Tag: end of life

In October of 1858, John Stuart Mill and his wife, Harriet, were traveling near Avignon, France. She developed a cough, which seemed like just a minor inconvenience, until it got worse. Soon Harriet was racked with pain, not able to sleep or even lie down. Mill frantically wrote to a doctor in Nice, begging him to come see her. Three days later her condition had worsened further, and Mill telegraphed his forebodings to his stepdaughter. Harriet died in their hotel room on November 3.

Mill sat alone with her body in their room for a day. He was despondent over the loss of his marriage: “For seven and a half years that blessing was mine. For seven and a half years only!”

Later that same month, he sent a manuscript to his publisher, which opened with a lavish dedication to Harriet. He subsequently wrote that she had been more than his muse; she had been his co-author. The book was, he said, “more directly and literally our joint production than anything else which bears my name, for there was not a sentence of it that was not several times gone through by us together.” The book’s “whole mode of thinking,” he continued, “was emphatically hers.”

The book was called On Liberty. It is one of the founding documents of our liberal world order. Individuals, the Mills argued, have the right to be the architect of their own life, to choose whom to marry, where to live, what to believe, what to say. The state has no right to impinge on a citizen’s individual freedom of choice, provided that the person isn’t harming anyone else.

A society organized along these lines, the Mills hoped, would produce a rich variety of creative and daring individuals. You wouldn’t have to agree with my mode of life, and I wouldn’t have to agree with yours, but we would give each other the space to live our fullest life. Individual autonomy and freedom of choice would be the rocks upon which we built flourishing nations.

The liberalism that the Mills championed is what we enjoy today as we walk down the street and greet a great variety of social types. It’s what we enjoy when we get on the internet and throw ourselves into the messy clash of ideas. It is this liberalism that we defend when we back the Ukrainians in their fight against Russian tyranny, when we stand up to authoritarians on the right and the left, to those who would impose speech codes, ban books, and subvert elections.

After he sent in the manuscript, Mill bought a house overlooking the cemetery where Harriet was buried, filled it with furniture from the room in which she’d died, and visited every year for the rest of his life. It’s a sad scene to imagine—him gazing down at her grave from the window—but the couple left us an intellectual legacy that has guided humanity another step forward in civilization’s advance.

Many good ideas turn bad when taken to their extreme. And that’s true of liberalism. The freedom of choice that liberals celebrate can be turned into a rigid free-market ideology that enables the rich to concentrate economic power while the vulnerable are abandoned. The wild and creative modes of self-expression that liberals adore can turn into a narcissistic culture in which people worship themselves and neglect their neighbors.

These versions of liberalism provoke people to become anti-liberal, to argue that liberalism itself is spiritually empty and too individualistic. They contend that it leads to social breakdown and undermines what is sacred about life. We find ourselves surrounded by such anti-liberals today.

I’d like to walk with you through one battlefield in the current crisis of liberalism, to show you how liberalism is now threatened by an extreme version of itself, and how we might recover a better, more humane liberalism—something closer to what the Mills had in mind in the first place.

In 2016, the Canadian government legalized medical assistance in dying. The program, called MAID, was founded on good Millian grounds. The Canadian Supreme Court concluded that laws preventing assisted suicide stifled individual rights. If people have the right to be the architect of their life, shouldn’t they have the right to control their death? Shouldn’t they have the right to spare themselves needless suffering and indignity at the end of life?

As originally conceived, the MAID program was reasonably well defined. Doctors and nurses would give lethal injections or fatal medications only to patients who met certain criteria, including all of the following: the patient had a serious illness or disability; the patient was in an “advanced state” of decline that could not be reversed; the patient was experiencing unbearable physical or mental suffering; the patient was at the point where natural death had become “reasonably foreseeable.”

To critics who worried that before long, people who were depressed, stressed, or just poor and overwhelmed would also be provided assistance to die, authorities were reassuring: The new law wouldn’t endanger those who are psychologically vulnerable and not near death. Citing studies from jurisdictions elsewhere in the world with similar laws, Prime Minister Justin Trudeau declared that this “simply isn’t something that ends up happening.”

But the program has worked out rather differently. Before long, the range of who qualifies for assisted suicide was expanded. In 2021, the criterion that natural death must be “reasonably foreseeable” was lifted. A steady stream of stories began to appear in the media, describing how the state was granting access to assisted suicide to people who arguably didn’t fit the original criteria.

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If you are having thoughts of suicide, please know that you are not alone. If you’re in danger of acting on suicidal thoughts, call 911. For support and resources, call the National Suicide Prevention Lifeline at 988 or text 741741 for the Crisis Text Line.

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For example, the Associated Press reported on the case of Alan Nichols. Nichols had lost his hearing in childhood, and had suffered a stroke, but for the most part was able to live independently. In June 2019, at age 61, he was hospitalized out of concern that he might be suicidal. He urged his brother Gary to “bust him out” of the facility as soon as possible. But within a month, he applied for a physician-assisted death, citing hearing loss as his only medical condition. A nurse practitioner also described Nichols’s vision loss, frailty, history of seizures, and general “failure to thrive.” The hospital told the AP that his request for a lethal injection was valid, and his life was ended. “Alan was basically put to death,” his brother told the AP.

In The New Atlantis, Alexander Raikin described the case of Rosina Kamis, who had fibromyalgia and chronic leukemia, along with other mental and physical illnesses. She presented these symptoms to the MAID assessors and her death was approved. Meanwhile, she wrote in a note evidently meant for those to whom she had granted power of attorney: “Please keep all this secret while I am still alive because … the suffering I experience is mental suffering, not physical. I think if more people cared about me, I might be able to handle the suffering caused by my physical illnesses alone.” She was put to death on September 26, 2021, via a lethal injection, at the age of 41.

Read: Is aid in dying a better death?

In The Free Press, Rupa Subramanya reported on the case of a 23-year-old man named Kiano Vafaeian, who was depressed and unemployed, and also had diabetes and had lost vision in one eye. His death was approved and scheduled for September 22, 2022. The doctor who was to perform the procedure emailed Vafaeian clear and antiseptic instructions: “Please arrive at 8:30 am. I will ask for the nurse at 8:45 am and I will start the procedure at around 9:00 am. Procedure will be completed a few minutes after it starts.” Vafaeian could bring a dog with him, as long as someone would be present to take care of it.

About two weeks before the appointment, Vafaeian’s 46-year-old mother, Margaret Marsilla, telephoned the doctor who was scheduled to kill her son. She recorded the call and shared it with The Free Press. Posing as a woman named Joann, she told the doctor that she wanted to die by Christmas. Reciting basic MAID criteria, the doctor told her that she needed to be over 18, have an insurance card, and be experiencing “suffering that cannot be remediated or treated in some way that’s acceptable to you.” The doctor said he could conduct his assessment via Zoom or WhatsApp. Marsilla posted on social media about the situation. Eventually, the doctor texted Marsilla, saying that he would not follow through with her son’s death.

Personally, I don’t have great moral qualms about assisted suicide for people who are suffering intensely in the face of imminent death. These cases are horrible for individuals and families. What’s important here is that the MAID program has spilled beyond its original bounds so quickly.

When people who were suffering applied to the MAID program and said, “I choose to die,” Canadian society apparently had no shared set of morals that would justify saying no. If individual autonomy is the highest value, then when somebody comes to you and declares, “It’s my body. I can do what I want with it,” whether they are near death or not, painfully ill or not, doesn’t really matter. Autonomy rules.

Within just a few years, the number of Canadians dying by physician-assisted suicide ballooned (the overwhelming majority of them by lethal injection). In 2021, that figure was more than 10,000, one in 30 of all Canadian deaths. The great majority of people dying this way were elderly and near death, but those who seek assisted suicide tend to get it. In 2021, only 4 percent of those who filed written applications were deemed ineligible.

If autonomy is your highest value, these trends are not tragic; they’re welcome. Death is no longer the involuntary, degrading end of life; it can be a glorious act of self-expression. In late 2022, the Canadian fashion retailer La Maison Simons released a branding video that paid tribute to the assisted suicide of a 37-year-old woman afflicted with Ehlers-Danlos syndrome, which affects the body’s connective tissue. The video, titled “All Is Beauty,” was released the day after the woman’s death. In a series of lush images of her on tourist-destination beaches and at a dinner party, the video portrayed her death as “the most beautiful exit”—a sort of rich, Instagram-ready consumer experience that you might get from a five-star resort.

Back in 2016, critics of the MAID law saw this coming. They warned that soon enough, people in anguish and near death wouldn’t be the only ones given assistance to die. That warning turned out to be understated. Within a few years, Canada went from being a country that had banned assisted suicide to being one of the loosest regimes in the world.

Some people leading pathos-filled lives have begun to see assisted suicide as a release from their misery. Michael Fraser, though not terminally ill at age 55, had become unable to walk and suffered from an array of medical problems—liver disease and incontinence, as well as mental-health issues after what he described as prolonged sexual abuse as a child. His monthly check from the Ontario Disability Support Program was barely enough to live on. “Some of the struggles he talked to me about was this feeling of not being worthy,” the doctor who gave Fraser a lethal injection on July 2, 2022, told the Toronto Star. “There’s a social aspect to poverty, a hierarchy, that affected his psyche. He told me that it did.”

As assisted suicide has become an established part of Canadian society, the complex moral issues surrounding the end of life have drifted out of sight. Decisions tend to be made within a bureaucratic context, where utilitarian considerations can come to dominate the foreground. Or as the president of the Quebec College of Physicians, which regulates medical practice in the province, put it, assisted suicide “is not a political or moral or religious issue. It is a medical issue.” A materialist cost-benefit analysis, for some people, crowds out affirmations that life is sacred, and socioeconomic burdens weigh heavily in the balance.

Tyler Dunlop is a physically healthy 37-year-old man who suffers from schizoaffective disorder and PTSD, and has no job or home or social contact. “When I read about medically assisted dying,” he told a local news website earlier this year, “I thought, well, logistically, I really don’t have a future.” Knowing that “I’m not going anywhere,” as he put it, he has started the process for approval under MAID. The New Atlantis published slides from a Canadian Association of MAID Assessors and Providers seminar, in which a retired care coordinator noted that a couple of patients had cited poverty or housing uncertainty, rather than their medical condition, as their main reason for seeking death.

Health-care costs also sometimes come into play. According to the Associated Press, Roger Foley, a patient at a hospital in Ontario who has a degenerative brain disorder, was disturbed enough by how often the staff talked about assisted dying that he began recording their conversations. The hospital’s director of ethics informed Foley that if he were to stay in the hospital, it would cost Foley “north of $1,500 a day.” Foley replied that he felt he was being coerced into death. “Roger, this is not my show,” the ethicist replied. “I told you my piece of this was to talk to you about if you had an interest in assisted dying.” (The hospital network told The Atlantic that it could not comment on specific patients for privacy reasons and added that its health-care teams do not discuss assisted dying unless patients express interest in it.)

These trends have not shocked Canadian lawmakers into tightening the controls on who gets approved for MAID, or dramatically ramping up programs that would provide medical and community-based help for patients whose desperation might be addressed in other ways. On the contrary, eligibility may expand soon. On February 15, a parliamentary committee released a set of recommendations that would further broaden MAID eligibility, including to “mature minors” whose death is “reasonably foreseeable.” The influential activist group Dying With Dignity Canada recommends that “mature minors” be defined as “at least 12 years of age and capable of making decisions with respect to their health.” Canada is scheduled to move in 2024 to officially extend MAID eligibility to those whose only illness is a mental disorder.

The frame of debate is shifting. The core question is no longer “Should the state help those who are suffering at the end of life die?” The lines between assisted suicide for medical reasons, as defined by the original MAID criteria, and straight-up suicide are blurring. The moral quandary is essentially this: If you see someone rushing toward a bridge and planning to jump off, should you try to stop them? Or should you figure that plunging into the water is their decision to make—and give them a helpful shove?

I don’t mean to pick on Canada, the land of my birth. Lord knows that, in many ways, Canada has a much healthier social and political culture—less bitter and contentious—than the United States does. I’m using the devolution of the MAID program to illustrate a key feature of modern liberalism—namely, that it comes in different flavors. The flavor that is embedded in the MAID program, and is prevalent across Western societies, is what you might call autonomy-based liberalism.

Autonomy-based liberalism starts with one core conviction: I possess myself. I am a piece of property that I own. Because I possess property rights to myself, I can dispose of my property as I see fit. My life is a project that I am creating, and nobody else has the right to tell me how to build or dispose of my one and only life.

The purpose of my life, in this version of liberalism, is to be happy—to live a life in which my pleasures, however I define them, exceed my pains. If I determine that my suffering outweighs my joys, and that things will never get better, then my life isn’t working. I have a right to end it, and the state has no right to prevent me from doing so; indeed, it ought to enable my right to end my life with dignity. If you start with autonomy-based liberalism, MAID is where you wind up.

But there is another version of liberalism. Let’s call this gifts-based liberalism. It starts with a different core conviction: I am a receiver of gifts. I am part of a long procession of humanity. I have received many gifts from those who came before me, including the gift of life itself. The essential activity of life is not the pursuit of individual happiness. The essential activity of life is to realize the gifts I’ve been given by my ancestors, and to pass them along, suitably improved, to those who will come after.

Gifts-based liberals, like autonomy-based liberals, savor individual choice—but our individual choices take place within the framework of the gifts we have received, and the responsibilities to others that those gifts entail. (This understanding of choice, I should note, steers a gifts-based liberal away from both poles in the American abortion debate, endorsing neither a pure abortion-rights stance rooted in bodily autonomy, nor a blanket ban that ignores individual circumstances and pays no heed to a social consensus.) In our lives, we are citizens and family members, not just individuals and property owners. We have obligations to our neighbors as well as to those who will come after us. Many of those obligations turn out to be the sources of our greatest joy. A healthy society builds arrangements and passes laws that make it easier to fulfill the obligations that come with our gifts. A diseased society passes laws that make it easier to abandon them.

I’m going to try to convince you that gifts-based liberalism is better than autonomy-based liberalism, that it rests on a more accurate set of assumptions about what human life is actually like, and that it leads to humane modes of living and healthier societies.

Let me start with four truths that gifts-based liberalism embraces and autonomy-based liberalism subverts:

You didn’t create your life. From the moment of your birth, life was given to you, not earned. You came out bursting with the gift of being alive. As you aged, your community taught you to celebrate the prodigality of life—the birds in their thousands of varieties, the deliciousness of the different cheeses, the delightful miracle of each human face. Something within us makes us desperately yearn for longer life for our friends and loved ones, because life itself is an intrinsic good.

The celebration of life’s sacredness is so deeply woven into our minds, and so central to our civilization, that we don’t think about it much until confronted with shocking examples of when the celebration is rejected. For example, in the early 2000s, a German man named Armin Meiwes put an ad online inquiring whether anybody would like to be killed and eaten. A man came by and gave his consent. First, Meiwes cut off the man’s penis, and the two men attempted to eat it together. Then Meiwes killed and butchered him; by the time of his arrest, he had consumed more than 40 pounds of his flesh. Everything was done with the full consent of both participants, but the extreme nature of the case forced the German court system not only to sentence Meiwes to life in prison, but to face an underappreciated yet core pillar of our civilization: You don’t have the right to insult life itself. You don’t have the right to turn yourself or other people into objects to be carved up and consumed. Life is sacred. Humanity is a higher value than choice.

You didn’t create your dignity. No insignificant person has ever been born, and no insignificant day has ever been lived. Each of us has infinite dignity, merely by being alive. We can do nothing to add to that basic dignity. Getting into Harvard doesn’t make you more important than others, nor does earning billions of dollars. At the level of our intrinsic dignity, all humans are radically equal. The equal dignity of all life is, for instance, the pillar of the civil-rights movement.

Once MAID administrators began making decisions about the life or death of each applicant based on the quality of their life, they introduced a mode of thinking that suggests that some lives can be more readily extinguished than others—that some lives have more or less value than others. A human being who is enfeebled, disabled, depressed, dwindling in their capacities is not treated the same way as someone who is healthier and happier.

When such a shift occurs, human dignity is no longer regarded as an infinite gift; it is a possession that other humans can appraise, and in some cases erase. Once the equal and infinite dignity of all human life is compromised, everything is up for grabs. Suddenly debates arise over which lives are worth living. Suddenly you have a couple of doctors at the Quebec College of Physicians pushing the envelope even further, suggesting that babies with severe deformations and limited chances of survival be eligible for medically assisted death. Suddenly people who are ill or infirm are implicitly encouraged to feel guilty for wanting to live. Human dignity, once inherent in life itself, is measured by what a person can contribute, what level of happiness she is deemed capable of enjoying, how much she costs.

You don’t control your mind. “From its earliest beginning,” Francis Fukuyama writes, “modern liberalism was strongly associated with a distinctive cognitive mode, that of modern natural science.” In liberal societies, people are supposed to collect data, weigh costs and benefits, and make decisions rationally. Autonomy-based liberalism, with its glorification of individual choice, leans heavily on this conception of human nature.

Gifts-based liberals know that no purely rational thinker has ever existed. They know that no one has ever really thought for themselves. The very language you think with was handed down as a gift from those who came before. We are each nodes in a network through which information flows and is refracted. The information that is stored in our genes comes from eons ago; the information that we call religion and civilization comes from thousands of years ago; the information that we call culture comes from distant generations; the information that we call education or family background comes from decades ago. All of it flows through us in deep rivers that are partly conscious and partly unconscious, forming our assumptions and shaping our choices in ways that we, as individuals, often can’t fathom.

Gifts-based liberals understand how interdependent human thinking is. When one kid in high school dies by suicide, that sometimes sets off a contagion, and other kids in that school take their own life. Similarly, when a nation normalizes medically assisted suicide, and makes it a more acceptable option, then more people may choose suicide. A 2022 study in the Journal of Ethics in Mental Health found that in four jurisdictions—Switzerland, Luxembourg, the Netherlands, and Belgium—where assisted dying is legal, “there have been very steep rises in suicide,” including both assisted and unassisted suicide. The physician who assists one person to die may be influencing not just that suicide but the suicides of people he will never see.

From the March 2010 issue: Ludwig Minelli crusades for “the last human right”

Gifts-based liberals understand the limitations of individual reason, and have a deep awareness of human fallibility. Gifts-based liberals treasure having so many diverse points of view, because as individuals, we are usually wrong to some degree, and often to a very large degree. We need to think together, over time, in order to stumble toward the truth. Intellectual autonomy is a dangerous exaggeration.

Gifts-based liberals understand that at many times in life, we’re just not thinking straight—especially when we are sick, in pain, anxious, or depressed. My friend the Washington Post columnist Michael Gerson, who died of cancer last year, once said, “Depression is a malfunction of the instrument we use to determine reality.” When he was depressed, lying voices took up residence there, spewing out falsehoods he could scarcely see around: You are a burden to your friends; you have no future; no one would miss you if you died. This is not an autonomous, rational mind. This is a mind that has gone to war with its host.

In these extreme cases, human fallibility is not just foolish; it is potentially fatal. To cope with those cases, societies in a gifts-based world erect guardrails, usually instantiated in law. In effect the community is saying: No, suicide is out of bounds. It’s not for you to decide. You don’t have the freedom to end your freedom. You don’t have the right to make a choice you will never be able to revisit. Banish the question from your mind, because the answer is a simple no. Individual autonomy is not our ultimate value. Life and belonging are. We are responsible for one another.

You did not create your deepest bonds. Liberal institutions are healthiest when they are built on arrangements that precede choice. You didn’t choose the family you were born into, the ethnic heritage you were born into, the culture you were born into, the nation you were born into. As you age, you have more choices over how you engage with these things, and many people forge chosen families to supplant their biological ones. But you never fully escape the way these unchosen bonds have formed you, and you remain defined through life by the obligations they impose upon you.

Autonomy-based liberals see society as a series of social contracts—arrangements people make for their mutual benefit. But a mother’s love for her infant daughter is not a contract. Gifts-based liberals see society as resting on a bedrock of covenants. Rabbi Jonathan Sacks once captured the difference this way: “A contract is a transaction. A covenant is a relationship. Or to put it slightly differently: a contract is about interests. A covenant is about identity. It is about you and me coming together to form an ‘us.’ ”

A society constructed on gifts-based liberalism does everything it can to strengthen the bedrock layer of covenants. The MAID program, by contrast, actively subverts them. It has led a mother to plead with a doctor not to end her son’s life. It has left a man enraged, feeling that he and his other family members were shut out of the process that led to the killing of his brother. The state, seeing people only as autonomous individuals, didn’t adequately recognize family bonds.

Families have traditionally been built around mutual burdens. As children, we are burdens on our families; in adulthood, especially in hard times, we can be burdens on one another; and in old age we may be burdens once again. When these bonds have become attenuated or broken in Western cultures, many people re-create webs of obligation in chosen families. There, too, it is the burdening that makes the bonds secure.

I recently had a conversation with a Canadian friend who told me that he and his three siblings had not been particularly close as adults. Then their aging dad grew gravely ill. His care became a burden they all shared, and that shared burden brought them closer. Their father died but their closeness remains. Their father bestowed many gifts upon his children, but the final one was the gift of being a burden on his family.

Autonomy-based liberalism imposes unrealistic expectations. Each individual is supposed to define their own values, their own choices. Each individual, in the words of Supreme Court Justice Anthony Kennedy in Planned Parenthood v. Casey, is left to come up with their own “concept of existence, of meaning, of the universe, of the mystery of human life.” If your name is Aristotle, maybe you can do that; most of us can’t. Most of us are left in a moral vacuum, a world in which the meaning of life is unclear, unconnected to any moral horizon outside the self.

Jeffrey Rosen: The Supreme Court justice who believed in America

Autonomy-based liberalism cuts people off from all the forces that formed them, stretching back centuries, and from all the centuries stretching into the future. Autonomy-based liberalism leaves people alone. Its emphasis on individual sovereignty inevitably erodes the bonds between people. Autonomy-based liberalism induces even progressives to live out the sentence notoriously associated with Margaret Thatcher: “There is no such thing as society.” Nearly 200 years ago, Alexis de Tocqueville feared that this state of affairs not only makes

As Émile Durkheim pointed out in 1897, this is pretty much a perfect recipe for suicide. We now live in societies in which more and more people are deciding that death is better than life. In short, autonomy-based liberalism produces the kind of isolated, adrift people who are prone to suicide—and then provides them with a state-assisted solution to the problem it created in the first place.

Gifts-based liberalism, by contrast, gives you membership in a procession that stretches back to your ancestors. It connects you to those who migrated to this place or that, married this person or that, raised their children in this way or that. What you are is an expression of history.

This long procession, though filled with struggles and hardship, has made life sweeter for us. Human beings once lived in societies in which slavery was a foundational fact of life, beheadings and animal torture were popular entertainments, raping and pillaging were routine. But gradually, with many setbacks, we’ve built a culture in which people are more likely to abhor cruelty, a culture that has as an ideal the notion that all people deserve fair treatment, not just our kind of people.

This is progress. Thanks to this procession, each generation doesn’t have to make the big decisions of life standing on naked ground. We have been bequeathed sets of values, institutions, cultural traditions that embody the accumulated wisdom of our kind. The purpose of life, in a gifts-based world, is to participate in this procession, to keep the march of progress going along its fitful course. We may give with our creativity, with our talents, with our care, but many of the gifts people transmit derive from deeper sources.

A few years ago, the historian Wilfred McClay wrote an essay about his mother, a mathematician, in The Hedgehog Review. One day he mentioned to her that H. L. Mencken had suffered a stroke late in life that left him unable to read or write and nearly unable to speak. His mother coolly remarked that if such a fate ever befell her, he should not prolong her life. Without a certain quality of life, she observed, there’s no point in living.

A couple of years later, she suffered a near-fatal stroke that left her unable to speak. She cried the most intense sobs of grief McClay had ever heard. It might have appeared that her life was no longer worth living. But, McClay observed, “something closer to the opposite was true. An inner development took place that made her a far deeper, warmer, more affectionate, more grateful, and more generous person than I had ever known her to be.”

Eventually McClay’s mother moved in with his family. “It wasn’t always easy, of course, and while I won’t dwell on the details, I won’t pretend that it wasn’t a strain. But there are so many memories of those years that we treasure—above all, the day-in-and-day-out experience of my mother’s unbowed spirit, which inspired and awed us all.”

She and her family devised ways to communicate, through gestures, intonations, and the few words she still possessed. She could convey her emotions by clapping and through song. “Most surprisingly, my mother proved to be a superb grandmother to my two children, whom she loved without reservation, and who loved her the same way in return.” McClay noted that her grandkids saw past her disability. They could not have known how they made life worth living for her, but being around her was a joy. After she died, McClay writes that “it took a long time to adjust to the silence in the house.” He concluded, “Aging is not a problem to be solved, my mother taught us. It is a meaning to be lived out.”

Read: Why disability-rights advocates are fighting doctor-assisted suicide

Sometimes the old and the infirm, those who have been wounded by life and whose choices have been constrained, reveal what is most important in life. Sometimes those whose choices have been limited can demonstrate that, by focusing on others and not on oneself, life is defined not by the options available to us but by the strength of our commitments.

If autonomy-based liberals believe that society works best when it opens up individual options, gifts-based liberals believe that society works best when it creates ecologies of care that help people address difficulties all along the path of life. Autonomy-based liberalism is entrenching an apparatus that ends life. Gifts-based liberalism believes in providing varieties of palliative care to those near death and buttressing doctors as they forge trusting relationships with their patients. These support structures sometimes inhibit choices by declaring certain actions beyond the pale. Doctors are there for healing, at all times and under all pressures. Patients can trust the doctor because they know the doctor serves life. Doctors can know that, exhausted and confused though they might be while attending to a patient, their default orientation will be to continue the struggle to save life and not to end life.

John Stuart and Harriet Taylor Mill believed in individual autonomy. But they also believed that a just society has a vision not only of freedom but also of goodness, of right and wrong. Humans, John Stuart Mill wrote, “are under a moral obligation to seek the improvement of our moral character.” He continued, “The test of what is right in politics is not the will of the people, but the good of the people.” He understood that the moral obligations we take on in life—to family, friends, and nation, to the past and the future—properly put a brake on individual freedom of action. And he believed that they point us toward the fulfillment of our nature.

The good of humanity is not some abstraction—it’s grounded in the succession of intimates and institutions that we inherit, and that we reform, improve, and pass on. When a fellow member of the procession is in despair, is suffering, is thinking about ending their life, we don’t provide a syringe. We say: The world has not stopped asking things of you. You still have gifts to give, merely by living among us. Your life still sends ripples outward, in ways you do and do not see. Don’t go. We know you need us. We still need you.

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This article appears in the June 2023 print edition with the headline “The Canadian Way of Death.” When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.