Dialogue needed on doctor-aided suicide

TORONTO—Canadians need to engage in a broad national dialogue on the issue of whether terminally ill patients should have the legal right to physician-assisted suicide, says an editorial in the Canadian Medical Association Journal.
The editorial—entitled “Choosing when and how to die: Are we ready to perform therapeutic homicide?”—follows a recent report by a Quebec government commission which recommends that dying patients should have the right, under strict conditions, to request medical assistance to die.

The Dying with Dignity commission—a multi-partisan group of nine members of Quebec’s national assembly—issued its 180-page report a month ago after two years of research and public and expert consultation on the thorny issue.
Among its 24 recommendations is one suggesting that Quebec’s attorney general suggest to Crown prosecutors in the province that a doctor who has helped a terminally ill patient die not be charged with an offence. Euthanasia and assisted suicide are illegal in Canada under the Criminal Code.
In yesterday’s editorial, editor-in-chief Dr. John Fletcher and senior associate editor Dr. Ken Flegel write that the right-to-die issue should not be decided by the courts, such as the recent ruling rendered by a B.C. judge, but as part of a democratic process.
“Really what we wanted to say is that there are consequences of having a policy either way, but it’s probably time that we do,” Flegel said in an interview from Montreal.
“It’s going to involve some sort of democratic process to arrive at a decision. And whatever the decision is, part of the country is not going to be very happy,” he said.
“We’ll just have to live with the fact that social choices and values will mature, change, move on, and we have to adapt to them. And it’s time to have a very open public discussion and, we’re hoping, a very democratic process for deciding how to change the law.”
On June 15, a B.C. Supreme Court judge struck down the laws banning doctor-assisted suicide as unconstitutional, but suspended her ruling for one year to give Parliament time to draft new legislation.
Judge Lynn Smith also ruled that one of the plaintiffs in the case, Gloria Taylor, would be allowed to seek assisted suicide within the year if she so chooses. Taylor, 64, of West Kelowna, B.C., has Lou Gehrig’s disease.
Flegel said repeated surveys show that more than half of Canadians support a dying patient’s right to end their suffering, and the proportion of doctors favouring medically assisted suicide tend to mirror the public’s majority view.
“But there’s a little extra issue inside this, and that’s who is going to do this,” he said, “because no one perceives themselves to have been trained to do it.”
While the Hippocratic Oath charges physicians to “do no harm,” Flegel said surgery, inserting needles to get blood samples and myriad other invasive procedures mean health providers do indeed do harm, but with the goal of healing.
Under the Assault and Battery Act, doctors given patient consent are not subject to charge.
Flegel, an internal medicine specialist, acknowledged that terminally ill patients can have their deaths hastened as a result of being given heavy doses of morphine to control pain.
Under a bioethical principle called “second intention,” doctors often relieve patients’ suffering with drugs to the extent necessary, even if the secondary adverse effect means it shortens their lives, he said.
“That’s really not an issue anymore and that’s a foundational principle of modern palliative care,” added Flegel.
The Quebec report is important because it moves beyond the locked-in position that palliative-care physicians find themselves in by saying there are times when patients’ suffering is so intolerable that they would rather stop that care and end their lives, Flegel said.
However, the commission stresses that euthanasia or doctor-assisted suicide would be allowed only under “very strict conditions.”
“Then it goes on to say that we do not want this done by back-street operators, we do not want this done in non-transparent clinics in another country. We want it done where it can be monitored, where it can be adjudicated, where it’s subject to controls and all the good things that happen when people make decisions openly and democratically and transparently.”
The editorial says it’s time for Canadians to speak up with conviction, no matter whether they are for or against the idea of a dying person’s right to seek help to end their life.
“Personally, in an ideal world, I would like to see people calling their MPs,” said Flegel. “And I think we need a free vote in the House of Commons on this. I don’t think a referendum is appropriate here.”
Flegel, who has accessed palliative care for many dying patients over his 33 years of practice, declined to disclose his own stance on assisted suicide, but said his position is deeply nuanced and took a lot of work and time to formulate.