MUST DOCTORS BE THE ONES TO HELP END A LIFE?
The role of physicians is at the heart of the heated assisted-dying debate
In 1996, a McGill University professor of medicine, ethics and law said philosophers are better equipped to provide assisted dying than doctors are.
Academic philosophers seemed more comfortable with the idea than doctors did, Carl Elliott wrote in a commentary in the Canadian Medical Association Journal. If philosophers believe assisted death is a positive development, and helping people to die would reflect well on their profession, then maybe they should be the ones to do it.
“Lethal injection is a technically uncomplicated procedure that philosophers could easily learn to perform. It is already employed in several United States jurisdictions as a means of capital punishment without the aid of doctors.”
Elliott’s poke at philosophers was satire in the vein of Jonathan Swift’s A Modest Proposal in 1729, which suggested that the impoverished Irish could relieve their suffering by selling children to rich people for food.
Physicians have long argued that helping people die is contrary to their ethics and the ancient oaths of their profession. Two decades after Elliott wrote his commentary, the idea that assisted death is not a job for doctors is still percolating.
“It doesn’t take 10 years of medical school to learn how to do this,” says Dr. John Patrick, an Ottawa physician and researcher who now lectures on ethical issues in medicine. “I suggest it should be lawyers or politicians. And I’m only half-joking.”
The Canadian Medical Association’s 2015 consultation with its members showed doctors are divided about who should provide Medical Assistance in Dying (MAID). Many indicated they wanted no part of it.
“My solution would be that there be an independent facility set up and managed by those who support medical intervention by killing,” one doctor told the CMA.
Another argued there is no other profession equipped to take on the dual role of providing MAID while at the same time taking on a guardian role.
“There is no profession currently existing in Canada which would be better able to provide (patients with) and protect patients from assisted dying than physicians.”
“Clearly, there are physicians who feel that there is no room for assisted death in medicine,” says Dr. Jeff Blackmer, the Canadian Medical Association’s vice-president of medical professionalism. However, doctors provide endof-life care and they have access to better drugs and symptom control than ever before. Assisted dying “is in many ways an extension of that,” he says.
The fundamental question of whether MAID is part of the scope of medicine is important for two reasons.
First, assisted death provides significant power to physicians. Second, it imposes a significant burden on them, says Trudo Lemmens, the Scholl Chair in health law and policy at the University of Toronto’s faculty of law.
The doctor-patient relationship is a power relationship. Patients find it hard to contradict a doctor’s advice. When a patient makes an appointment for life ending treatment, it may be hard for the patient to say he or she has had second thoughts at the last possible moment.
“You have someone who comes over to provide a service,” says Lemmens. “For a patient in a difficult position and who is ill, it’s harder to say, ‘I’m not 100 per cent sure. Come back tomorrow.’ ”
In some other countries where assisted death is legal, the responsibility doesn’t rest entirely with doctors. In the Netherlands, for example, every case is assessed, after the death, by a committee that includes a judicial expert or lawyer, an ethicist and a physician. The message is that the act has legal and ethical parameters as well as medical ones.
If physician-assisted death is part of the continuum of medicine, it needs the same careful evaluation as any other medical innovation, from new medications to wart removers, says Dr. Harvey Max Chochinov, the Canada Research Chair in palliative care at the University of Manitoba and director of the Manitoba Palliative Care Research Unit.
If it’s not a medical act, then it should have a legal and social policy framework. Decision-making should have legal markings and a process that determines whether a patient is eligible for assisted death, as well as screen patients for undue influence and verify informed consent, he says.
“While some physicians may choose to include hastened death in their practice, it is not a foregone conclusion that it should necessarily remain in their domain.”
Some health-care regions are implementing MAID by way of multidisciplinary teams, which include various professionals besides doctors, says Chochinov. “This suggests that the skill sets required to address MAID requests are not exclusively within the domain of medicine.”
So who else could or should perform assisted dying, if not doctors, philosophers, lawyers, politicians (or veterinarians, as some wags have suggested, pointing out that animal doctors have far more training and experience in euthanasia than physicians do). No professional group has stepped up to the plate, and organizations from palliative care providers to children’s hospitals are not exactly lining up to promote it. For one thing, the optics are bad for fundraising.
Pashta MaryMoon, is a “death midwife” and the executive director of the Canadian Integrative Network for Death Education and Alternatives, which has about a dozen members and a mailing list of about 300.
Death midwives assist their clients and families through the transition to death. There are no credentials, and each member would have to make their own decisions about whether to include assisted or hastened deaths in what they offer. The term “death midwife” is contentious.
For a patient in a difficult position and who is ill, it’s harder to say, ‘I’m not 100 per cent sure. Come back tomorrow.’
Midwives who assist in births have already objected to its use.
Speaking for herself, MaryMoon says she supports assisted death but can see how doctors who are sworn to preserve life are conflicted. If it were legal and she had the training, she would consider becoming a “death coach” and administering life-ending drugs prescribed by a doctor.
“Some patients have a very strong relationship with their doctors,” she says. “But I don’t think a doctor has to be there.”
For some jurisdictions, the answer is essentially do-ityourself death — although a physician still has to write up the prescription. Dignitas, the Swissbased right-to-die society, offers “accompanied suicide” through the use of a lethal barbiturate. Although those who use the service don’t have to be a Swiss citizen, it requires a Swiss doctor’s prescription.
Dignitas also has doctors who provide the prescription after at least two meetings with the patient. The doctor is not present when the patient takes the drug. This solution is not without risks — a patient who wants to die could end up in hospital being revived if the drugs fail.
In the Netherlands, mobile euthanasia clinics consisting of a doctor and a nurse go to patients’ homes. The Dutch Euthanasia Society, a lobby group, promoted the mobile system, in part, because family physicians were balking at providing assisted death. Critics of this development point out that there is no longterm relationship between physician and patient in these cases.
Lemmens has other concerns about euthanasia specialists, including practitioners who are overly enthusiastic about their work or stand to profit from it.
“What do we do when people develop this kind of professional zeal? What if there is fee-for-service?” he says. “We would want to make sure that there are no improper incentives.”
Polls of CMA members show that between 20 and 30 per cent of are willing to provide MAID, so there’s no question that there will be enough doctors to meet the demand, Blackmer says.