases (e.g., for spina bifida). Defenders say this is only done for children, regardless of whether they are actually dying or not, whose suffering would be extreme and have no hope for improvement. Moreover, they assert, this practice merely extends to newborns the type of care that would be offered to the old. Nevertheless, regardless of one’s reasoning, such medical “aid in dying” is certainly nonvoluntary for the child. More recently, in October 2022 the Quebec College of Physicians suggested this possibility for neonates on this side of the Atlantic. 

Such nonvoluntary cases of euthanasia are not confined to neonates. For instance, in 2016 in the Netherlands, a 74-year-old woman with Alzheimer’s had previously written that she would prefer to be euthanized than placed in a nursing home. However, whenever the family brought up the topic after she entered an assisted living facility, the woman would say “not yet” or “that is going a bit far.” Nevertheless, the family decided it was her time and that she did not understand anymore how terrible her life was in her condition; so, without informing her they put a sedative in the mid-morning coffee which she had with her family. The goal was that the woman would go to sleep and a physician would give her the lethal medication. However, the patient awoke when her physician was administering the “medicine.” The doctor had the family help her restrain the woman so she could complete the euthanasia procedure. Courts concluded in 2019 that the doctor acted rightly in this situation and ruled that dementia and Alzheimer’s patients can be euthanized if there is a prior document, even if they cannot now consent to (or seemingly resist) their previously expressed desire for euthanasia. The court ruled that such people can be euthanized because they no longer “understand euthanasia” and are incapable of sound judgment to reject the previous decision 

Similar examples can be found in Canada as well, where the family of one 80-year-old woman with dementia “brought forward” the request for assisted suicide. After she transitioned to a long-term care facility, the family again “initiated” the request for MAiD, and the woman dubiously “express[ed] consent” by repeating back the consent question and squeezing the hand of the healthcare practitioner. Likewise, in 2024 another elderly woman, Mrs. B, was euthanized even after explicitly withdrawing her request for MAiD and instead requesting in home hospice care. Her husband, who was experiencing “caregiver burnout,” brought her to the emergency room after her request was withdrawn. Though she was in stable condition and discharged with palliative care, he requested an urgent MAiD assessment, which was approved, and “MAiD was completed later that evening.” Canada’s own reports note that they lacked documentation or clear evaluation of voluntariness such that this may have been a case of “possible external coercion.”  

Unfortunately, these are not isolated cases of “less than fully voluntary” euthanasia. Canada has already approved allowing an 80-year-old man diagnosed with dementia and Parkinson’s to receive assisted suicide when he is determined to be no longer able to speak and communicate clearly. The Uncle Louis case presumes an autonomous, voluntary choice, but the practice of euthanasia does not warrant that presumption. 

A sixth misleading aspect is that the Uncle Louis case generally recommends itself as a “safe, legal, and rare” healthcare scenario. However, euthanasia and assisted suicide are unlikely to remain rare. In Canada, euthanasia (MAiD) accounted for 5.1 percent of all deaths in 2024 and has grown every year since being legalized. Canada’s own official reports forecast continued expansion. Indeed, current rates in Canada are now 16x what they were when MAiD was legalized in 2016 and have more than doubled again in the last five years. Determining where MAiD ranks in the leading causes of death in Canada is made difficult by the fact that Canada does not list “medical aid in dying” as a cause of death, but rather lists what “initiated the train of events” ending in MAiD. However, when one compares the total number of MAiD deaths in Canada in 2023 (15,343) with figures on the top ten leading causes of death in Canada, one realizes that euthanasia and assisted suicide (MAiD) are now the fourth leading cause of death, behind cancer, heart disease, and accidents.  

So too have numbers in the Netherlands generally followed an upward trajectory, with 5.4 percent of all deaths in 2023 and 5.8 percent in 2024 coming from MAiD generally. For comparison, if there were a similar rate of euthanasia and assisted suicide in the U.S., that would mean that just over 178,000 people would die by medical killing every year. To put this in perspective, that would be more people than the entire resident populations of Charleston, South Carolina or Syracuse, New York. Such cases hardly seem “rare.” 

Seventh, the Uncle Louis case presents euthanasia and assisted suicide as purely self-regarding and without any larger social issues that would merit consideration. However, Uncle Louis’s decision and those of euthanasia programs are not self-regarding. What one affirms as “good” for oneself has implications for those in similar situations and for the less fortunate. For instance, consider again those neonatal children in the Netherlands who are euthanized rather than facing a life of “hopeless and unbearable suffering” because of some deformity. Affirming as rational the idea that “this child is better off dead” doubtless has implications for adults living with the same condition. For this reason, disability advocates are often firm allies with Catholic organizations opposing euthanasia since both seek to affirm the dignity of all. 

Furthermore, as noted above, those countries that have implemented both euthanasia and physician assisted suicide (and who keep good records) have seen dramatic increases in the number of people who seek MAiD. This is not surprising. It is a well-known fact that suicide is a kind of social contagion and has a copy-cat effect. Moreover, this rise in suicidality is not confined merely to “medically assisted” suicide. Despite arguments that euthanasia and assisted suicide could actually reduce overall suicide numbers by giving people the option to receive it nonviolently from a medical professional, the data actually show the opposite. Studies from the Southern Medical Journal and the Journal of Ethics in Mental Health show that having the option of euthanasia or assisted suicide is not associated with a decrease in non-medical suicide; rather, having the option of these practices is correlated with a rise in suicidality in other individuals. These studies found these trends to be the case independently both in Oregon and in the Netherlands, respectively. Such findings are entirely unsurprising and clearly show that euthanasia and assisted suicide are not merely self-regarding acts but influence the rest of society.  

Eighth, the Uncle Louis case presents MAiD as a last resort for “dying with dignity.” This idea is already a myth, especially for the poor. Once assisted suicide becomes “healthcare” and is viewed by society as a “good” offered to patients to help them preserve dignity, why would a society not push this “good” on behalf of its weakest and most vulnerable? Furthermore, MAiD creates a perverse incentive structure for both insurance companies and governments where it can become a cost-saving measure that is preferable to other (and more costly) options. For instance, Stephanie Packer was diagnosed in 2012 in California with a terminal autoimmune lung disease, scleroderma, at 29. She is a mother of 4 and was told she had 3 years to live. When her doctors prescribed a new treatment that could help extend her life in 2015, she was denied coverage by her insurance in California but was told she could have drugs to end her life for a $1.20 co-pay. Indeed, during England’s recent debates over a MAiD bill, advocates openly made the “pragmatic argument” that MAiD will decrease pension costs as well as the general costs of healthcare for the government. The idea that other costly “last resort” options (especially for the poor) will not be used in the face of cheap MAiD drugs is no scare tactic, but rather is a very real “benefit” according to some advocates. End of life care is some of the most expensive care. There will be financial incentives encouraging MAiD. 

However, and perhaps most starkly, the economic model need not be considered at all, since the idea that MAiD will be a last resort is already mythic. The Netherlands does not require those seeking euthanasia (for themselves or neonates) to have a terminal condition. Similarly, neither do Canada or Belgium or Spain. There is no necessity that euthanasia and assisted suicide be a “last resort” for Uncle Louis. In fact, the case of Miriam Lancaster, a Canadian woman in her 80s, perfectly reflects this. In 2025, she was offered MAiD by her physician in Vancouver before ever being told that what she was suffering from was a hairline fracture of the sacrum due to osteoporosis that needed three weeks rest to heal. 

Lastly, the Uncle Louis case claims that the patient has a long-standing relationship with his physician. This is highly unlikely. Leaving aside that many people do not have a consistent, long-term primary care physician, “having a physician that knows you well” is not a standard for any MAiD program. Moreover, such programs tend to push in the opposite direction: requiring that physicians not know the patient in order to preserve “objective” and “independent” assessment. For instance, in Belgium, where those suffering from psychiatric disorders can seek euthanasia, the law requires that for psychiatric MAiD cases a team of three doctors, one attending and “two independent physicians,” who do not know the patient, must agree to the request. There is a one-month waiting period between the most recent written request (which triggers the doctor’s meeting) and the “procedure.” One month and such “independent” physicians do not constitute a long-term close relationship. In fact, things can go very wrong with this. For instance, in 2012 in Belgium Tom Mortier’s mother, Godelieva de Troyer, had depression but was in otherwise good health. She spoke to her primary care physician about euthanasia but the physician did not recommend euthanasia for her depression. The physician wanted to try other options and did not deem her to have “a medically futile” condition. Godelieva instead went to a different doctor with whom she had no long-term relationship and who had no psychiatric qualifications but who would recommend euthanasia for “incurable depression.” Tom’s mother died by lethal injection after two other physicians, both of whom were psychiatrists, also agreed. Tom Mortier and his siblings only found out afterwards when the hospital called for him to retrieve his mother’s body and take care of her affairs. 

Thirty years ago Keenan predicted that just as when abortion was legalized and was largely relegated to specialized clinics outside of hospitals, so too a similar situation would likely develop with MAID. In such a scenario, he suggested, MAiD procedures would be done by clinicians whom patients did not know and who did not have a long-term relationship with their patients. This exact pattern appears to be taking shape in Canada. 361 providers performed 66% of Canada’s 15,343 MAiD cases in 2023 and 174 providers performed almost half (48.5%). Moreover, a mere 89 providers accounted for 5345 deaths (35%), i.e., an average of 60 deaths each and more than one euthanasia each week. If these numbers and Tom Mortier’s mother are any indication, then Keenan was right. 

The Case of Uncle Louis, while emotionally and rhetorically powerful, tries to present euthanasia to us as about the individual rights of a man who has exhausted all his treatments, consulted with his physician, and who faces uncontrollable pain. Nevertheless, this case is largely fictitious or highly misleading in no fewer than nine ways. The more likely example of the average euthanasia case is that of a woman who is worried about being a burden to others as her “autonomy” decreases and who fears the loss of independence. If she is worried about pain management at all, it is because her healthcare system at times struggles to properly regulate pain. In this example we are far from the standard rhetorical autonomy case. Indeed, despite thirty years passing since the publication of his article, Keenan’s strong conclusion rings as true today as it did when he wrote it. The Uncle Louis case “is evidently inadequate when confronted with the more likely case of an isolated and depressed woman who does not want to be a burden and who has at best uncertain access to adequate health care and whose own wishes are rarely elicited or heeded.” The most likely case of euthanasia going forward is not Uncle Louis but that of Aunt Mary—“a widow facing a chronic illness, fearing dependency on her children [and extended family], …and who therefore, without a personal physician with whom she can talk, is depressed.” Indeed, proponents who want to “help” Uncle Louis are seeking to invalidate “the same law that keeps the more common Mary X from being marginalized to death.” In fact, Henry Marsh, a neurosurgeon for the British National Health Service, bluntly confirmed this during England’s recent debate over assisted suicide, “They argue that grannies will be made to commit suicide. Even if a few grannies get bullied into it, isn’t that the price worth paying for all the people who could die with dignity?” 

If the “Uncle Louis Case” is woefully misleading, where does this leave us? Ultimately, we must recognize that despite all rhetorical examples, the “pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love.” In reality, it is not intense pain that motivates the drive for euthanasia and assisted suicide. Rather, the cry for death is in reality a cry of desperation from the depressed and isolated, in short, the plea for love. Uncle Louis (or any other patient who is suffering and/or dying) should not be medically killed, or confirmed by others in the idea that he or society would be better off with him dead. The sick should be loved to the very end and affirmed as a beloved part of our community. Acting intentionally to end another’s life because she is infirm or suffering is always gravely wrong and contrary to our common humanity and our dignity. Rather, we must seek to ease their pain, help them heal relationships, and help them know they remain beloved members of our communities. Our society and our families are better off and richer with Uncle Louis and Aunt Mary. They image God to us, and it is always a poverty to lose them. Even when we cannot cure, we can always care for each other.  

Image licensed via Adobe Stock.