In wake of ruling, who does the killing?
A dilemma is emerging as doctors come to grips with the Supreme Court of Canada’s ruling on doctor-assisted suicide: Who should help take the lives of consenting adults?
The Canadian Society of Palliative Care Physicians says a survey conducted in January, one month before the high court ruling, shows a majority — 74% — of its members would not help their patients commit suicide when the act becomes legal. “It is just anathema to us, to many of us,” said president Dr. Susan MacDonald, an associate professor of medicine and family medicine at Memorial University in St. John’s, N.L. “How would I ever inspire trust when people already have this terrible fear of what it is I do already?”
Some worry patients seeking their legal right to assisted death could face the same significant gaps in access as women seeking abortion have encountered since the high court struck down the law criminalizing abortion in 1988.
Others wonder if the task would be left to “euthanologists,” or whether doctors need be directly involved in any assisted-death regimen.
“I really hope wisdom prevails here, and that the spirit of the ruling carries through into the legislative framework,” said Dr. Ross Upshur, a Canadian physician and professor in the Dalla Lana School of Public Health at the University of Toronto.
“The worst case scenario is a situation like the provision of abortion care, where there is no standard set and you have a patchwork of different approaches by different provinces.”
Dr. Upshur was a member of the Royal Society of Canada’s expert panel in 2011 that called for a lifting of the ban outlawing assisted suicide and euthanasia. The panel also raised the possibility of whether it should be limited to health-care professionals.
Three years ago, two Harvard Medical School ethicists writing in the New England
Journal of Medicine, proposed a scheme that would remove doctors from direct involvement in the process. Under their system, a doctor could certify a patient meets the criteria for assisted suicide, and the patient would then obtain a lethal prescription through an “independent authority” — much like the declarations doctors sign for Canadians to get legal access to medicinal pot. A federal body would confirm the “authenticity and eligibility” of requests, dispense the drugs and monitor demand and use, the Harvard duo wrote.
In Canada, the Supreme Court lifted the ban on doctorassisted suicide only, and the idea of taking physicians out of the equation in any meaningful way makes many nervous.
“Ten jurisdictions in the world that have legalized this, none have felt the need to create another profession, or to farm it out to another profession,” said Dr. James Downar, a critical care and palliative care physician at the University Health Network in Toronto, and one of the few doctors in Canada who has spoken out publicly in support of legalized doctor-assisted death.
“You also need the extra safeguard that the person who provides assisted death can also provide something else, right up to the last minute,” Dr. Downar said.
“If you go to see someone whose exclusive job is to provide assisted death — even assuming there’s no question the person has a vested interest in performing it — even if they wanted to dissuade the person, what other option could they present? None,” he said.
A recent poll by the Canadian Medical Association suggests one-quarter of doctors would be willing to participate in doctor-assisted suicide.
“That’s a hefty number,” Dr. Downar said, adding that concerns over supply shouldn’t exaggerate expected demands. Experience from other jurisdictions where doctor-hast- ened death is legal shows that assisted deaths account for only a small proportion of total deaths.
But he is troubled the organization representing those who specialize in caring for the dying strongly opposes decriminalizing assisted suicide.
“We are trying to get as many people as possible to be followed by palliative care providers prior to death,” he said.
“If we establish right off the bat that there is this thing that we’re not going to be involved in — a right that 84% of Canadians believe they should have access to — to me, that’s a potential barrier, not to assisted death, but to palliative care.
“It’s not like these patients are able to advocate for themselves. It’s not like they can just hop out of bed and go to the palliative care unit across the street and get the service there.”
Dr. John Turnbull is head of neurology at McMaster University in Hamilton. He also runs a clinic for patients with ALS, amyotrophic lateral sclerosis, or Lou Gehrig’s disease. Most of his patients die at home, and many under the care of palliative care doctors.
“How are we going to operationalize this? Who’s actually going to do it?” Dr. Turnbull said of the assisted-suicide ruling.
“The easy part is for me to say, ‘ Mr. or Mrs. Smith has got an incurable disease, they’re in considerable discomfort, they want to end their life, and they’re not depressed.’ That I can do,” Dr. Turnbull said.
“But then what? Is there some sort of an executioner class of people without the negative connotations of an executioner? Does it have to be a physician? What happens if it becomes a non-accessible service because of a refusal of people to do it?”
Dr. Russell Goldman is director of the Temmy Latner Centre for Palliative Care at Toronto’s Mount Sinai Hospital. His team of home care doctors is discussing how it would meet requests for assisted suicide while still respecting individual doctors’ rights not to participate based on their moral or religious views.
Goldman and others say no doctor practising today went into medicine thinking this is what they would one day be asked to do, and that many feel deeply conflicted.
“I think that’s an unknown right now — how would people respond and react to this, over time? What is the trauma associated with it?” Goldman said.
“But I think it also has to be balanced out by the trauma sometimes of standing by someone’s bedside who is in severe suffering, and feeling like you’re out of options.”