The Open Door and the Duty to Care

“The door is open.”

Epictetus, Discourses 1.9

I believe a person can own their life so completely that they may refuse to keep living it. The door is open. I have not changed my mind about that.

But I have learned to distrust the slogan that grew around it. The open door is not freedom when the room behind you is on fire and someone lit the match, then left it burning.

When I read what is happening around medical assistance in dying, MAID, in Canada, I do not see the philosophy of a former slave being honoured. I see it being borrowed.

What Epictetus Actually Said

Epictetus was born into slavery. He knew what it meant to be owned. His open door was never a recruitment poster for death.

In Discourses 1.9, he comforts a man crushed by bodily hardship: if sustenance fails, you need not despair, because exit remains possible. In Book 4.1, he tells the same thing to a student impatient to leave, and then tells him to wait, to examine the reasons, to endure. The door stands open. Walk through it without reason, and you have surrendered the very judgment that makes you free.

This is the part the slogan forgets. The open door exists so that you may endure. Knowing you can leave is what gives you the strength to stay. It is a therapy of the inner life, a comfort against despair, not a clinic with a queue.

When an institution takes that image and stamps it on a programme, it has not honoured Epictetus. It has put words in a dead man’s mouth.

A Boundary That Keeps Moving

Canada legalized MAID in 2016 for people whose death was reasonably foreseeable. By 2021, the law had dropped that limit. Track 2 opened the door to people who were not dying, not soon. In March 2027, the same door is scheduled to open further still, to mental illness as the sole condition, to depression as grounds for an irrevocable act.

Look at the steps. Reasonably foreseeable death, to not-foreseeable death, to no death at all. Each was unthinkable until it was policy. That is not conspiracy. It is how boundaries move.

There is a name for this. Joseph Overton, of the Mackinac Center for Public Policy, described the Overton window: the band of policies a society will presently accept. Politicians rarely act outside it. They wait until the window moves. And the window moves when yesterday’s unthinkable is spoken aloud often enough to become merely radical, then acceptable, then sensible, then normal. Then the cycle begins again from the new edge.

We have watched MAID do exactly this. The argument never needed a hidden hand behind a curtain. It only needed each expansion to be measured against the last one rather than against the original line. Standing on step two makes step three look small. Standing on step three makes step four look small. No single step feels like the cliff. The cliff is the staircase.

This is what I mean by slippery slope, and it is not metaphor. It is the structural fact that precedents lower the threshold of the imaginable, and the unimaginable never had to be defended all at once, only one acceptable increment at a time.

Orwell saw the mechanism from the other end. In Nineteen Eighty-Four, the Party does not forbid revolt by force alone. It shrinks the vocabulary until revolt can no longer be thought. Freedom is slavery is not meant to be believed. It is meant to be repeated until the word freedom stops meaning anything in particular. Once language bends, the act it names bends with it.

The word bending here is freedom itself, and the word care. A death offered for lack of housing is called autonomy. A request shaped by loneliness is called consent. A useful body is called altruism. When the words have moved far enough, no one has to argue for the next step. It simply sounds humane.

I do not say that anyone in particular planned this. I do not need to. A system that is rewarded for solving problems cheaply will drift toward the cheap solution on its own. Pressure does not require a villain. It requires a gradient.

The Hidden Goal

Here is what I believe the drift serves, without anyone having to ordain it.

A person in unending need is expensive. A bed in a hospital is a bed someone else could use. A caregiver burning out at home is a cost the state will eventually carry. The math, run honestly, treats suffering as a cost line and death as a saving. No memo needs to be written. The incentive is in the structure, and structures do not need intentions to act.

Call it triage, if you like. Call it efficiency. The old word is uglier and more accurate. It is eugenics by spreadsheet, a quiet sorting of who is worth sustaining and who is too heavy to keep. It never announces itself. It arrives as compassion, in a clean room, with forms.

And note who the sorting tends to choose. The isolated. The poor. The disabled. The ones whose complaints are easy to lose in a file and whose absence causes no trouble at the next budget meeting. If freedom were truly the goal, the programme would measure itself against who it reached. It does not. It measures itself against how many.

That is the tell. A programme built on autonomy would ask, Was this person genuinely free to choose otherwise? A programme built on throughput asks, Did the paperwork clear?

The Weaponization of Loneliness

This is where loneliness becomes a weapon, even with no one holding it.

No official has to tell a person they are a burden. A person who needs daily care, who watches another’s life bend around their needs, who hears the exhaustion they did not cause and cannot repair, will begin saying it to themselves. They will say it kindly. They will say it rationally. They will say it as concern for the very people who love them.

Health Canada’s 2024 report recorded 16,499 MAID deaths, 5.1 percent of all deaths in Canada that year. Among people whose death was not reasonably foreseeable, 44.7 percent reported isolation or loneliness as part of their suffering, and about half said they felt like a burden on family, friends, or caregivers. Let me be careful with these numbers. The report says loneliness was never the sole source of suffering in any recorded case. The numbers do not prove that anyone died because they were lonely.

They prove something quieter and worse. They prove that loneliness was already in the room when the decision was made, and that the system did not treat its presence as a reason to stop.

A person can pass a legal test for voluntariness while living in circumstances that have steadily closed every door except one. Poverty narrows it. Inaccessible housing narrows it. Caregiver exhaustion narrows it. Awaiting treatment that never comes narrows it. None of these has to become a formal eligibility rule. They only have to be present, unaddressed, the morning someone signs.

That is what I mean by the weaponization of loneliness. Not a single villain, but a society that lets the room close and then calls the only remaining exit a choice.

When the Body Becomes Useful

A recent National Post report pulled a further line into view. A paper in the New England Journal of Medicine asks whether organs could be taken from consenting, anesthetized MAID patients before they are legally dead, with the retrieval itself causing death. The authors argue that voluntary euthanasia changes what the old dead-donor rule is for.

I will say what this is and is not. It is an argument in academic ethics. It is not Canadian law and not Canadian practice. A review of the literature found “death by donation” permitted in no jurisdiction it examined. Today, donation after MAID happens only after death has been determined.

But the proposal tells me where the window is being pushed.

Think of the person who already feels they take more than they give. Tell them their death could save several lives. Watch how quickly I am a burden becomes at least I could be useful. Altruism is real, and can be beautiful. But once the medical system gains from the timing and manner of a death, the wall between care for that one person and benefit to the others must be load-bearing. The dead-donor rule was not a scheduling detail. It was the promise that medicine would never make a body worth more dead than alive.

Break that promise, and ask yourself who trusts medicine less afterwards. The poor. The disabled. The alone. The very people already being sorted.

Who Decides When the Mind Is Suffering?

For a competent adult, in full possession of judgment, choosing freely and informed, I can hold the open door with them. But the question changes when judgment itself is what is suffering. Then the sovereignty cannot simply be handed to another, as if capacity were a parcel you pass along.

The government? The state is made of people who will never meet you, who carry no consequence of your death, who answer to a budget and a calendar. The clinician? A clinician is human, fallible, and embedded in a system whose incentives I have just described. The family? A family can be exhausted, frightened, grieving in advance, and in no state to weigh a life they are too close to see clearly.

None of them is God. None of them gets it back if they are wrong.

Mental illness sharpens the whole question. The suffering is real. The future, in the thick of an episode, can be impossible to imagine as anything but this. The 2026 parliamentary review found no consensus on how to tell a settled request from suicidal intent, nor on how to call a mental disorder irremediable when its course so often changes. It heard that one in three Canadians who needed mental-health care could not get it for the cost.

If treatment was not offered, that does not make the suffering untreatable. If a person was left alone, that does not make the loneliness permanent. If a person, in a dark season, cannot see a future, the state should not mistake that narrowed view for proof that no future exists.

Where capacity is uncertain, where irremediability is unsure, the burden must rest on care. Because the act is one that permits no correction.

The Duty to Care

Here is the ground I keep returning to. Care is not a feeling. It is a discipline, and it has a price.

The healers pledged it long before MAID existed. The Hippocratic tradition names it in three words that never go out of date: primum non nocere, first, do no harm. The World Medical Association’s Declaration of Geneva asks the physician to consecrate their life to the service of humanity, to put the patient’s health and well-being first, and to maintain the utmost respect for human life. These duties were never meant to be set against the patient’s autonomy. They were meant to surround it, hold it up, keep it honest.

Care without autonomy becomes domination. We have seen that, and we do not want it back. But autonomy without care becomes neglect dressed in the language of respect, and we are living inside that now.

I want to say plainly what care looks like in the places where MAID is being offered, because the abstraction hides the cost.

Care in a family is the parent who lifts a body that can no longer lift itself, again, at three in the morning, for the thousandth night, and does not call it virtue because it is simply what love does. It is the sibling whose own life has bent quietly around a person who will not get better. It is the exhaustion no respite programme reaches and the grief that begins long before a funeral. When we speak of the family, we are speaking of people who are already paying, in their bodies and their years, for what the state has underbuilt.

Care in a clinic is the nurse on the twelfth hour of a shift who still stops, who still sits, who still sees the person and not the bed number. It is the doctor who has been asked, again, to weigh a life, and who carries that weight home. It is the palliative team that shows what a good death can be when it is not hastened, and the mental-health services that exist too rarely and too late.

These people hold the line. They are holding it now. The scandal is not that they fail. It is that we ask them to hold a line the institution beneath them has already walked away from.

So when someone in a white coat, or a legislature, tells a suffering person that the door is open, the honest reply is: Yes, and what have you done to the other doors? Did you build the housing? Did you fund the treatment? Did you staff the ward? Did you relieve the family? Did you sit with the loneliness? Or did you leave every other door shut, paint this one gold, and call it freedom?

Do no harm is not a slogan either. It is the test. And a programme that solves suffering by removing the sufferer has failed the test, however neatly the paperwork reads.

The Door That Matters

The door Epictetus left open was a private door, a last freedom held by a person no power could finally reach. It still stands. I will defend it.

But a door kept open by care is not the same as a door left open by abandonment, and we are learning, in Canada, how easily the second disguises itself as the first.

A decent society should be able to say more than You may leave. It should be able to say, with evidence behind the words and not merely kindness: You may stay. There is a bed. There is treatment. There is someone to sit with you through the worst hour. Your loneliness will not be entered on a form as a reason. Your body will not be weighed for what it can yield. Your life will not be measured against the cost of keeping it.

Until it can say that, and mean it, the open door is not freedom. It is the one door the institution found affordable to build.