Second post in a series on the First Annual Interprofessional Health Law Conference.
- family, community, faith traditions, society
- care provider values
There are often tough questions to ask, like how to deal with internal defibrillators. They are necessary for the patients who use them, but they can also cause a lot of pain at the end of life.
However, the main reason most patients want euthanasia is not because of pain, which can often be managed these days through pharmaceuticals. More often it’s about feelings of being a burden to those around them, especially family. Feelings of loneliness and isolation are also common motivations.
The greater challenge for those in health care is to ask whether we should use all the technology we have simply because we have it. There are also issues of distributive justice, which needs advocates to champion various causes.
Trudo Lemmens, an Assoc. Prof. at UofT in both Medicine and Law, discussed the claim for legalization of assisted suicide and euthanasia. Refusing treatment is often more often accepted internationally than active euthanasia.
The case law on the subject was basically leading in this direction, providing more self-determination and control of the body by the patients.
The arguments against this, which were expressed at the level of the Supreme Court of Canada, was the impact this would have on attitudes and protections in society. It could easily be projected, for example, on to people with disabilities. In an environment with limited health funding, there is enormous potential for abuse.
The Charter does provide a heavy ones on the government to ensure there are no less restrictive means of infringing individual liberty rights. This essentially is a question of evidence, and some countries do have legal euthanasia already.
Lemmens discussed a case of a Jehovah’s Witness who didn’t want a blood transfusion, but was provided one anyways by a physician and sued. The court held that people have a right to make choices, even if they are foolish.
He also discussed another case in the Netherlands, where a woman who was severely depressed, had lost two sons, and could not be treated conventionally. The court there ruled that she had a right to assisted suicide, and that psychological suffering can also be a form of unbearable suffering.
Dianne Williams is a palliative care nurse and nurse practitioner at St. Michael’s Hospital. Her role was to explain what palliative care was, and how palliative care used to be synonymous with hospice care. Hospice is actually community based care, whereas palliative care is a philosophy of care associated with more medical and professional services.
Most of the patients they see in palliative care was cancer patients, but they are now seeing more cardiovascular problems, respiratory cases, HIV/AIDS, and end-stage cardiac or renal disease. There is now more integration of palliative care outside of cancer to other disease trajectories.
Palliative care improves the quality of life through prevention and relief of suffering. They use early identification, assisting in treatment, and deal with physical and pyschosocial problems. Palliative care can start right at the time of diagnosis.
She closed with a quote from Robert Buckman to emphasize the role all of us can play through communication instead of relying exclusively on pharmaceuticals,
Communication skills make an appreciable difference to clinical management. We take for granted our own communication abilities in history taking, but further training can enhance our ability to diagnose and treat conditions, including depression.1 Communication is often a major component of the medical management in chronic and palliative care: sometimes it is all we have to offer. Compared with most medications, communication skills have undoubted palliative efficacy (often reducing symptoms significantly), a wide therapeutic index (overdose is rare), and the commonest problem in practice is suboptimal dosing. At a more mercenary level, poor communication skills have been shown to be a predictor of medicolegal vulnerability and also of burnout.2,3
Finally, Hugh Sher of Scher & De Angelis LLP, spoke against euthanasia. Sher held several executive roles including with the Human Rights Committee of the Council of Canadians with Disabilities and ARCH Disability Law Centre.
He started by asking,
If only choice is to suffer to death or kill yourself, some would say its not a choice at all.
Euthanasia is not about pain, according to Sher, but about fear and desperation. The debate focuses on how we define our choices in society.
A religious basis used to serve as fundamental prohibition vs these discussions, but we don’t live in that same framework. We now live in a secular society based on individual freedoms and rights.
But this argument transforms doctors as healers to doctors as killers, which is a fundamental transformation. Physicians are gatekeepers of services, and also have their own perspectives based on their own ethical, cultural and religious views.
He related the ordeal of one of his clients who had a severe disability. He had wonderful relationships and wished to live, even though there was no likelihood of dying from his condition any time soon.
But the person needed oxygen to survive. And the cost of this service was more than what he got from the government.
Sher raised the example of some Aboriginal communities in the Maritimes who have a high rate of depression and a dependancy on solvents, but nobody would advocate euthanasia, nor should they.
Euthanasia requires consent, but this notion is often ignored. This decision is often made for people in the terminal end of life, not when they are earlier on in their disease. They do not lose their humanity over this continuum of the disease, so why do perspectives of euthanasia then change?
He claimed over 1600 people were killed in the Netherlands without proper protocols being followed. Another report following this finding discovered that another 800 people had been similarly killed.
According to Sher, once you make the decision to rationalize ending people’s lives, it’s much easier to rationalize the failure to follow protocol. It creates a culture permissive of these acts, and we can move the goal posts more and more.
Lemmens did say in response that at least in the Netherlands we know what the situation is. In Canada, we still do not fully know what practices are being observed in end-of-life care.