Assisted Dying and Abortion are Connected

Don't backslide on autonomy

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Objections to medical assistance in dying (MAiD) often generalize to other areas of health care. It’s easy to get caught up in the debates about assisted dying and miss this, but it presents a type of consistency test. If an argument against MAiD applies to other areas, we should see what the effects of the argument would be. If they’re bad, it might be because there are relevant differences between MAiD and the other area, so the argument doesn’t actually generalize. Or it might be that the anti-MAiD argument is mistaken, so we need to abandon it.

Abortion is an example. Many of the common objections to MAiD could be used to justify restricting abortion access. I don’t think they should be used this way. Instead, I think they show that the objections to MAiD are mistaken and that, despite what MAiD opponents say, broad access to MAiD is the most ethically justified option.

There Were Abortion Committees

Although abortion access in Canada varies a lot, if you can get to a willing provider in a non-Catholic hospital, you can probably get an abortion at no cost and with few questions asked.

It used to be much worse. From 1968 to 1988, if you wanted a legal abortion, your request would have to be approved by a hospital Therapeutic Abortion Committee, which could only grant approval if it deemed that your “life or health” was endangered. Since a committee required at least three physicians in addition to the abortion provider, smaller hospitals wouldn’t have them, and hospitals weren’t obligated to have one even if they had the staff, so access was limited.

That changed in 1988 with the Supreme Court of Canada’s Morgentaler decision, which got rid of the committees. The basis of the decision is that restricting abortion to when life or health are endangered violates the right to life, liberty, and security of the person: 

Forcing a woman, by threat of criminal sanction, to carry a foetus to term unless she meets certain criteria unrelated to her own priorities and aspirations, is a profound interference with a woman’s body and thus an infringement of security of the person.

The judges add that abortions occur for lots of reasons: “[abortion] is a decision that deeply reflects the way the woman thinks about herself and her relationship to others and to society at large. It is not just a medical decision; it is a profound social and ethical one as well.”    

MAiD’s Expansion Has Some Critics

In 2021, Canada expanded access to MAiD by removing the condition requiring that natural death be reasonably foreseeable. Some people think this was a mistake, since it allowed new cases they think shouldn’t be allowed. I’ve talked about the most well-known ones here, here, here, and here. (A couple of the ones that got picked up by international media were of people who hadn’t been approved for MAiD and didn’t go through with it, but they might have.)

The case that got the most media attention was of Sophia, an Ontario woman with multiple chemical sensitivities (MCS), which causes reactions to common chemicals such as cigarette smoke and cleaning products. She had MAiD last year. The media coverage framed her decision in terms of her failed search to find affordable housing that didn’t trigger her condition. However, in a brief submitted to the Special Joint Committee on Medical Assistance in Dying, Dr. Chantel Perrot, who was one of Sophia’s physicians, quotes an unnamed MCS patient as follows:

Even if I were to find a medically-safe, affordable home, I would still be isolated from the rest of the community, unable to go into public buildings OR visit friends/family [due to the risk of exposure to triggers] …With my health deteriorating… I made the only decision that I felt was available: I chose MAiD now.   

These details are important, since the main case people use as an example of MAiD due to poverty turns out not to be about poverty. (And most of the other popular cases involve people who didn’t actually get MAiD.) But even if Sophia’s decision had been about housing, MAiD still would have been ethically acceptable. Lack of affordable housing is a preventable tragedy, but banning MAiD would have condemned Sophia to years of intolerable suffering, which would have been worse.

Not so, say the critics. For them, if finances play a role in your medical decision, then you were coerced. Or, if circumstance forces a choice, especially unjust circumstances of the sort Sophia faced, then your decision isn’t sufficiently autonomous and shouldn’t be respected. 

The thing is, these arguments apply to abortion too. My sense is that many of the people who are against MAiD expansion support liberal abortion laws, so I think they’re being inconsistent. The way to resolve the inconsistency is not to restrict abortion, but to support expanded MAiD. Here are some of the common anti-MAiD arguments and how they apply to abortion.

1. We should prohibit MAiD when finances play a role in the decision

It’s a tragedy, and sometimes an injustice, when money influences someone’s choice to get MAiD. In the media version, poverty was the reason Sophia chose MAiD, though we now know this isn’t true. (Dr. Perrot said that Sophia would be appalled to know she was described as living in poverty.) It was also the basis of Amir Farsoud’s MAiD request. He said that “I don’t want to die but I don’t want to be homeless more than I don’t want to die.”

This argument generalizes. If we should ban MAiD when finances play a role—perhaps because we worry that it isn’t actually a free choice—then we should ban other healthcare decisions when finances play a role. So we might ask how often money plays a role in abortion decisions. In a U.K. survey last year, 60.5 percent of respondents who had an abortion in the last five years said that the high cost of childcare was a reason for their decision. Almost 20 percent said it was the main reason. For women of colour, over seventy percent said money was a factor.

If they’re coerced by circumstance, then we should ban abortion. But we shouldn’t ban abortion, because, even when people are put in bad situations, they can still make informed decisions in line with their values. Abortion decisions are still autonomous, so MAiD decisions are too. The alternative in both cases is worse.

2. People will get pressured into choosing MAiD

Opponents of MAiD expansion often worry that people will be pressured or coerced into choosing it. Sara Jama, the executive director of Disability Justice Network of Ontario, told the Special Joint Committee that she objects to MAiD expansion because it amounts to “systemic coercion” and that “We can’t lose another single life of somebody who should have been fed or housed or offered therapy.”

I agree with Jama that voluntary choice is important, and that the government should be doing more to address the housing shortage and long healthcare wait times. MAiD assessors are required to assess voluntariness, as are healthcare providers as part of any consent process. The problem is that, if you think that systemic factors inhibit voluntary consent for MAiD, then you should also think that abortion is systemically coerced. This would justify restricting abortion access for the U.K. women who had an abortion because they couldn’t afford childcare. 

But we shouldn’t restrict access to abortion. Even if people are being pressured by circumstance, they can still make autonomous decisions. I’ve also argued that coercion presents a paradox. Even if we knew for sure that someone was being coerced, that doesn’t mean that it would be wrong to perform the procedure they’re being coerced to do, though it also doesn’t mean we should do it.   

3. MAiD should be reserved for medical reasons   

Here’s philosopher Daryl Pullman in a recent Impact Ethics article describing Canada’s ‘out-of-control MAiD regime’:

When a society devolves to the point where it redefines every kind of social injustice as a “medical problem” such that MAiD is a legitimate or even preferred option, society in general and bioethicists in particular must consider the moral options. Either we challenge the legal and moral processes that now sanction such desperate actions, or we perform the moral and intellectual gymnastics necessary to justify those tragic “choices”.

Pullman’s view is that Sophia didn’t make an autonomous choice. And, since her choice wasn’t autonomous, we shouldn’t respect it. (I’m not sure what Pullman’s views on abortion are—I emailed him to ask about this argument but haven’t heard back.)

My interpretation of his argument is that it’s a mistake to apply a medical solution to a social problem. The argument is that, since Sophia’s decision was (incorrectly!) portrayed as being about housing, MAiD is the wrong tool because MAiD is a medical intervention.

Now, as I’ve said a bunch, the lack of affordable housing in Canada is a tragedy that should be addressed. Pullman’s mistake is thinking that medicine, or at least MAiD, is just for medical stuff, but it’s not. Instead, medicine is a powerful means for helping people live according to their values, even if those choices are influenced by social injustices.   

To see why, here’s the abortion version of his argument, which only requires changing one word:

When a society devolves to the point where it redefines every kind of social injustice as a “medical problem” such that abortion is a legitimate or even preferred option, society in general and bioethicists in particular must consider the moral options.

As the U.K. survey shows, people have abortions in response to social injustices all the time. Abortion was once restricted to medical factors, but that limitation was appropriately eliminated. Here’s the Morgentaler decision again: “[abortion] is not just a medical decision; it is a profound social and ethical one as well.” 

One woman quoted in the U.K. survey said that

I have found it heartbreaking that I have had to have an abortion primarily because we could not afford the cost of childcare. If I had continued my pregnancy of a much wanted child I would have had to quit my job to care for them, this would have meant we had to sell our home as one salary would not cover the bills.

Is this a tragedy? Absolutely. Would banning abortion help? No. So, we shouldn’t ban MAiD either.   

Liberty and Justice For All

All these arguments against MAiD also apply to abortion: people aren’t making free choices, abortion is just for health, and the lack of money, housing, and social assistance is coercive. I think they clearly fail when applied to abortion. This isn’t because abortion and MAiD are different, though there are differences between them, but because the arguments against MAiD don’t work.

So why are people taken in by them? In one way or another, the mistake stems from a well-meaning interest in protecting people. But the objections overdo it. Liberty and autonomy are the foundations of abortion: people have the right to make important decisions about their bodies. We trust that people can make their own decisions about abortion, and even if they might make mistakes, it isn’t the role of doctors or the government to override their decision. The argument generalizes.