This essay examines the impact of linguistic choices on the perception and regulation of assisted dying, particularly in Canada. It argues that euphemistic terms like “medical assistance in dying” and its acronym, “MAID,” serve to normalize the practice, potentially obscuring its moral gravity.
Abstract
This essay examines the impact of linguistic choices on the perception and regulation of assisted dying, particularly in Canada. It argues that euphemistic terms like “medical assistance in dying” and its acronym, “MAID,” serve to normalize the practice, potentially obscuring its moral gravity.
This contrasts with what is seen in Belgium and the Netherlands, where terms like “euthanasia” are used, as well as in France and the United Kingdom, where terminology remains divisive and contested.
By tracing the evolution of these terms and what they reveal about different cultural and legal approaches, this essay sheds light on the politics of language in end-of-life discourses. It suggests that the shift toward euphemistic language reflects a broader discomfort with death that can shape public attitudes and legal frameworks.
It calls for a more transparent, philosophically grounded approach to terminology and suggests that continued debate about semantics is necessary to capture the complexities and ethical significance of assisted dying.
Essay
A 2023 news article, entitled “Embarquez, les enfants, on emmène Papi à son euthanasie!” (“Jump in, kids, we’re taking Grandpa to his euthanasia!”) and published in Québec’s La Presse, argues that Canada would have fewer medically assisted deaths if it were willing to call the practice what it is, namely, euthanasia.1
The author, bioethicist and long-term palliative care health worker Caroline Kilsdonk, worries that Canada’s official terminology for the procedure, “medical assistance in dying” (“MAID”)—in Québec, “aide médicale à mourir” (“AMM”)—is a euphemism that has significantly affected how Canadian society views the issue.
She warns her readers that, by replacing words like “euthanasia” and “death” with innocuous acronyms and the vocabulary of “assistance” or “aide,” Canada has gone some way toward rendering assisted death not radical but banal, turning it into one form of health care among others.
While the tone of Kilsdonk’s article is somewhat polemical, she raises the important point that language influences how we think about end-of-life decisions.
Indeed, as conversations on eligibility for assisted dying develop in various countries, with each one seeking to examine and learn from other jurisdictions’ experiences, it seems important to reflect on the language societies use to discuss this issue.
“Assisted dying” and “assistance in dying,” the terms increasingly used by medical associations, and the ones we use here, come with their own drawbacks. As umbrella terms, they do not distinguish between whether the lethal substance is self-administered or physician-administered, and, as anthropologist Mara Buchbinder has pointed out, they align more closely with the vocabulary of proponents than of opponents of these practices.2
But, in this essay, even though our main argument is that circumlocutory language, such as the acronym “MAID,” may indicate an increasing general discomfort with discussions about death, we have opted to use the terms “assistance,” “death,” “dying,” and their cognates. This allows us to focus on the term and concept of death, to explore the multiple meanings of assistance, and to avoid the more loaded connotations, in the anglophone context, of terms such as “euthanasia” and “suicide.”
The semantics and politics of assisted dying are particularly topical in Canada, where a 2023 Health Canada Report revealed that 6.6 percent of all deaths in Québec in 2022 were medically assisted and that the growth rate for such deaths in the country as a whole, compared to 2021, was 31.2 percent.3
The figures in countries in which assisted dying is a long-established practice—and where the language used to describe it is “assisted suicide,” “euthanasia,” or both—are comparatively low at 2.1 percent (in Switzerland in 2022),4 2.5 percent (in Belgium in 2022),5 and 5.1 percent (in the Netherlands in 2022).6
Many possible factors have been named to explain current increases in assisted dying in Canada generally and in Québec in particular. These include a staunchly secular society that places significant cultural value on individual autonomy and choice, as well as the more worrying possibility that the safeguards governing the practice in Canada may be too lax.7
But terminology matters too, and Canada’s semantics are specifically chosen to reduce taboos and fears around assisted dying. Indeed, Kathy Kortes-Miller, author of Talking about Death Won’t Kill You (2018), argues that Canadians “do not talk about death and dying enough.” “[O]nly 13% [of Canadians] have an advance care plan prepared,” she reports, “which means too few of us are actively discussing end of life.”8
Canada’s experience with naming “assisted death” may also reflect a process whereby death itself is becoming a culturally taboo subject in the Global North. For example, a study on meetings between the parents of critically ill children and clinicians conducted in 2022 found that, although death was the topic at stake, the word and its cognates were rarely used (only in about 8 percent of meetings) and were mostly replaced with euphemisms.9
The Lancet Commission on the Value of Death has highlighted that “the lack of clear, explicit criteria of what constitutes dying limits the idea of a diagnosis of dying” and may be contributing to the avoidance of the term in clinical settings.10
Even though palliative care is the medical subspeciality that “regards dying as a normal process”11 and to which other specialists often hand over “difficult conversations,” there is still a noticeable decline in the use of language that openly engages with death and dying within palliative and hospice care.
Shifts toward terms such as “life-threatening illness” and “the end of life” and away from “terminal” and “death” in recent years have sought to counteract the fear that patients associate with the terms “palliative” and “hospice.” But it has also meant that dying has been rendered increasingly invisible.
As sociologist David Clark notes in his history of palliative care, some of the promotional material advertising palliative care in the United States “contains no mention of suffering in any wider existential way, and strikingly, the language of death and bereavement is completely absent.”12
Some, such as John Troyer from the Center for Death and Society at the University of Bath, argue that the issue is not so much that death, in and of itself, is a taboo subject but that “we aren’t encouraged to discuss our own individual demise.”13
There may not be enough empirical evidence to draw specific conclusions about the evolution of public attitudes toward death and dying—particularly across languages and cultures—but, as a 2022 study in the United Kingdom confirms, “[H]ealthcare professionals find it difficult to initiate discussions of [advance care planning,] and the take up of such planning within the population remains low.”14 The outcome of this discomfort around the topic of death is that it remains an inconvenient truth, even within health care settings.
In addition to shifting attitudes toward death in general, both the French language and the distinctiveness of Canada’s history and politics are important for understanding the country’s current end-of-life lexicon.
Crucially, the Criminal Code, which prohibits aiding or abetting another person’s suicide, is under federal jurisdiction, while provinces have jurisdiction over health care. In 2012, a cross-party commission in Québec examined the question of “mourir dans la dignité” (“dying with dignity”) and filed a report clearly in favor of a law on end-of-life issues, including aide médicale à mourir.15
At stake was not only the status of aid in dying, as a specifically medical rather than a moral or criminal procedure—therefore ensuring that the province could legislate on it—but also its relationship to other forms of end-of-life care, including palliative care. In 2014, the Québec parliament adopted the Loi concernant les soins de fin de vie (Act Respecting End-of-Life Care), which sought to offer an integrated vision for the provision of both palliative care and medical aid in dying.
While the law gave a place of honor to both the autonomy and dignity of patients, it also emphasized that patients require assistance/aide to access and participate in their preferred forms of end-of-life care, whatever those may be.16 The terminology of “aide médicale à mourir” thus served to normalize the practice, avoiding words like “suicide” and “euthanasia,” which carry potential stigma for patients and their families alike.17
Participants in Canadian debates were aware of recent developments in the United States, where proponents’ preferred terms, “aid in dying,” “death with dignity,” and “end-of-life options,” had been taken up in legal discussions. Oregon and Washington State enacted Death with Dignity Acts in 1997 and 2009, respectively, and Montana ruled in 2009 that physician aid in dying was not illegal. Vermont had recently introduced the Patient Choice and Control at the End of Life Act (2013), and the End of Life Option Act was signed into law in California in 2015 (under all of these laws, the patient, not the physician, self-administers a lethal substance).
The lexicon used in this legislation was largely the result of lobbying by various right-to-die advocacy groups, such as the organization Compassion and Choices, the latest iteration of the Hemlock Society, founded by activist Derek Humphry.18
Even as the terminology of “aide” in Québec was roundly criticized by palliative care organizations at the time for being an “euphémisme inconvenant” (“inappropriate euphemism”),19 it was welcomed in English translation by various activist associations that had long sought to associate death with the involvement of doctors, dignity, and individual choice.
Indeed, in a 2015 ruling on a case filed by the British Columbia Civil Liberties Association, the Canadian Supreme Court decided to decriminalize what it termed “physician-assisted dying.”
However, the formulation became more passive and specifically “medical” in the 2016 law Loi canadienne en matière d’aide médicale à mourir/Canada’s medical assistance in dying (MAID) law, which legalized the practice throughout the country. Here too, this choice of phrasing was supported by advocates of the law; Dying with Dignity Canada, an advocacy group, praises the phrase “medical assistance in dying” and explains why neither the terms “euthanasia” nor “assisted suicide” are opportune to describe ending one’s life with clinician involvement.20
Stefanie Green, head of the Canadian Association of MAID Assessors and Providers, refers to assisted dying as one among other forms of end-of-life care, describing it as “legalized, compassionate end-of-life care provided by Canadian physicians and nurse practitioners in specifically outlined, safeguarded circumstances.”21
The significance of this language should not be underestimated. The normalization of the acronym “MAID” as a way of referring to the provision of assisted dying in Canada, together with the positioning of the practice as merely another care option at the end of life, has clearly contributed to the procedure’s acceptance.
These linguistic trends and some of the ways in which legal terminologies cross national borders are visible in countries that are actively discussing legislating on the practice.
In France, for example, since the presentation of the conclusions of the Convention citoyenne sur la fin de vie (Citizens’ Assembly on the End of Life) in April 2023, much work has been done on drafting a new bill on palliative care and assisted dying.22 The minister who was initially responsible for leading the bill was keen to follow the Canadian terminological model of “assistance” in dying, since she, like the French president, was uneasy with the term “euthanasia,” given its link to the Nazi eugenics project, and was concerned that “assisted suicide” connoted hopelessness and unwanted stigma.23
A conceptualization of assisted death as “aide,” moreover, draws on notions of solidarity and fraternité that underlie traditional conceptions of the French Republic—which was made explicit in an interview with Emmanuel Macron.24 The term “accompagnement,” which is related to “assistance,” or “aide,” and its connotation of “being there with” (“accompagner”) someone in their time of need, was crucial for garnering widespread acceptance of palliative care in France and, for that reason, has long been seen as belonging to palliative care.25
This is evident in the name of the association for palliative care professionals in France: La Société française d’accompagnement et de soins palliatifs.26 The terminology of “assistance,” “aide,” and “accompagnement” in relation to assisted dying is therefore designed to signal that the practice is compatible with—and even analogous to—the provision of high-quality palliative care.
At the same time, the iterative process associated with proposed legal changes offers privileged insights into societal divisions around the semantics of end-of-life practices. The language of the proposed bill remains divisive in French society, with ongoing debates about whether terminology is being used as a smokescreen to hide what is at stake. Currently, the French terminology is “aide à mourir,” which could be passive or active, medical or nonmedical.
The French decision to exclude a medical context from the terminology (so far) suggests that physicians may end up playing a different role in the practice if and when it is adopted, which is what the text of the proposed French bill indicates. Whereas in Canada either a medical professional administers the lethal medication or the patient administers it themself, it seems that, in the French case, the patient will always be required to self-administer the medication, unless they are physically unable to.
Clinicians will, however, be on hand to intervene when the outcome is not smooth and painless, to hasten the patient’s death, that is, if the self-administration of a lethal substance goes wrong—a practice called “un secourisme à l’envers” (“reverse first aid”) in the early drafts of the legal text.27
This phrase has been heatedly debated, with those opposed to the bill and the role of French physicians in potentially expediting a patient’s death describing the practice as “euthanasia in disguise.”28
Debates around the terminological divergence from Canada—with some pushing to show that the practice should be called “euthanasia” due to the potential active involvement of physicians and others insisting that what is at stake is “aide”—reveal the interplay between the lived experiences of patients and their families and the aspiration to come up with what Macron has termed “a French model of end-of-life care.”29
These debates also bear witness to the inevitably political nature of language, as evinced by the fact that a group of experts led by the writer Eric Orsenna has not been able to complete the ostensibly simple task of creating a nonpartisan glossary of key words describing the practices currently under debate.30
Semantics are also at the center of debates across the channel in the United Kingdom, where assisted dying remains illegal but further attempts to change the law are being discussed.
Parliamentary research briefings and public-facing publications on the proposed bill generally favor “assisted dying” as an umbrella term for both physician-assisted suicide and euthanasia.31 At the same time, the opponents of potential legislation use “assisted suicide” to refer to the provision of life-ending drugs for terminally ill adults, emphasizing the term’s negative connotations.32
However, some advocates of a U.K. assisted-dying bill, or similar legislation, have rejected the use of the term “assisted dying” because of its inherent vagueness. Baroness Warnock, a peer who, during her life, was a staunch advocate for a change in the law, stated that she “prefer[red] the terms ‘euthanasia’ and ‘assisted suicide’—not sanitising these words with euphemisms like ‘assisted dying.’”33
These terminological discussions around ongoing law-making procedures reveal uncertainties and societal tensions rooted in political ideology and ethical positions. They thereby also reflect persistent difficulties in reaching broad agreement about exactly what is at stake: not all patients and their families experience asking for help in dying as “suicide”; not all citizens can accept that receiving help to end one’s life is anything but “suicide.” Part of the challenge for political actors is therefore choosing language that attenuates, rather than aggravates, these differences.
Meanwhile, noneuphemistic language seems to have settled in countries in which assisted dying is a long-established practice. France’s near neighbor, Belgium, has had no difficulty in calling their physician-administered assisted-dying provision by what, for Belgians, is its name: “euthanasia.”34
The geographical proximity to the Netherlands, where the term “euthanasia” is also used, albeit does not appear in Dutch law, may explain why French-speaking Belgium has adopted it. In Spain, where legal distinctions between “active” and “passive” and “direct” and “indirect” end-of-life practices have a long history, the region of Andalusia sought to redefine and depoliticize the term “euthanasia” and to link its etymology of a good death to the ideal of dying with dignity in a 2010 law.35
The Spanish government followed suit, using the term “eutanasia” in the law decriminalizing active euthanasia in 2021. In contrast with conventions in other jurisdictions where “euthanasia” refers to physician-provided assistance in dying, there is no distinction in Spanish law between the two “active,” “direct,” or “voluntary” modes of assisted death—patient- or physician-administered; both are referred to as “euthanasia.”
In German-speaking countries, the term “Euthanasie” is avoided due to its association with Nazi crimes, and the practice is instead referred to as “aktive Sterbehilfe” (“active aid in dying”). As a term, “assisted suicide” seems to carry less stigma in a German-language context.
In Switzerland, where it has been available via private organizations since the 1980s, the practice is usually referred to as “assistierter Suizid,” or “suicide assisté.” In German-speaking regions, however, it is also known as “Freitodbegleitung,” which literally means “free death accompaniment” (with “Freitod” being a common euphemistic term for suicide). In French-speaking regions, the term “assistance à l’autodélivrance” is used, though less frequently, and translates to “assistance in self-deliverance.”
Unlike in these countries with the longest histories of some legal form of assisted dying, among countries now considering or newly legislating on such practices, debates about whether to use euphemistic language remain heated.
While euphemisms can normalize what might begin as a controversial practice, their use necessarily raises controversies of its own.
To be clear, our suggestion is not that societies should return uncritically to the language of euthanasia and (assisted) suicide but, rather, that they should think about why the laws and the public are avoiding terms like “death” and why they favor acronyms like “MAID,” when its vagueness removes people from the specific ethical issues at stake. In that respect, it seems desirable to aspire to what linguist Anna Wierbizcka calls a “language-independent philosophical perspective,” which involves an awareness of the values encoded into any particular word.36
In the case of assisted dying, it is crucial to acknowledge that cultural and personal baggage often prevents people from seeing death clearly and that persistent societal tensions around different visions of a good death will never be overcome. These debates on semantics reflect the diversity of views about assisted death and highlight the impact of the language people use to describe the radical act of helping another person die.37
In a conversation in October 2023, Justin Sanders, the head of palliative care at McGill University, suggested that what is at stake in Canada today is not the existence of MAID itself but, rather, ensuring that the physicians who assess patients for and provide it to them retain a sense of the profound nature of their own actions and associated ethical dilemmas.
It seems easier to keep these essential ambiguities alive when we all use terms that clearly point back to the practices they describe, rather than euphemisms or acronyms.
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Anna M. Elsner, Charlotte E. Frank, Marc Keller, Jordan O. McCullough, Vanessa Rampton
First published: 02 November 2024
https://doi.org/10.1002/hast.4910
**This essay its republished from The Hastings Centre Report under the Creative Commons License. The cover photo is of a privately owned painting and is used here with permission.
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Acknowledgments
Research that has contributed to this essay is supported by an H2020 European Research Council grant (101040399) and funded by the Swiss State Secretariat for Education, Research and Innovation under contract MB22.00067.
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Volume54, Issue5
September‐October 2024
Pages 3-7
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