Growing old and falling ill is expensive. No one costs more than in the final third of life. Medical progress is good news for patients, but not for insurers, who must fund ever more costly therapies, treatments and medicines for an ageing population. If people could be persuaded to prefer death to continued life, the financial balance would certainly improve.

The history of euthanasia is therefore also a history of overburdened health and care systems. Where extended families once took responsibility for the old and the sick as a matter of course, there is now a shortage of carers – and a pressing question: who will pay for the treatments?

The point must be put plainly, even cynically, if one is to grasp the full reality of euthanasia debates in many countries. What begins with heart-rending stories of the gravely ill, used to justify legal options, often ends with subtle pressure on patients to make use of them.

Suicide as a heroic act for others

For now, the seriously ill are not told outright that they are a burden, though even that may only be a matter of time. The underlying message of euthanasia, however, is unmistakable: die sooner, and remain useful even in death.

We all die anyway – so why not relieve our families, the healthcare system and society of our presence in illness, choose an early death for the common good and, before that, serve others one last time?

Anyone who considers such thinking mere cynicism need only look back a few years to the coronavirus pandemic. At the time, Julian Savulescu and Dominic Wilkinson at the University of Oxford explored precisely that question. Writing on the blog of the Journal of Medical Ethics, they outlined proposals under the heading ‘extreme altruism in a pandemic’.

They did not propose forcing anyone to become a hero before death. Rather, they argued that people should at least be given the option. Savulescu, Professor of Practical Ethics at St Cross College, and Wilkinson, Professor of Ethics and Director of the Uehiro Centre for Practical Ethics, called for a ‘right to altruism’ in times of crisis.

If someone were mentally competent and fully informed of the risks, they argued, that person should be free to risk – or even sacrifice – health or life for others or for society at large. The reasoning was disarmingly simple: if individuals are permitted to risk their lives for personal fulfilment in activities such as mountaineering, boxing or parachuting, why should they not be allowed to do so for a meaningful purpose? The comparison was drawn between ‘meaningful’ and ‘meaningless’ risk. If people may take their own lives for personal reasons, the argument ran, there is no basis for prohibiting suicide undertaken out of compassion or for the common good.

More concretely, the two academics suggested that elderly people with limited life expectancy, for instance those already infected with the coronavirus, might volunteer as test subjects for new vaccines.

Patients nearing the end of life, they argued, should also be permitted to take part in trials of euthanasia methods so that others might benefit from the findings. Even the practice of killing must, after all, be refined – lest anything go wrong and the intended sacrifice fail.

Useful organs

The proposal went further still. Patients should be allowed, provided they are of sound mind, to register in advance as organ donors so that their organs could be removed if life support were withdrawn in intensive care.

Why, moreover, should such ‘heroism’ be confined to the old and the sick? The same opportunity could be extended to the young and healthy. Soldiers, for example, might volunteer for high-risk vaccine trials in exchange for exemption from combat duties. If risk is inevitable, why not allow it to be chosen? One might as well ask those on death row.

When a few healthy individuals begin to consider how the old and the sick might still be put to use, the result quickly becomes macabre. The Oxford proposals provoked neither outrage nor widespread alarm. They were, after all, only ‘options’ and ‘suggestions’, presented as a way to ensure that no one need die in vain – that every death might be self-determined and serve a higher purpose.

Death instead of treatment

The story of overstretched healthcare systems seeking relief at the expense of the gravely ill can also be told through the example of Canada. Over the past decade, the country has turned assisted dying for the elderly and seriously ill into what some see as a new model for easing financial pressure on the healthcare system.

In 2016, Canada legalised both physician-assisted suicide and active euthanasia under the term MAiD – Medical Assistance in Dying. What was initially framed as an exceptional measure for competent adults enduring ‘intolerable suffering’ and facing a foreseeable natural death, such as terminal cancer, was expanded in 2021 to include further groups.

Under the revised framework, euthanasia is now available to people with serious or incurable illnesses, as well as to those with disabilities whose death is not imminent but who suffer physically or psychologically. There is ongoing debate about extending the regime further – to minors, to those with purely mental illness and even to individuals unable to give consent.

Within five years, the number of cases rose from 970 in 2016 to 10,064 in 2021. By that point, a total of 31,664 Canadians had ended their lives with medical assistance. By 2023, the figure had reached 60,301, with the upward trend continuing.

In some provinces, including Quebec, as much as 7% of deaths are now attributed to euthanasia rather than natural causes, according to findings cited by the Canadian physician Ramona Coelho.

Assisted dying for long Covid patients and veterans

What may appear to be a free and autonomous choice is, in some cases, the result of delayed or denied treatment, leaving patients to choose death out of desperation. Reports from Coelho and from institutions such as the Austrian bioethics institute IMABE describe cases in which patients with long Covid, disabilities or military service backgrounds were actively offered euthanasia as an option – even when they had not asked for it.

In a number of hospitals, specially appointed staff are said to present assisted dying proactively to patients who have never expressed a wish to die.

The 84-year-old Miriam Lancaster recently described how, while seeking treatment in a Canadian emergency department for back pain, she was offered euthanasia before any diagnosis had been made. The cause later turned out to be a simple fracture, treatable with rest. Death had been proposed instead.

Canadian media also reported the case of 50-year-old Tracey Thompson, who suffered from long Covid and chronic fatigue. Unable to work and with savings sufficient for only a few months, she applied for euthanasia. ‘It is a purely financial decision; my options are to die slowly and painfully, or quickly’, she said.

It is as if one were to call out to a person standing on a bridge: jump.

Coelho cites similar cases, including that of a man with chronic inflammatory bowel disease and mental health problems, to whom assisted suicide was suggested during a psychiatric assessment ‘although his mental and addiction issues remained largely untreated’. She also points to a clear link with poverty, limited access to care and insufficient support. In 2023, fewer than half of non-terminal patients had access to mental health services or counselling. Almost 30% lived in poverty, and 6.7% had no fixed address. Killing is cheaper than treatment.

One death for 2,327 dollars

Among economists in Canada, death has long since become a calculation. The British magazine The Spectator asked in April 2022: why is Canada euthanising its poor?

In that context, the political scientist Yuan Yi Zhu argued that those dependent on the public healthcare system become a financial burden. Care for chronically ill patients is costly. Euthanasia, by contrast, costs the taxpayer just 2,327 dollars per case and is free for the patient.

As early as October 2020, the Canadian parliament had commissioned economists to estimate potential savings. The result suggested that euthanasia could reduce annual healthcare expenditure by around 149 million Canadian dollars.

At the same time, the government has invested millions to expand access to assisted dying, even as waiting times for basic medical care continue to grow. One might be tempted to see a pattern. Carla Qualtrough, former minister for disability inclusion, noted during a hearing in the House of Commons of Canada that in some regions it is easier to obtain euthanasia than a wheelchair.

Where the sick come to be seen as too costly, dying risks becoming a duty.