On MAID and the Canadian Church

Notes on my Plough piece

As you may have seen via social media, I have a piece in the Spring 2023 issue of Plough Quarterly on the Christian response to the legalization and expansion of euthanasia in Canada (it’s known here is Medical Assistance in Dying, or MAID). You can read that piece here. In it, I outline the history of MAID in Canada, and in particular the way in which pro-MAID advocacy is wrapped up in an account of the good life which suggests that experiences of dependency, suffering, or requiring care take away one’s dignity. And then I explore the church’s response: in the mainline, a refusal to make firm judgments that ends up baptizing pro-MAID ideology; on the part of Catholics, evangelicals, and conservative confessional Protestants, resistance to MAID expansion alongside disability rights groups. I argue that crucial to resisting MAID is articulating an account of the good human life which does not exclude dependency or limitation, but rather sees it as part of the human condition.

It’s a piece that I found quite difficult to write. I confess to feeling some trepidation as a priest (and a rather junior one at that) writing so critically about the leadership of the church in which I serve. I also wondered at times whether I was the best messenger: Canadians do not tend to be particularly fond of Americans criticizing their country, and it must be admitted that Canadian frustration with Americans thinking they can pronounce on how things ought to be in other countries is…not particularly unreasonable. And then once I got over these worries and decided to write, I found the work of researching and writing this piece to be psychologically challenging. Time on the Dying with Dignity website or reading mainline justifications and equivocations took a real toll on me; this is, quite frankly, dark stuff.

And yet I am very glad to have written the piece. I wish I didn’t have to. I wish that MAID had never been legalized here in Canada, or that at least Christian churches had spoken with one voice alongside the disability rights community in opposing it. But I think it needed to be said. I hope that my words will contribute in whatever small way to the fight against MAID in Canada and to the unembarrassed application of Christian anthropology in the teaching and public witness of the mainline churches here. If you haven’t read it yet, I’d encourage you to do so!

What I want to do in this Substack is tease out a thread from my piece that space did not allow me to expand upon, about the particular ideology of pastoral care underlying the mainline church’s sorry response to MAID.

MAID and The ‘CPE-fication’ of Pastoral Care

One of the core arguments of my piece is that mainline responses to MAID, perhaps most clearly the Anglican Church of Canada report In Sure and Certain Hope, represent an abandonment of the teaching office of the church in favor of a style of pastoral care that avoids the imposition of values or making definitive judgments and focuses instead on listening and accompaniment. Startlingly, In Sure and Certain Hope declares that the church has “become increasingly skeptical of our capacity to understand and interpret the work of God in the life of another person.”¹ Clergy can do nothing more than ask questions and listen and be present, maybe - maybe - venture a few possible connections between the person’s story and Christian teaching, but nothing authoritative, no frank naming of good and bad and inviting people to follow Jesus.

This is a strange account of Christian pastoral care. To the extent that it strikes many mainliners as normal, it is evidence of our isolation from the rest of the church across time and space. The instructions for the conduct of Christian ministry one finds in Scripture see Christian pastoral care as involving judgments about right doctrine and right behavior, about exhorting people towards the truth and away from error and wickedness (one thinks especially, but not only, of the pastoral epistles here). One finds the same throughout the history of Christian reflection on the pastoral task, in Gregory of Nazianzus, John Chrysostom, Gregory the Great, and so many others. In the Anglican tradition more specifically, the bishop’s address in the 1662 BCP rite for the ordination of priests includes a stern exhortation to the priest-to-be to perform “all that lieth in you, according to your bounden duty, to bring all such as are or shall be committed to your charge, unto that agreement in the faith and knowledge of God, and to that ripeness and perfectness of age in Christ, that there be no place left among you, either for error in religion, or for viciousness in life.” And this emphasis not only found in premodern writing: if the language is somewhat less forceful, the 1979 BCP ordinal by which I was ordained to the priesthood still includes an exhortation to “nourish Christ’s people from the riches of his grace, and strengthen them to glorify God in this life and in the life to come.” The work of nourishing and of strengthening I promised to undertake is specifically Christian, bound to Christian beliefs and commitments about God, human beings, the good life, and so on. I am to nourish Christ’s people from the riches of his grace, not merely with attentiveness or nonjudgmental affirmation.

So if the Christian tradition is quite clear that pastoral care involves judgments about or interpretations of the work of God in the lives of other people, how do we get statements like those in In Sure and Certain Hope? How is the work of Christian ministers caring for their people reduced to affirmation, active listening, and the withholding of judgment lest you contravene anyone’s autonomy? I have not puzzled out the history to my satisfaction, but it seems to me that what we see here is what I want to somewhat clumsily (and, I confess, polemically) call the CPE-fication of Christian pastoral care: the reduction of the work of Christian pastoral care to the techniques of hospital chaplaincy that one picks up over the course of a summer-long internship during seminary called clinical pastoral education.²

Most mainline denominations requires a unit of CPE for ordination; my own Episcopal Church is no outlier here. And what one does in CPE is essentially work as a (typically unpaid) intern hospital chaplain for a summer, meeting weekly with other CPE interns and a chaplain supervisor to process your experiences together, going over ‘verbatims’ (records of patient care interactions) and paying particular attention to how providing pastoral care effects you, the caregiver. Typically, CPE training emphasizes building a set of tradition-independent skills that help you make connection with and comfort the people you are serving, people of a variety of faiths or none at all. You spend a lot of time thinking and talking about active listening, about a nonjudgmental presence that enables people to open up to you, about avoiding imposing your own views on people but seeking instead to help them draw upon whatever spiritual resources they possess for comfort. There’s also a focus on attending to and processing healthily your own emotional responses to the people you encounter, so that your own reactions do not prevent you from caring for people.

Now, let me be clear: these are all helpful, even vital skills for ministers and other pastoral caregivers to have. It’s not that these are wrong to include as part of ministerial formation. The problem comes when you end up thinking that pastoral care in Christian ministry ends with providing a warm, nonjudgmental presence. This is far from the case with hospital chaplaincy,³ and the work of hospital chaplaincy itself is not a very good analogue to pastoral care provided by ministers within the context of a parish. Hospital chaplaincy, as typically organized in the US and Canada, is basically nonsectarian: chaplains have to be able to care for people coming from all sorts of religious traditions. Further, chaplains are typically dealing with people in crisis, where there isn’t time to correct beliefs or nudge people in a different direction before you get them to a more stable place. Right after the death of a child isn’t the time to correct the eschatology of the grieving parent who says that “at least heaven has another angel now.” But in congregational ministry, it’s different. You still have crisis situations, of course, but you also have the chance to care for your people over years, even decades within the context of a shared confession of faith. Discipleship isn’t really an option in the context of most hospital stays, but it is (or should be) at the heart of the pastoral care that our churches provide. Pastoral care should be about helping people follow Jesus more closely, which pace the Anglican report, involves clergy working with their people to interpret and make judgments about the work of God in their lives.

But unfortunately, the often-helpful-but-insufficient experience of CPE is often taken as the beginning and end of pastoral care training for mainline ministers.⁴ To be sure, seminaries will have additional pastoral care courses, but they are not infrequently crisis- and technique-focused, at least in my experience, rather than aimed at training you to form people in a particular theological tradition over the long haul. I’m not sure why exactly this is. I suspect part of it has to do with a desire for respectability among mainline denominations, a desire to establish the clergy among the ‘helping professions’ rather than embracing our theological particularity. Doubtless it is also a reaction to genuine experiences of clerical authoritarianism and rigidity, although I am compelled to note the gentle therapeutic language of contemporary pastoral care is just as amenable to clergy power-grabs as traditional language of moral judgment and exhortation. But whatever mix of good and bad motives behind its adoption, the results seem to me to be disastrous.

It is when you give up a sense of pastoral care as involving fidelity to a particular theological tradition that you can get the stances that the Anglican Church of Canada, the United Church of Canada, and the Evangelical Lutheran Church in Canada have taken, where what matters is non-judgmental accompaniment whatever decisions people make. Where this thinking leads is powerfully demonstrated in the ‘MAID and Spirituality’ blog series that Dying with Dignity, the largest pro-MAID organization in Canada, put together to argue that religious faith is not opposed to embracing euthanasia. In their Anglican entry, which is broadly representative of the rest, they describe the ministry of the retired priest they profile as having this focus: “to honour the lived experience of individuals, and not worry too much about rules, doctrines and practices.” His job, he says, is “not providing answers but asking appropriate questions.” Here you have an ordained Christian minister who denies that he is to provide answers about questions of life and death, God, right and wrong! He evidently rejects any normative guidance from his faith traditions in favor of supposedly neutral, nondogmatic pastoral care. But of course, as I argue in my piece, this care isn’t actually value-neutral at all, but ends up reflecting a whole set of judgments about what is most important about human life - choice, autonomy, independence. And these judgments simply are not compatible with Christian teaching.

I don’t have a silver bullet solution to this problem. I expect that on an educational-institutional level it is related to how the modern seminary curriculum is organized.⁵ I tend to think that a careful engagement with pre-modern texts about Christian pastoral care may help us better situate our understanding of the pastoral task. But beyond needing a better book list or a curricular reorganization, I suspect that the deeper issue is a more basic failure of nerve in the teaching office of the church. I've written about this failure repeatedly. See, for example, here and here. And my time in Canada, my time investigating church responses to MAID, has only deepened my commitment to the recovery of this teaching office. If we are indeed going to provide anything more than a Jesus-y gloss on whatever broader middle class liberal-ish culture is doing plus an invitation to maybe come to church (if you feel like it), we are going to need to change. We need church that is willing to teach authoritatively, that preaches the Gospel in season and out of season, even when itching ears make the church's teaching unpopular. A church that is unflinching about proclaiming the Christian message - about sin, Jesus’ divinity, his bodily resurrection and ascension, his return in glory, about the demands that following Jesus puts on all aspects of your life - even while being gentle with those who wish to believe but struggle to do so, who try to follow Jesus but fail (that is, gentle with all of us!). And this doesn't mean that we need to toss out CPE, give up concern for a welcoming pastoral presence. But it means that we need to use the genuine skills CPE can provide for the purposes of Christian pastoral care, rather than remaking Christian pastoral care in CPE's image.

A few parting thoughts

This piece is already long enough, but in lieu of a conclusion, I wanted to lay out a few other topics of potential interest around MAID and the church that didn’t make it into the article:

1. One of the noteworthy aspects of MAID is that MAID’s legalization and expansion have been driven by court cases. For US readers, this may not seem particularly surprising, but in a Canadian context it is somewhat more remarkable. The courts found that the lack of euthanasia provision violated the Canadian Charter of Rights and Freedoms - a document that was adopted in 1982. Its adoption has resulted in what critics call a ‘judicialization’ of politics, that is, the increasing involvement of the courts and especially the Supreme Court of Canada in setting the agenda for Parliament and provincial legislatures based on Charter jurisprudence. Such critics tend in Canada to be concentrated on the conservative side of the political spectrum (although Quebec has its own unique history with the Charter that complicates this story). But there are interesting analogues to debates on both the US left and right about the current role of the US Supreme Court in US politics. Without wanting to pass judgment about broader Canadian debates about the Charter and ‘judicialization’, I think it’s clear that MAID shows the dark side of Charter jurisprudence: a ‘right to euthanasia’ is found by the courts to exist in the Charter by the application of various broad Charter principles and is now removed from democratic deliberation. Of course, to be fair, MAID is broadly popular in Canada (although the polling before its legalization was more complicated), and it is possible that even without the courts Parliament would have moved to legalize it.

2. One of the things that I touch on briefly in the piece but am hoping to expand upon (in a piece that is long overdue to another publication - my apologies to my editor if you read this!) is euthanasia as a distinctly post-Christian practice. Anti-MAID activists often use the language of eugenics to condemn it or suggest that euthanasia is being advocated as a cost-cutting tool. And certainly you will find no disagreement here with the notion that MAID is profoundly ableist or that doctors do sometimes bring up MAID in the context of costs of patient care. But I think it is important that the rhetoric and (as far as I have access to them) the commitments motivating pro-MAID advocacy are very different than classical eugenics. You won’t see people talking about ‘strengthening the race’ or ‘improving the stock’ or what have you, with the language of ‘mercy’ or ‘compassion being secondary or not present at all. No: the language is all of pity and compassion, of easing unimaginable suffering, of care for the people being killed. In this sense, I suspect that MAID represents a specifically post-Christian ideology, in which (as I say in the piece) Christian concern for the poor and marginalized is detached from Christian anthropology. The end result is doctors arguing that they have a positive obligation to inform disabled people that the state will end their lives - for their own good, as an expression of care and compassion! Look for more on this from me soon.

3. One of the accusations that pro-MAID campaigners will often make against those opposed to MAID is that we are committed to keeping people alive, whatever their condition, in a misguided fear of death and refusal to admit the truth about human suffering and mortality. I think that this is a fairly absurd accusation, given that opposition to MAID in Canada, at least among the religious and disability rights groups I looked at, is generally linked to robust support for increased palliative care and disability services funding. See, for example, the ‘We Can and Must Do Much Better’ open letter I discuss in the article. However, I think it is true that churches need to be much more willing to talk openly about the nature of not just a good life and also a good death. In a great deal of pre-twentieth-century Christian devotional literature, treatments of how to die are ubiquitous, with prayers for the dying person to say and prompts for self-examination before death, making peace with one’s loved ones, etc. Jeremy Taylor’s Holy Dying is a particularly famous example of this genre. I wonder if there are materials worth retrieving there, and more broadly if the church might contest the basically medical-technical take-over of the dying process. There’s a lot to learn from the hospice movement about what a more human approach to dying could be, it seems to me. There was a helpful discussion along these lines in the PloughCast episode with Leah Libresco Sargeant and Alexander Raikin (whose reporting on MAID I commend to your reading!).

4. One of the grimmer parts of MAID discourse in Canada is the way that MAID advocates are attempting to use the language of equity to criticize opposition to MAID by disability organizations or even force organizations ideologically opposed to MAID to make it available to those they serve. Quebec, for example, is currently trying to require all palliative care homes to offer access to assistance in dying (the source, here, is in French). It is now not uncommon to see disability rights organizations with banners on their websites or signs in their buildings saying that they will not recommend MAID to those who use their services. The image which is the social media image for this post is a collage of such signs. It is really incredibly bleak that disability orgs need to say “we will not recommend you arrange your death” at the outset. One hopes at the very least that they will be able to continue to do so.

By way of a conclusion, I would ask for your prayers for the churches in Canada, for disability rights groups and disabled people, and for MAID providers and advocates. Please pray that the mainline churches may come to join other Christian churches, non-Christian religious groups, and disability organizations in standing against MAID and the ideology undergirding it. Pray for the disabled people particularly under attack by Canada’s MAID program, that their voices might be heard and respected and that they secure what they need to live well. Pray that MAID providers might repent of their participation in this death-dealing system. And pray that the ideology that leads people genuinely moved by compassion and concern for the less fortunate to believe that these values are best served by removing the safeguards to doctors killing their patients lose its grip on Canada.

1. It is perhaps worth adding here that In Sure and Certain Hope was produced by a task force of the Anglican Church of Canada but was not formally adopted by the bishops, the General Synod or the Council of General Synod. In fact, none of these bodies have made formal statements on MAID at all since its legalization, leaving only this task force report and the primate’s remarks as the only official churchwide Anglican reflection on MAID. Some individual dioceses have had conversations about it, though, and I know of one diocese which has adopted a policy opposing it.

2. In my reflections here I find myself in broad sympathy with the observations that Stanley Hauerwas and Will Willimon made in their much-derided 2021 piece on pastoral care that you can read here: https://www.christiancentury.org/article/interview/dangers-providing-pastoral-care. I think the piece suffered from being released in the midst of the pandemic, and I admit the two men occasionally perform a sort of grumpiness that I find unhelpful - but their basic claim about the capture of mainline pastoral care by therapeutic language and concepts and its emptying of specifically Christian theological content is essentially correct.

3. I think there is often a temptation for those, like me, who are critical of the importation of tradition-independent models of pastoral care into our congregations to be unjustly dismissive of vocational chaplaincy, on the basis of little more than our own single semester of CPE. Now, chaplaincy as practiced in North American hospitals is not necessarily above critique, but I want to be very clear that chaplaincy absolutely cannot be reduced to the first unit of CPE. Chaplains, indeed, require far more pastoral care training than congregational ministers. I’m thankful for chaplain friends who have pushed back against unfair caricatures of their field to me.

4. Here I commend this piece by Josh Rodriguez-Hobbs to your reading: https://earthandaltarmag.com/posts/the-cure-of-souls-after-the-triumph-of-the-therapeutic

5. I have an argument that the historical, theological, Biblical, and pastoral/practical disciplines in many contemporary divinity schools/seminaries are siloed off from each other, and often are grounded in mutually contradictory commitments, in ways very unhelpful for ministerial formation. But that’s a topic for another Substack - and I should add that I do know of some mainline institutions (Candler and Duke come to mind) that are actively combatting this tendency.