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)
Pain or death: euthanasia again
Usually, the police raids crack houses and gang hideouts in Toronto. Last Thursday, November 26, 2009, officers descended on the Toronto Humane Society, a 118-year-old charity sheltering abandoned cats and dogs. Some of the most noted charges were cruelty to animals, which is a criminal offence in Canada. Apparently, the Society kept very sick animals alive instead of putting them to death. Assuming that’s what happened and that both managers and vets are responsible, this case may very well come down to whether keeping sick animals alive out of opposition to euthanasia is a crime in this country.
Four sections of the Criminal Code of Canada cover the crime of cruelty to animals. There are four possible offences. Three of them, injuring animals in transit or abandoning them, keeping a cockpit, and breaching a prohibition order, are not relevant to this case. The offence that the Society’s managers allegedly committed is causing unnecessary suffering to animals. “Every one commits an offence who … wilfully causes or, being the owner, wilfully permits to be caused unnecessary pain, suffering or injury to an animal or a bird…” (s. 445.1(1)(a) of the Criminal Code).
If the Society’s managers can prove that the pain their policy caused to the animals was necessary, they will be acquitted. Tim Trow is the Society’s President who faces charges of cruelty to animals. According to the Toronto Star, he is “a retired lawyer known for his opposition to euthanasia.” Assuming there is no other relevant information, he isn’t a sadist. He kept animals suffering from incurable diseases alive because he believed it was wrong to kill them. If he can prove that choosing pain over death is necessary, he will be acquitted.
Only those causing “unnecessary” pain are guilty of the crime. The courts have said that “unnecessary” in this context means something that can be avoided. And you must handle the animal for a legitimate purpose in the first place. For example, it is legitimate to euthanize your terminally sick dog, but you can’t cut its throat to kill it because painless alternatives are available. But what about keeping a terminally sick dog alive? Assuming it’s a legitimate purpose and assuming they don’t prescribe morphine for dogs, there is indeed no alternative to pain. So Tim Trow’s defence will come down to whether keeping a terminally sick animal alive is a legitimate purpose.
And that’s a philosophical question, isn’t it?
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.
