Until very recently, all countries prohibited euthanasia, although it has been legally tolerated - not legalised but not prosecuted, provided it complies with various conditions - since the early 1970s in the much studied and cited case of the Netherlands. Many countries are now experiencing an unprecedented rise in calls to legalise euthanasia - some of which from within the medical profession.

The euthanasia debate is a momentous one. It involves problems that range from the nature and meaning of human life to the most fundamental principles on which societies are based. This debate involves our individual and collective past (the ethical, legal and cultural norms that have been handed down to us as members of families, groups and societies); the present (whether we will change those norms); and the future (the impact that this would have on those who come after us).

This means that we must consider the impact of legalising euthanasia, not only at an individual level (which, in the mass media, and therefore in the general public forum, has been the focus of debate), but also at institutional, governmental and societal levels. And not only in the present but also for the future. We need to consider not only factual realities - such as the possibilities for abuse - that legalising euthanasia would open up, but also the effect that doing so would have on the values and symbols that make up the intangible fabric that constitutes our society and on some of our most important societal institutions.

What do we mean by "euthanasia"?

Whatever one's personal position on the acceptability of euthanasia, it is essential to know what we mean by that word. Euthanasia is a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person's suffering. Refusals of treatment - including life-support treatment or artificial hydration and nutrition - and provision of necessary treatment for the relief of pain or other symptoms of serious physical distress are not euthanasia, even if they do shorten life. In the latter case, the primary intention is to respect the right to inviolability - the right not to be touched without consent - or to relieve pain, not to inflict death (as it is in the former case).

The term "physician-assisted suicide" is often used to describe what is really euthanasia. The physician carries out the act that causes death. In physician-assisted suicide, properly so-called, physicians would give patients the means to kill themselves with the intent that patients would so use them. Legally, there is a difference between physician-assisted suicide and euthanasia. The latter is homicide, not suicide. It is either murder or manslaughter under the criminal law in the United Kingdom, Australia, Canada and each state of the United States. Criminal liability for physician-assisted suicide would lie in aiding, abetting or counselling another person to commit suicide.

The use of terms such as "physician-assisted suicide" - or the even more ambiguous "physician-assisted death" - to mean euthanasia, leads to confusion. But although these interventions are legally distinct crimes (and, some believe, morally distinguishable), at a societal level many of the worries that legalising them would present would be the same. From this perspective, they can be discussed together. Unless some distinction must be made, therefore, I use the word "euthanasia" to include physician-assisted suicide.

It is necessary, and only honest, to state at the outset where one stands. I am against legalisation. I cannot argue against euthanasia from an empirical base, however. Carrying out euthanasia constitutes a very serious criminal offence in the vast majority of jurisdictions; consequently, research may not be undertaken to produce "hard" evidence of the impact that legalising it would have. This leaves opponents of legalisation open to the criticism and challenge that their arguments are purely speculative and lacking in scientific rigour.

This difficulty has become manifest in another way. The burden of proof has somehow shifted from those who promote legalisation to those who oppose it. This leads to what many of us would see as a lamentable situation. How ironic that the norm that we must not kill now must be defended more vigorously than its opposite.

The problem of producing evidence is not as severe for those who are pro-euthanasia, because they base their case on respect for individual autonomy, the failure of palliative care to relieve all suffering, and often the allegation that physicians are secretly practising euthanasia anyway. They can use polls and surveys - which have the appearance, at least, of producing "hard" data - to show that many people believe they should have a right of access to euthanasia, that the suffering of some terminally ill patients cannot be relieved, and that some physicians admit to carrying out euthanasia.

The fact that it is easier to establish the case for legalisation than against it, moreover, could distort the process of making a decision about legalising euthanasia and, consequently, the ultimate decision. Other facts would have the same effect. It would be an interesting research project to compare the number of pro- and of anti-euthanasia articles in leading medical journals and examine the reasons for any discrepancies found between these numbers. I predict that most would be pro-euthanasia. If so, we would need to take care that the popularity of that position does not unjustifiably influence the decision.

Legalising euthanasia - why now?

So why are we considering legalising euthanasia now, after our society has prohibited it for almost two millennia? It is true that the population is aging; modern medicine has extended our life span with the result that it is more likely now than in the past that we will die of chronic degenerative diseases, not acute ones. It is true also that many countries lack adequate palliative care. It is true that some physicians are ignorant about treatments for the relief of pain and suffering. And it is true that some of them either fail or refuse to provide them.

Medical practice, too, has also changed. A lifetime relationship with "the family doctor" is largely a relic of the past. And the isolation that people can experience in seeking help from health-care professionals is probably a reflection of the wider isolation that individuals and families experience. But the capacity to relieve pain and suffering has improved remarkably. Not one of the bottom-line conditions usually seen as linked with the call for euthanasia - that terminally ill people want to die and that we can kill them - is new. These factors have been part of the human condition for as long as humans have existed. Why, then, are we considering such a radically different response to this situation?

I suggest that the principal cause is not a change in the situation of individuals who seek euthanasia; rather, it is profound changes in our secular, Western, democratic societies. Some of these changes involve trends that have been emerging since the eighteenth century, but only recently have all co-existed and each overwhelmingly dominated its opposite, or countervailing, trend.

The factors that I single out here do not constitute a comprehensive list. They are not all of the same nature, so they are not all treated in the same way or depth. Indeed, I mention some very briefly. In any case, each requires a much more thorough examination. And my conclusions about their strength, causal link to euthanasia, or impact are clearly open to challenge. My aim is to provide a rough map - a somewhat impressionistic overview - of the societal and cultural factors giving rise to and influencing the movement to legalise euthanasia. (Keep in mind that there are still strong forces that resist the legalisation of euthanasia, most notably the Catholic Church, evangelical Christian churches, Orthodox Judaism and Islam.)

Individualism

Our society is based on "intense individualism" (much as we might regard this as perverted or distorted version of individualism as it was understood by the eighteenth-century founders of American democracy) - possibly, individualism to the exclusion of any real sense of community - even in connection with death and bereavement. If this highly individualistic approach is applied to euthanasia, especially in a society that gives pre-eminence to personal autonomy and self-determination, it is likely to result in the belief that euthanasia is acceptable.

There seems to be either a total lack of consciousness or a denial that this kind of individualism can undermine the intangible infrastructure on which society rests, the communal and cultural fabric. Individualism untempered by at least concern and perhaps the duty to protect and promote community will inevitably result in destruction of the community. Thus, although legalising euthanasia is a result of unbridled individualism, the latter would also promote it, at least in terms of balance between the individual and the community.

There is yet another sense in which "intense individualism" might give rise to calls for euthanasia. In Western societies, death is largely a medical event that takes place in a hospital or other institution and is perceived as occurring in great isolation - patients are alone, separated from those they love and the surrounding with which they are familiar. Death has been institutionalised, depersonalised and dehumanized. "Intense individualism" and seeking to take control, especially through euthanasia, are predictable and even reasonable responses to the circumstances. To avoid legalising euthanasia, therefore, we must give death a more human scale and face.

Media

At first, we created our collective story in each other's physical presence. Later on, we had books and print media, which meant that we could do so at a physical distance from each other. Now, for the first time, we can do so through film, television and social media and, consequently, at a physical distance from - but still in sight of - each other no matter where we live on the planet.

We do not know how this will affect the stories we tell each other in order to create our shared story, our societal and cultural paradigm - the store of values, attitudes, beliefs, commitments and myths - that informs our collective life and through that our individual lives and helps to give them meaning. Creating a shared story through the mass media could alter the balance between the various components that make it up. In particular, we might engage in too much "death talk" and too little "life talk." We can be most attracted to that which we most fear, and the mass media provide an almost infinite number of opportunities to indulge our fear of, and attraction to, death.

Failure to take into account societal and cultural level issues related to euthanasia is connected with "mediatization" of our societal dialogues in general and the one about euthanasia in particular. We see these only as presented by the media, which introduces additional ethical issues - those of "media ethics." The arguments against euthanasia, based on the harm that it would do to society in both the present and the future, are very much more difficult to present in the mass media than arguments for euthanasia, which can make for dramatic, emotionally gripping television. Anti-euthanasia arguments do not make dramatic and compelling television. Visual images are difficult to find. Viewers do not personally identify with these arguments that come across as just abstractions or ideas in the same way that they do with those of dying people who seek euthanasia. Society cannot be interviewed on television and become a familiar, empathy-evoking figure to the viewing public.

Only if euthanasia were legalised and there were obvious abuses - such as proposals to use it on those who want to continue living - could we create comparably riveting and gripping images to communicate the case against euthanasia. Ironically, the most powerful way in which the case against euthanasia has been presented on television is probably through Jack Kevorkian's efforts to promote euthanasia and the revulsion they evoked in many viewers, including many of those who support euthanasia.

When it comes to euthanasia, it could be argued, people react one way in theory and another in practice. It is much easier to approve of euthanasia in theory than in practice, which probably reflects moral anxiety about euthanasia and an ethical intuition as to its dangers. That should send a deep warning, which should be heeded.

Denial and control of death and "death talk"

Ours is a death-denying, death-obsessed society. Those who no longer adhere to the practice of institutionalised religion, at any rate, have lost their main forum for engaging in "death talk." As humans, we need to engage in it if we are to accommodate the inevitable reality of death into the living of our lives. And we must do that if we are to live fully and well. Arguably, our extensive discussion of euthanasia in the media is an example of contemporary "death talk." Instead of being confined to an identifiable location and an hour a week, it has spilled out into our lives in general. This makes it more difficult to maintain the denial of death, because it makes the fear of death more present and "real."

One way to deal with this fear, is to believe that we have death under control. The availability of euthanasia could support that belief. Euthanasia moves us from chance to choice concerning death. (The same movement can also be seen at the very beginning of human life, when it results from the use of new reproductive and genetic technologies at conception or shortly thereafter.) Although we cannot make death optional, we can create an illusion that it is by making its timing and the conditions and ways in which it occurs a matter of choice.

Fear

We are frightened not only as individuals, however, but also as a society. Collectively, we express the fear of crime in our streets. But that fear, though factually based, might also be a manifestation of a powerful and free-floating fear of death in general. Calling for the legalisation of euthanasia could be a way of symbolically taming and civilising death - reducing our fear of its random infliction through crime. If euthanasia were experienced as a way of converting death by chance to death by choice, it would offer a feeling of increased control over death and, therefore, decreased fear. We tend to use law as a response to fear, often in the misguided belief that this will increase our control of that which frightens us and hence augment our safety.

Legalism

It is not surprising, therefore, that we have to varying degrees become a legalistic society. The reasons are complex and include the use of law as a means of ordering and governing a society of strangers, as compared with one of intimates. Matters such as euthanasia, which would once have been the topic of moral or religious discourse, are now explored in courts and legislatures - especially through concepts of individual human rights, civil rights and constitutional rights.

Man-made law (legal positivism), as compared with divinely ordained law or natural law, has a dominant role in establishing the values and symbols of a secular society. In the euthanasia debate, it does so through the judgements and legislation that result from the "death talk" that takes place in "secular cathedrals" - courts and legislatures. It is to be expected, therefore, that those trying to change society's values and symbols would see this debate as an opportunity to further their aims and, consequently, seek the legalisation of euthanasia.

Materialism and consumerism

Another factor, which I can mention only in passing, is that our society is highly materialistic and consumeristic. It has lost any sense of the sacred, even just of the "secular sacred." The result favours a pro-euthanasia position, because a loss of the sacred fosters the idea that worn-out people may be equated with worn-out products; both can then be seen primarily as "disposal" problems.

Mystery

Our society is very intolerant of mystery. We convert mysteries into problems. If we convert the mystery of death into the problem of death, euthanasia (or, even more basically, a lethal injection) can be seen as a solution. As can be seen in descriptions of death by euthanasia, euthanasia can function as a substitute for the loss of death rituals, which we have abandoned at least partly to avoid any sense of mystery.

A sense of mystery might be required also to "preserve ... room for hope," as C.S. Lewis put it. And, as Harry Moody suggested, euthanasia could be a response "based on a loss of faith in what life may still have in store for us. Perhaps, what is needed ... is a different kind of faith in life and in the community of caregivers." This is especially true in situations of serious illness. If so, I postulate a complex relation between some degree of comfort with a sense of mystery and being able to elicit in others and experience ourselves hope and trust. This leads to a question: could the loss of mystery - and, therefore, of hope, faith and trust - be generating nihilism in both individuals and society? And could calls for the legalisation of euthanasia be one expression of it?

The loss of mystery has been accompanied by a loss of wonder and awe, both of which, in some form, we need as humans. Also lost is the sense that we, as humans, are sacred in any meaning of this word (that we are, at least, "secular sacred"). These losses are connected in both their nature and their causes, but they might not be inseparable. We might be able to retain some of these senses (for instance, a sense of the sacred) and not others (a sense of awe, at least in the form of traditional taboos used to elicit awe).

Scientific advances

Among the most important causes of our loss of the sacred is extraordinary scientific progress, especially insofar as science and religion are viewed as antithetical. New genetic discoveries and new reproductive technologies have given us a sense that we understand the origin and nature of human life and that, because we can, we may manipulate - or even "create" - life.

Transferring these sentiments to the other end of life would support the view that euthanasia is acceptable. Euthanasia would be seen as a correlative and consistent development with the new genetics; its acceptance, therefore, would be expected. According to this view, it is no accident that we are currently concerned with both eu-genics (good genetics: good at birth) and eu-thanasia (good death: good at death, of no trouble to anyone else). Yet another connection between genetics and euthanasia could arise from a new sense of our ability to ensure genetic immortality - seeing ourselves as an immortal gene - and, as a result, some reduction of anxiety about the annihilation presented by death.

The paradigms used to structure knowledge in general have been influenced by genetic theory. These paradigms have already been the bases for new schools of thought in areas well beyond genetics. They can challenge traditional concepts of what it means to be human and what is required to respect human life. For instance, evolutionary psychology, a sub-category of socio-biology, sees the characteristics usually identified as unique markers of being human - namely, our most intimate, humane, altruistic and moral impulses - as the product of our genes and their evolution. At a macro-genetic level, deep concern about overpopulation (as compared with earlier fears of extinction due to underpopulation) might, likewise, have diminished a sense of sacredness in relation to human life.

But countervailing trends, such as the environmental-protection movement, are beginning to emerge. A powerful recognition of innate dependence on the ecological health of our planet has resurrected a sense of the "secular sacred" by re-identifying the absolute necessity of respectful human-earth relations.

Moreover, science can be linked with the sacred; it just depends on how we view it. Rather than assuming that the new genetics is a totally comprehensive explanation of life, for example, we can experience it as a way of deepening our sense of awe and wonder at that which we now know - but even more powerfully at that which, as a result of this new knowledge, we now know that we do not know. We can, in other words, see the new genetics and other sciences as only some of the lenses through which we are able to search for "the truth."

The euthanasia debate and worldviews at war

Though immensely important in itself, the debate over euthanasia might be a surrogate for yet another, even deeper, one. Which of two irreconcilable worldviews will form the basis of our societal and cultural paradigm?

According to one worldview, we are highly complex, biological machines, whose most valuable features are our rational, logical, cognitive functions. This worldview is in itself a mechanistic approach to human life. Its proponents support euthanasia as being, in appropriate circumstances, a logical and rational response to problems at the end of life. (Though, of course, being anti-euthanasia can be just as logical and rational a response.)

I hesitate to evoke the Nazi atrocities, because these can readily be distinguished from situations in which the use of euthanasia is currently being proposed; it is easy to argue that those horrific abuses were different in kind from any that would occur if euthanasia were to be legalised in our society. But consider the question regarding the Nazi doctors that George Annas and Michael Grodin describe as "among the most profound questions in medical ethics" - namely, "How could physician healers turn into murderers?" According to Robert Proctor, the fundamental answer is, "Society, itself, was primed to develop a biological basis for its political platforms." I would suggest that current efforts to legalise euthanasia might reflect a connection of these same two factors, but in the reverse order: those who are pro-euthanasia are, at one level, seeking a political platform for a solely or predominantly biological view of human life - especially in terms of having this form an important element in any new societal paradigm. This can be called the "gene machine" or "pure science" position. The far-reaching impact and consequences of that should, at the least, cause us to think carefully before taking any steps to legalise euthanasia.

The other worldview (which for some people is expressed through religion, but can be, and possibly is for most people, held independently of religion, at least in a traditional or institutional sense) is that human life consists of more than its biological component, wondrous as that is. It involves a mystery - at least the "mystery of the unknown" - of which we have a sense through intuitions, especially moral ones. This worldview includes a sense of a space for (human) spirit and of the "secular sacred." It sees death as part of the mystery of life, which means that to respect life, we must respect death.

Although we might be under no obligation to prolong the lives of dying people, we do have an obligation not to shorten their lives deliberately. There are some fine, but immensely important, distinctions to be made when it comes to grey areas of decision-making at the end of life. Giving pain-relief treatment that is necessary to relieve pain but that could or would shorten life would be morally, ethically and legally different from giving a lethal injection to end life deliberately. This can be called the "science-spirit" position.

The impact of legalised euthanasia on medicine

We also need to consider how the legalisation of euthanasia could affect the profession of medicine and its practitioners. Euthanasia takes both beyond their fundamental roles of caring, healing and curing whenever possible. It involves them, no matter how compassionate their motives, in the infliction of death on those for whom they provide care and treatment. Euthanasia thus places the soul of medicine itself on trial. We thus need to be concerned about the impact that legalisation would have on the institution of medicine - not only in the interests of protecting it for its own sake, but also because of the harm to society that damage to the profession would cause.

With the decline of organised religion in many modern, secular, pluralistic societies, it is difficult to find consensus on the fundamental values that create society and establish its ethical and legal "tone" - those that provide the "existential glue" that holds society together. Many people do not personally identify with the majority of societal institutions. There are very few institutions, if any, with which everyone identifies except for those - such as medicine - that make up the health-care system. These, therefore, are important when it comes to carrying values, creating them, and forming consensus around them. We must take great care not to harm their capacities in this regard and, consequently, must ask whether legalising euthanasia would run a high risk of causing this type of harm.

Can we imagine teaching medical students how to administer euthanasia - how to kill their patients? A fundamental attitude we reinforce in medical students, interns and residents is a repugnance toward the idea of killing patients. If physicians were authorised to administer euthanasia, it would no longer be possible to instil that repugnance. Maintaining this repugnance and, arguably, the intuitive recognition of a need for it, are demonstrated in the outraged reactions against physicians carrying out capital punishment when laws provide for them to do so. We do not consider their involvement acceptable - not even for those physicians who personally are in favour of capital punishment.

We, as a society, need to say powerfully, consistently and unambiguously, that killing each other is wrong. And physicians are very important carriers of this message, partly because they have opportunities (not available to members of society in general) to kill people.

It is sometimes pointed out that many societies do justify one form of killing by physicians: abortion. This was justified, traditionally, on the grounds that it was necessary to save the life of the mother. We now have liberalised abortion laws, which reflect a justification that hinges on the belief that the foetus is not yet a person in a moral or legal sense. As well, in justifying abortion, attention is focused on the woman's right to control her body; access to abortion is considered necessary to respect this right. Besides, it is argued, abortion is aimed primarily not at destroying the fetus but at respecting women's reproductive autonomy. Indeed, when destroying the foetus is the primary aim - as it is in sex selection - even those who agree with abortion on demand often regard it as morally unacceptable. And the rarity of third-trimester abortions in most countries shows that, once we view the foetus as a "person," we do not find killing it acceptable.

Consequently, legalised euthanasia would be unique in that the killing involved could not be justified on the grounds either that it is necessary to protect the life of another (which, as well as being the justification for some abortions, is also that for the other examples of legally sanctioned killing - namely self-defence, just war and, in theory and in part, capital punishment) or that it does not involve taking the life of a person (the justification used for some abortions). Euthanasia would seem likely to affect physicians' attitudes and values, therefore, in ways that, arguably, abortion does not.

We need to consider whether patients' and society's trust in both their treating physicians and the profession of medicine as a whole depends in large part on this absolute rejection by physicians of intentionally inflicting death.

Moreover, we cannot afford to underestimate the desensitisation and brutalization that carrying out euthanasia would have on physicians. Keep in mind that the same might be true of abortion. We should remain open-minded about this possibility - even if we believe women should have a right of access to safe, legal abortion. Sometimes, dealing with new ethical issues can cause us to review ones that we believe have already been settled ethically. It could be that rightful concerns about the impact on physicians of their being involved in euthanasia would cause us to reconsider that on physicians involved in abortion. In short, one problem with the position of those who promote abortion on demand is that it threatens to continue undermining the link between medicine and respect for life.

It is sometimes remarked that physicians have difficulty accepting death, especially the deaths of their patients. This raises the question of whether, in inculcating a total repugnance to killing, we have evoked a repugnance to death as well. In short, there might be confusion between inflicting death and death itself. We know that failure to accept death, when death would be appropriate, can lead to overzealous and harmful measures to sustain life. We are most likely to elicit a repugnance to killing while fostering an acceptance of death - and we are most likely to avoid confusion between a repugnance to killing and a failure to accept death if we seek to convey a repugnance to killing when that is the appropriate word (although it is an emotionally powerful one), instead of death. Achieving these aims would be very difficult in the context of legalised euthanasia.

Finally, I would propose that it is an important part of the art of medicine to sense and respect the mystery of life and death, to hold this mystery in trust and to hand it on to future generations - including future generations of physicians. We need to reflect deeply whether legalising euthanasia would threaten this art, this trust, this legacy.

***

Every country will need to decide whether to legalise euthanasia. Making this choice will be, and will require, a complex process. It is crucial that all of us in each of our roles - whether as concerned citizens, professional organisations, or policy-makers - engage in the euthanasia debate.

This will involve many questions about euthanasia at both individual and societal levels, but three of the most important are the following. First, would legalisation be most likely to help us in our search for meaning in our individual and collective lives? Second, how do we want our grandchildren and great grandchildren to die? And third, in relation to human death, what memes (fundamental units of cultural information that are inherited by being passed from generation to generation) do we want to pass on?

Margaret Somerville holds the Samuel Gale Chair in Law at McGill University in Montreal, Canada, is the Founding Director of the Centre for Medicine, Ethics and Law. She is the author of many books, including The Ethical Canary: Science, Society and the Human Spirit and Death Talk: The Case against Euthanasia and Physician-Assisted Suicide. You can hear Margaret Somerville and other guests discuss "matters of life and death" with Scott Stephens on Radio National's Encounter program, on 1 June 2013.