RSS FeedAgainst assisted suicide
A few days ago the Canadian House of Commons rejected an assisted suicide bill. The proposed legislation would allow doctors to help terminally ill patients or people in unrelenting pain to end their lives. Currently, doctors or nurses or anyone else who helped someone die would be liable to murder or manslaughter charges and perhaps civil damages. Very few jurisdictions in the world authorize assisted suicide, which seems to be a “victimless crime.” The recent failure of this bill in Canada is a good opportunity to review reasons why society denies us an inalienable right to control our own death.
The dying person certainly has an interest in the right to end own life. First, suicide would stop unimaginable suffering. Second, the debilitating suffering is an affront to the patient’s dignity. Third, the dying person may want to accelerate the transfer of his or her property to the heirs. Fourth, the patient desiring suicide may wish to spare his or her loved ones the mutual torture of the situation. Finally, the patient may want to cap his or her health care bill. That of course is not very relevant in Canada unless your province refuses to pay for a life-saving cancer drug.
Not all public interest is against the dying person’s wish. Respect for private will and the freedom to choose is an important part of the Western way of life. But the difficulty here is that dying patients and people in unrelenting pain may have lower decision-making capacity so the society must take extra steps to ensure it understands the will of the patient correctly and that the patient is capable of forming decisions.
Generally, all issues that the society has with assisted suicide are rooted in the overarching interest to protect human life. Death is irreversible, so the risk of mistake is unacceptable even if the risk is small. The harm from assisted suicide based on a mistaken conception of the true will of the patient is enormous. People in great suffering are vulnerable and may have a lower capacity to make decisions or to communicate their true will. It is reasonable to speak of a slippery slope where we take less and less precautions or where our precautions are not enough in harder cases, which we cannot recognize. That path will take the society to where it may kill people who do not really want to die but simply cannot tell us about it.
That’s why, incidentally, the death penalty should be abolished: unless we can guarantee guilt, every time we kill a convict we risk killing an innocent man. Unless a convict’s life is less valuable than a patient’s, our highest duty to preserve life must make any risk of unjustified killing, including in the death penalty, unacceptable.
Another slippery slope argument is that the society will be seduced into tolerating more relaxed requirements for assisted suicide to lower the high cost of caring for the dying. The flip side of this argument is that we should prohibit assisted suicide to protect our standards of caring for the dying.
Our society is extremely complex and it is far from perfect. We make mistakes all the time. Sometimes, politics, ideology, or emotion influence decisions that should be exclusively technical. The risk of killing a dying patient who may not really be willing to die is too high given our paramount social duty of preserving life. Besides, modern science can certainly come up with means of reducing or eliminating suffering on the death bed, if not push the death farther away. Authorizing assisted suicide (just like authorizing the death penalty) is not a good idea.
(Post sponsored by AdviceScene)
The Right to Die
All law students come across the Sue Rodriguez case at some point, and the policy reason for forbidding assisted suicide — that it will be abused by caregivers. My Constitutional Law professor said it was obvious why we don’t allow it and despite much pondering, I still do not understand. It is all the more poignant because a good friend of mine is in Ms. Rodriguez’s shoes — she has ALS; and it is no surprise to me that she would like to have her life ended at the time of her choosing so as to avoid the intense suffering that will come if the disease progresses to its final stages.
So I ask this question: How is there room for abuse if the person whose life is being ended requests that her life be ended and chooses the time that her life is ended? I take it as obvious that assisted suicide should only be permitted for certain types of degenerative ailments like terminal bone cancer and ALS where there is no chance of recovery and the later stages of the disease bring about the kind of suffering that no living creature should be asked to endure. Someone who recently acquired a spinal chord injury and does not like the idea of life in a wheelchair, for example, should NOT be granted an assisted suicide. As well, for fear of abuse, we should not permit caregivers to request an assisted suicide on behalf of someone who cannot communicate. This much I understand.
But why do we force those who are incapacitated beyond the point of having any meaningful quality of life to suffer the final stages of a disease like ALS against their own wishes? To me this is inhumane. I would like to share with you the words of my friend Amy (fyi Carolyn is Amy’s daughter):
‘It’s not that I’m afraid to die; I just don’t want to be there when it happens.’(Woody Allen)
During a recent telephone conversation, I was reminded of an item I saw for sale once in the New Yorker magazine: solid rosewood pole capped with silver, 11 feet in length for those people who wouldn’t touch anything with a 10 foot pole.
And so I touch on the thorny debate on death – virtual pole in hand. It is a slightly different perspective than a healthy person’s approach, I grant you, but I imagine many of the questions would be the same. Perhaps, too, after being immersed in the Tudor series over the Christmas holidays, one realizes that rationalization can hide a multitude of sins and beliefs and the thirst for wealth and power has changed little in the intervening centuries. Should one, like a queen endure until dethroned (which sounds simple enough), or take the pre-emptive route of choosing the time and place of death before an even more hideous one can be devised? I routinely debate whether it takes more courage to live with something as debilitating as ALS or more courage to choose death on my own terms.
At this point, in 2009, my debate involves an innocuous phrase “quality of life” rather than being persecuted for religious beliefs or witchcraft or, as a woman, creating controversy simply through holding an opinion. It also involves the concept of suffering. How do we quantify such a thing to say enough is enough and does physical suffering that we can see outweigh mental suffering that we tend to ignore? And what about mercy? Anne Boleyn purportedly had her scheduled being burnt alive commuted to beheading with a really sharp sword. One could argue whether that was merciful. Conversations at deathbeds routinely include comments that a quick and timely death for a person who has no chance of recovery from catastrophic circumstances is merciful but Lord help you if you wish for it yourself and you are too disabled to do it.
We do not have the liberty of getting a verbal answer from a beloved cat or dog when asked if they would like to live in pain or be euthanized and, emotion aside, the decision is often a financial one. I know it can be considered crass, even unethical to many but if my care, presuming I could get it without bankrupting my family, costs thousands upon thousands of tax payer dollars and I want to die, why can’t I and have that money be used for people who have lives to live and can be saved? Another aspect not addressed much is the fact that a planned death would allow my annoyingly healthy body parts (heart, lungs, liver, kidneys) to be given to someone who would die otherwise without them. My life’s tragic turn of fate would be of real value to several people and I would know that my death also meant life. In the end, since I truly am in Sue Rodriguez’ unenviable shoes, I echo her famous question, whose body is this? I would also like to point out, I have not committed a crime (treason anyone?) so should not be forced to endure the consequences as if I had.
If there is one redeeming quality in suffering ALS, it is that, in most cases, a person dies in their sleep overcome by carbon dioxide; an effective analgesic. At which point the suffering and quality of life issues become too much to bear in between “the now”, where I can still communicate and do some things and “the then” of lying there 24/7 and receiving whatever my senses are capable of taking in and relying on the care and whims of those who will look after me, is the one hundred thousand dollar question.
I am not advocating death; I am an advocate for choice. The concept of choice when it is about birth or death is a highly emotionally charged, ethically challenging, controversial and divisive topic. Despite all of it, people are born and people die every second of every minute of every hour of every day. Last year of all the people who visited hospitals in Canada, 225,000 of them got something else that they didn’t go in for and of those, 8,000 of them died from the new invader…and they didn’t want to. And the rule-makers are worried about literally a few people who want to hasten their death? Something is wrong with this picture.
So why have I chosen now to share my views on this heavy topic? In mid-February, Carolyn and I spent several hours with a production company filming footage for a PSA TV commercial and a documentary on this subject. Because it is a difficult and mostly ignored topic, it is due for a public forum and they wanted to interview people and organizations who have to deal with death on the front lines. Spearheaded by an organization called Dying with Dignity, I was approached to participate. I was pleased that I was able to be succinct and articulate enough despite my slurry speech but I have had a lot of time to think about this and it certainly opened the dialogue for Carolyn and I to discuss it; agonizing though it may be. So, coming soon on a screen near you…….
Oh, and for those of you who don’t have wills; get one, now, for you forfeit so much to bureaucracy without one. Write your wishes down already (cremation, Beethoven’s 9th Symphony performed live, non-resuscitation, open bar, Aunt Mabel in sequins tap dancing on a white grand piano). Those left behind would rather not guess your intentions and you may hate lilies – still.
I am not a Hollow Man and T.S. Eliot may end with
This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.
But not in my world.
Namaste and Amen,
Amy Doo
> : )
The Values and Ethics of Euthanasia
Second post in a series on the First Annual Interprofessional Health Law Conference.
The euthanasia panel started off with Bob Parke, an ethicist with Humber River Regional Hospital. The discussion over euthanasia is often a conflict of different values, including:
- autonomy
- family, community, faith traditions, society
- beneficence
- 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.
