‘Dying with dignity’
Is just a euphemism for a dangerous policy, a pediatric surgeon says.
At the entry to Paris’s oldest hospital, the Hôtel Dieu, are these words: “To cure occasionally, to relieve often, to comfort always.” Medical historians ascribe this aphorism to Hippocrates, who also gave us our medical oath, an important principle of which is to not kill. And yet a culture of death, frequently disguised as the concept of “dying with dignity,” is creeping into society and becoming increasingly sanctioned by politicians and the medical establishment.
A National Assembly committee held public hearings in 2010-11 and concluded that euthanasia, euphemistically called “medical aid in dying,” should be legal in Quebec. This conclusion came in spite of the fact that two-thirds of the citizens who made presentations to the committee, including myself and many physicians, were opposed to euthanasia.
This week, spurred by a report from a panel of legal experts recommending that terminally ill adult patients be given the right to doctorassisted suicide, the Quebec government said it will introduce legislation to that effect.
Nowhere is euthanasia more dangerous than here in Quebec. In 2010, the Canadian Medical Association published sobering results of a national survey of Canadians’ attitudes, beliefs and experiences with their health-care system. A large majority of Canadians in every province concluded that the system is broken; but Quebec fared the worst.
As a pediatric surgeon in Montreal, I practise in an environment of constant triage, with decisions every day regarding which patient needs to go first. We do not have enough operating-room resources, intensive-care unit beds, hospital beds, nurses — and the list goes on. And we are the lucky ones, because we treat children; more resources are available to us than to those who treat adult patients. The situation for my counterparts who treat adults is far worse.
I have experienced the Quebec health-care system over a quarter of a century, first as a medical student in the late-1980s, then as a pediatricsurgical trainee in the late- 1990s and now as a staff pediatric surgeon for the last four years. After I graduated from McGill, I went back to my native California to start my residency, carrying a tremendous pride in the education I had received and holding the environment that I had been trained in as a model for humane and compassionate health care.
Unfortunately, since I have moved back, I have come to learn through my observations as a physician and my experiences as a patient, as well as through being a friend and relative to many patients, that health care in Quebec is in deep crisis. The denial of this crisis by politicians and health-care leaders does not make it any less severe.
The humanity of the health-care system has all but disappeared over the past 25 years. The patient has come to be seen as a burden to the system, rather than the reason for its existence. The resource limitations and senseless governmental macromanagement have destroyed the morale of many who are entrusted to take care of the most vulnerable. The voices of those who want to raise awareness of this decay are often drowned, rather than listened to. Encouraging stories of truly patient- and family-centred care are now the exception, not the rule. Is this the type of environment in which we should introduce assisted suicide?
Imagine a patient in his or her final days in such a resource-limited, highly depersonalized system. The patient is requiring large amounts of resources to sustain life. His or her physicians and nurses know that death is imminent, and that it can be hastened by a lethal injection, allowing resources to go to patients who are seen as more worthy. How much dignity will that patient have if he or she chooses to cling to life?
Is there a moral dimension to legalized killing? The three guiding principles of medicine are to do no harm, to support and sustain life and to relieve suffering. It
The humanity of the health-care system has all but disappeared. The patient has come to be seen as a burden.
can be argued that legalized euthanasia is consistent with that third principle: relief of suffering. That would be true if there were no alternatives to relieve suffering. But there are, and Quebec has been a leader in this field through the work of palliative care pioneers like Dr. Balfour Mount and the many disciples who followed him. Palliative care is now available in the home and the hospice, allowing people to die with dignity in the presence of their families andl oved ones. Pain medicine has matured into a specialty of its own, and billions of dollars have been invested into finding new treatments and methods to relieve pain and suffering. The armamentarium available to physicians has grown exponentially, and new medical journals are now exclusively dedicated to pain-management and palliative care. When pain becomes an argument for ending life, it is the pain that must be killed, not the patient. Legalizing assisted suicide due to poorly treated or untreated pain is no different than legalizing assisted suicide due to poorly treated or untreated depression. It is no coincidence that Dr. Mount, as well as most of his colleagues in palliative care, stand firmly against euthanasia.
As a pediatric surgeon, I am particularly concerned about the fate of children under legalized euthanasia. In Quebec, the age of consent is 14 — the youngest in North America. Will teenagers with terminal cancer or other diseases with a poor prognosis be able to choose to end their lives? Quebec has the highest elective-abortion rate in North America, and one of the highest in the Western world, despite the wide availability of birth control and sex education. It also has one of the highest pregnancy-termination rates for fetuses with congenital defects. Many of these defects are completely treatable, and are associated with excellent prognosis. It is legal in Quebec to terminate a pregnancy, even in the last trimester, when a congenital anomaly is identified. The fetus, who at that point may very well survive birth, is first killed
When pain is the argument for ending life, it is the pain that must be killed.
and then delivered. What if parents discover these anomalies after birth, as sometimes occurs? Will they have the legal right to end their newborn’s life?
The slippery slope is closer than we think. We only have to look at the model the Quebec government is using for its policies on euthanasia: Belgium. Recently Dr. Catherine Dopchie, a Belgian oncologist and director of a palliative care unit, visited Quebec and spoke to large audiences in Montreal and Quebec City. She described the Pandora’s box that was opened when euthanasia was legalized in Belgium 10 years ago. Out of fear of uncontrolled pain, many patients, their families and physicians don’t even attempt palliative care, and rush toward physician-inflicted death instead, she reported. The field of palliative care is thus compromised, its practitioners having to fight to propose their services to patients before they jump onto the euthanasia bandwagon. A choice for euthanasia becomes the “courageous” thing to do, and subtle or not-so-subtle coercion to make that choice is omnipresent among the elderly and terminally ill, Dr. Dopchie said. What was originally proposed as a solution for extreme cases has become a well-marketed “therapeutic option.”
After her departure from Montreal, we learned that doctors at Brussels University Hospital had euthanized twin brothers, 45 years old, who said they wanted to die because they had been told they were soon to go blind.
The consideration of euthanasia by a society that cannot provide adequate care to its most vulnerable members should be seen as an indictment of that society. Euthanasia is the easier choice for society to make. Mending a broken health-care system that often does not dignify life, long before its end, is the more difficult choice, the one that requires honesty and leadership.
Even with the most advanced medical care, we can still cure occasionally but comfort always. I do not want to practise in a health-care system where we kill occasionally and comfort rarely. For that reason, I have joined other Quebec physicians in a “total refusal of euthanasia” position. You can find out more about our position at caringalways.com.