EUTHANASIA: The means to an end                  

February 6, 2015 is a date in Canadian history that will forever be remembered because the Supreme Court of Canada published their decision that day for those unfortunate people who are suffering from an incurable disease and are constantly in pain and are permitted to die with the assistance of a physician.  (Carter v. Canada)

                   

November 1973 is a date that I will always remember because it was in that month that the medical journal, Modern Medicine of Canada mailed to all the 33,467 registered physicians in Canada that particular monthly edition in which the main article in that edition was written by me. It was titled, Euthanasia: the Issues and Implications. The article was in the first three pages of the journal. Six percent of those physicians responded to the questionnaire that was attached to that edition.  The questions were;

Have you ever been faced with a medical situation in which a decision on Euthanasia could have been involved?                                                                          

Do you feel that the legal position on Euthanasia should be examined?

Do you feel that the terminally ill patient of sound mind has the right to reject treatment which could prolong his or her life?

Do you feel that a physician should sustain life in a terminally ill patient who is suffering pain or indignity at any cost?

Do you feel in a case of a comatose patient who according to all indications is dying, the decision to discontinue life support services should be by a committee of physicians, a legal body, or the patient’s next of kin?

A survey was conducted in 2014 of 5,000 Canadian doctors in which 45% said that they support legalizing euthanasia while 27% of them said that they would be willing to provide that service to their patients if that was the only way to end their suffering. Then last summer, the Canadian Medical Association soften its rules on doctor assisted suicide. The vote on that resolution carried with 91 percent in support.

On the first page of my article, I wrote;

“It is very difficult for those of us who are healthy in mind and body to imagine ourselves begging for death, but it is also unlikely that any adult living has not at least on one occasion known personally or known of a person who would be better off dead. There are illnesses which are so horrible that death would come to the sufferers as a blessing.” 

Multiple Sclerosis comes to mind because one of the symptoms of this horrible disease is the difficulty in breathing. Several years ago, I suffered from congestive heart disease. The excess fluid in my body surrounded my lungs and heart which made it very difficult for me to breath. Believe me when I tell you that gasping for air is a horribly frightening experience. If it was a permanent disease, I would want to die as soon as I could. Fortunately, I was given emergency treatment in a hospital so I don’t suffer from that disease any longer but I do take drugs that keep that disease in check.

The Supreme Court of Canada has come to the rescue of all those unfortunate people in Canada whose suffering is so severe; death will come to them as a blessing. The Conservative government that vowed never to reopen the question of assisted suicide now has to deal with this issue because the court has given the federal government and the parliamentarians one year to bring in a law that will make these blessings available to those who are suffering so horribly. It was a historic and far-reaching decision of the Supreme Court of Canada having declared that desperately suffering patients have a constitutional right to doctor-assisted deaths. Alas, none of the political parties in Canada have previously championed the cause of legalizing doctor-assisted euthanasia so unless there is a sudden change of heart in their indifference to the suffering of terminal patients dying so horribly, the law the court proposed will die like a fetus before it is even born. The government can invoke the little-used  Constitution’s over-riding clause that allows the government to legislate against the proposal notwithstanding Canada’s basic rights legislation. The government should take heed in not angering the voters because the majority of the voters support the rights of people having more control over their end-of-life care. The present government is faced with a problem for them in this election year since many of the members of their party are against the Court’s proposal. To ignore the proposed legislation as suggested by the Supreme Court is to seek political suicide for the members of that party and their government.  

The decision in favour of consenting adults who determine they cannot tolerate the physical or psychological suffering brought on by a severe, incurable illness, disease or disability is a stunning reversal of the court’s 21-year-old ruling in the Sue Rodriguez case. The court’s decision overturned the court’s 1993 ruling in Sue Rodriguez’s bid for help to end her life before her disease of Multiple Sclerosis made it impossible to even ask. The high court said it was time to revisit that because of legal changes in how courts analyze the constitutionality of statutes, and evidence based on the international experience that now shows how “safeguards” can be built into a “permissive regime” to protect vulnerable people from error or abuse.

In the 9-0 judgment, the court declared the Canada’s Criminal Code’s absolute ban on assisted suicide goes too far. Its attempt to protect the lives of “vulnerable people” also prevents competent, consenting adults suffering “grievous and irremediable medical conditions” from making core decisions about how they live and die, and so it thereby breaches three of the most basic rights: to life, liberty and security of the person, all enshrined in Section 7 of Canada’s Charter of Rights and Freedoms and for this very reason, the ban is not justified in a free democratic society.

The ruling is not limited to disabled individuals who are unable to kill themselves unaided, nor is it limited to cases of terminal illness or people near death. Instead, the ruling applies broadly in cases of a major illness, disease or disability that inflicts intolerable physical or psychological suffering on a patient.

When I referred to psychological suffering, I wasn’t referring to people who simply want to die because they are bored with life. Psychological suffering was the reason for the following euthanasia deaths in the Netherlands: a healthy woman, with tinnitus, (ringing in the ears) chose to die by euthanasia; a healthy man who was lonely, depressed and recently retired chose to die by euthanasia; a healthy woman who was deaf chose to die by euthanasia.

Parliament could enact a new law laying out a scheme for physician-assisted suicides thereby setting out guidelines for determining consent, timelines, residency requirements, or the extent of medical assistance suicides. It could also decide not to draft a new law, allowing the ruling to stand as an expression of principles and leave details up to provinces or medical regulatory bodies and authorities to oversee.

 What this would mean is that if a physician chose to assist someone who is severely ill with a terminal illness and suffering from severe pain all the time and wants to die and is assisted in that death by a physician, the government may be hard pressed to get a conviction against the physician under the current law since such an act of mercy is protected by Section 7 of the Charter.  However, it would not permit anyone else to aid individuals to commit suicide at any time even if a new law came into effect because the Court was referring only to physicians carrying out the euthanasia.

Kay Carter and Gloria Taylor, another B.C. woman, suffered from different debilitating conditions when they launched the landmark case into the Supreme Court of Canada. Both have since died. Carter’s family escorted her to Switzerland which allows physician-assisted suicides. I should add that the State of Oregon also allows assisted suicides for those who have terminal and suffer from debilitating conditions. The British Columbia Civil Liberties Association took up their challenge. The court said the litigation was in a broad national public interest and therefore the full legal costs that are estimated to be in the millions of dollars are to be paid by the federal government with some costs to be paid by the government of British Columbia.

However, Canada’s highest court has left many questions for some of the physicians in any future assisted death proposal who will be asked to help put to death an adult who has decided that life is no longer worth living. That is because not every doctor wants to put someone to death if they feel that it conflicts with their Hippocratic Oath in which states in part; “do no harm.”

What is “grievous” suffering? Who defines it? What form of “physician-assisted death” would be permitted? Death by a lethal prescription the patient would take him or herself, or death by lethal injection? Would physicians opposed to medical aid in dying have the right to refuse to even refer a patient seeking assisted death to another doctor willing to perform it?

Would a doctor assist in the death of a patient who has a grievous and irremediable medical condition and who is also retarded and doesn’t really understand what options are available to that unfortunate person?

The court didn’t say whether an assisted death would apply to people with mental illness such as depression alone. Quite frankly, I can’t even envision any court going that far.

Chris Simpson, a cardiologist and the president of the Canadian Medical Association said that the court did set out some parameters. First, assisted dying would be permitted only for competent adults who could explicitly provide consent. The court did not say that it would apply to people who have been delegated as their substitute decision makers should the patient ever lose the capacity to speak for themselves.  That would appear to set aside concerns of substitute decision makers making the decisions for patients who don’t have competence to make the decision themselves.

Obviously, a wrong could be committed if the patient has previously written a Will and has left everything to the substitute decision maker. Imagine how frustrated the patient would be if he or she could hear everything that is being said but is unable to communicate his or her desire to continue living.

It will be up to physicians’ colleges, Parliament and guidance from civil rights movements to craft a comprehensive assisted death regimen for people experiencing physical or psychological suffering. Their guidelines would be based on the premise that assisted suicides should only apply when the patient suffers from a “grievous and irremediable medical condition” causing “enduring suffering that is intolerable to the individual in the circumstances of his or her condition and there is no hope of relief from that pain.

Unfortunately although the court defines a medical condition as an illness, disease or disability, it didn’t say specifically which conditions would qualify, or where in the course of the illness the person would have to be before he or she could legally be assisted in death.

The court said that the person’s condition doesn’t need to be terminal and it also that said doctors should be capable of assessing whether someone is competent, and that proper safeguards would protect the vulnerable from abuse or error.

The court said that declaring the current prohibition against assisted dying constitutionally invalid doesn’t mean doctors would be compelled by law to provide aid to the patient who desires to die to end his or her suffering. That is because a doctor’s decision to participate in the process of assistant suicide is a matter of conscience and, in some cases, of religious belief. But it was more circumspect on whether doctors would be compelled to refer patients to other providers, noting that the charter rights of patients and doctors will need to be reconciled. If a doctor doesn’t wish to recommend the services of another doctor who is willing to undertake that task, the patient or caregiver (a relative) can be given a list of doctors who will undertake the task.

The court didn’t say whether an assisted death would apply to people with mental illness such as depression alone. Quite frankly, I can’t even envision any court going that far.

Chris Simpson, a cardiologist and the president of the Canadian Medical Association said that the court did set out some parameters. First, assisted dying would be permitted only for competent adults who could explicitly provide consent. The court did not say that it would apply to people who have been delegated as their substitute decision makers should the patient ever lose the capacity to speak for themselves.  That would appear to set aside concerns of substitute decision makers making the decisions for patients who don’t have competence to make the decision themselves.

Obviously, a wrong could be committed if the patient has previously written a Will and has left everything to the substitute decision maker. Imagine how frustrated the patient would be if he or she could hear everything that is being said but is unable to communicate his or her desire to continue living.

It will be up to physicians’ colleges, Parliament and guidance from civil rights movements to craft a comprehensive assisted death regimen for people experiencing physical or psychological suffering. Their guidelines would be based on the premise that assisted suicides should only apply when the patient suffers from a “grievous and irremediable medical condition” causing “enduring suffering that is intolerable to the individual in the circumstances of his or her condition and there is no hope of relief from that pain.

Unfortunately although the court defines a medical condition as an illness, disease or disability, it didn’t say specifically which conditions would qualify, or where in the course of the illness the person would have to be before he or she could legally be assisted in death.

The court said that the person’s condition doesn’t need to be terminal and it also that said doctors should be capable of assessing whether someone is competent, and that proper safeguards would protect the vulnerable from abuse or error.

The court said that declaring the current prohibition against assisted dying constitutionally invalid doesn’t mean doctors would be compelled by law to provide aid to the patient who desires to die to end his or her suffering. That is because a doctor’s decision to participate in the process of assistant suicide is a matter of conscience and, in some cases, of religious belief. But it was more circumspect on whether doctors would be compelled to refer patients to other providers, noting that the charter rights of patients and doctors will need to be reconciled. If a doctor doesn’t wish to recommend the services of another doctor who is willing to undertake that task, the patient or caregiver (a relative) can be given a list of doctors who will undertake the task.

Doctors are far more deeply divided on assisted suicide than the general public is. The actual number of patients who would likely be eligible for, or even requesting assisted death, will probably be so small, based on the experience in other jurisdictions. For that reason, there still will probably be sufficient numbers of doctors willing to provide equitable access for all patients in need of that kind of relief without compelling a large number of doctors to personally participate in assisted dying who may have qualms in doing so. Nevertheless, many doctors are wondering how they will balance their personal ethics against their terminal and pain suffering patient’s new rights to assistant suicide. Dr. Margaret Cottle argues that assisted suicide shouldn’t be part of the doctor’s job description. I agree with her but no doctor is required to euthanize patients so her concern becomes academic. She said, “It is sad for our who country that we’re thinking about resorting to death, that we have crossed that bright line, where we have agreed as a society that lives are not worth living.”

Doctors who advocate euthanasia for the terminally ill and patients who are also suffering from continuing intolerable pain do not consider their patient’s lives worth not living but rather they look at their patient’s lives as being in agony and where death is the only means to end their agony. 

Canada has to have a system that balances the right of physicians not to participate, and perhaps not even to refer to another doctor to conduct the procedure but that has to be done in a way that doesn’t impair access to patients who would qualify for assisted dying.

Kathleen Carter, of B.C., died five years ago on January 2010 in a Zurich clinic, after ingesting a lethal dose of barbiturates. Her daughter Lee told Postmedia News. “It was a beautiful death, if that’s possible for   someone who wanted to go.” I remember reading years ago that in Switzerland, some doctors of such patients would place three morphine capsules on the table beside the patient’s bed and tell them to take one when the pain is intolerable but not take all three at the same time because if they do, they will die. After the doctors left the rooms; that’s what some of their patients did. Cause of death? Accidental overdose of morphine. 

In the State of Oregon usually an oral barbiturate is given to the patients as a means of ending their lives if they have a terminal illness that is expected to kill them within six months. The dying patients have to ask their doctor twice at least 15 days apart for the fatal drug and then submit a written request witnessed by two persons.

In the State of Montana, the doctors are permitted to prescribe the fatal drug but the patients must administer the drug themselves. The same applies with the State of Washington. In the State of Vermont, patients must state three times that they wish to die and must also get a concurring opinion from a second doctor that they have less than six months to live and are of sound mind.

What should be done if the hospital doctors are convinced that the patient is brain dead and wants to terminate the patient’s life but the family refuses to permit it? Here is a rather interesting case where this problem faced both the hospital and the family.

Thirteen-year-old Jahi McMath. a young California girl who went into the hospital for a routine tonsillectomy, suddenly suffered from a cardiac arrest after extreme bleeding following her surgery and was subsequently pronounced brain dead by hospital authorities. Then they decided that they should terminate life support interventions for the girl, despite her family's objections to these actions. The hospital petitioned the court system for authorization to cease all life support services, and a month-long legal battle between the hospital and the family ensued. Eventually, the court ordered that the young girl was to be released to her family from that hospital who then took her to another medical facility for treatment. A year later, Jahi still remained on a ventilator and was hooked to feeding tubes. Her case has ignited a debate over the definition of brain death.

You may wonder why the family wouldn’t let the girl’s life be terminated. Relatives say their religious beliefs dictate that as long as her heart is beating, Jahi is alive and deserves long-term care.

In October of last year, the family released videos of the girl showing her foot and hand appearing to move in response to her mother's commands. Is there any scientific basis for the family's belief that Jahi is responsive and could recover? Nancy Berlinger, a bioethicist with the Hastings Center, a nonpartisan research institute devoted to health and medical issues, says Jahi's body is only being maintained by machines. Others contend the family is confusing any movements with an involuntary muscle reflex sometimes seen in brain-dead patients— the so-called Lazarus effect.

A Florida woman named Terri Schiavo often is associated with end-of-life legal fights. Schiavo collapsed at her home when she was 26 and was on life support from 1990 to 2005. Multiple doctors diagnosed her as being in a persistent vegetative state, but her parents refused to accept that. Schiavo maintained signs of limited brain activity and was able to breathe without a ventilator. Jahi is different in that doctors say her heart would stop beating if she were removed from a breathing machine because her brain stem was not functioning. The lengthy and costly campaign by her family to keep the girl's heart beating is rare. When the tax-payers are paying to keep a brain dead patient alive and it is costing them millions of dollars, they are inclined to say that enough is enough. Eventually, she was taken off the breathing machine and permitted to die.

I would be less than honest however if I didn’t mention that there are instances when other comatose patients have been living via the machines for more than a decade and suddenly begin functioning normally again.

Despite its popularity in principle in the State of Oregon, euthanasia is rarely chosen by dying patients despite their pain.  In 2013, 752 people chose to take lethal doses to end their lives and pain. Another 421 patients had prescriptions written for the drugs that would end their lives but they chose not to take them. In that year, 71 people chose to die by euthanasia. It would appear that that even many terminally ill patients who are suffering from pain, are bearing the pain so that they can still live as long as they can.

The real problem facing doctors who are caring for terminally ill patients who are suffering from non-stop pain and their illness are terminal, is whether or not their patients are mentally competent enough to make the decision that they want to die. 

A person who is suffering from severe depression coupled with bipolar disorder is suffering from two mental illnesses. If they are also suffering from ongoing severe pain and are also suffering from a terminal illness, can we say that they are competent enough to make a life or death decision? Suppose a family member has the authority to instruct their loved one’s doctor to euthanize his or her patient, can anyone be convinced that is what the patient really wants?

Both individuals and families are often faced with difficult decisions regarding what degree they or their loved ones should fight to cling to life and at what point they should embrace their own death or that of their loved ones. Those decisions are unquestionably the most difficult decisions anyone has to make. As human beings, we all have to face the impending pain, suffering, and difficulty that may lie ahead and yet we do have the right to decide if we wish to leave this life with the help of physicians if our final hours are wracked with everlasting pain and our illnesses are terminal and what is left of our lives is valueless.  

 I remember reading an article many years ago of an event that is really sad. A man was severely burned in a fire and his entire body that was as a direct result of the fire, horribly disfigured. His wife visited him in the hospital after the bandages were removed from his face and she was shocked at what she saw. He had no nose, lips or ears and the rest of his face was terribly disfigured. Soon after, he received a letter from her telling him that she was leaving him because she couldn’t live with a man who was so disfigured. Upon receiving that letter, he committed suicide by slashing his wrists.

Now here is the quandary. If he asked his doctor to euthanize him so that he could be put out of his misery and the doctor complied with the man’s wishes, would the doctor be breaking the law?  Unfortunately he would because although the man would be hospitalized for the rest of his life, his pain could be controlled and his condition wasn’t terminal. If he sought permission from a court in Canada to permit his doctor to euthanize him, his request would be denied because it would conflict with the ruling of the Supreme Court.

Could that be murder? At first, it may seem so but ask yourself this question. If you were suffering from never-ending pain and your illness is terminal and at the same time, you can’t communicate with anyone in any manner whatsoever, would you prefer to be euthanized so that there would be an end to your suffering? In your mind, would your doctor be murdering you because he didn’t get your consent?

However, if he was living in Belgium, he would have better luck.  Belgian law requires that the person be competent, and a woman in that country died by euthanasia because she was experiencing situational depression related to a relationship break-up.

On the other hand, the Netherlands may not be the best place to be hospitalized if you want to remain alive despite the pain you are suffering from. Recent statistics from the Netherlands indicate that there are at least 300 assisted deaths performed each year without the consent of the patient. Of course, those wishing to die can go to Luxembourg, Belgium or Switzerland.  

Those in the province of Quebec in Canada as of next December can find doctor assisted death to end their lives of pain because that province passed legislation last Spring that terminally ill patients suffering from intolerable pain can request their doctors to give them drugs that will hasten their deaths.  It is the constitutional prerogative of the provinces and territories in Canada to set their own health policies. In doing so, they have the legal obligation to adopt end-of life procedures that reflect the Supreme Court’s ruling.

The Supreme Court states that the person must have “a grievous and irremediable medical condition (including an illness, disease or disability).” But this is an incredibly subjective statement because many people have a grievous and irremediable medical condition. Indeed, under this definition, nearly every person with a significant disability may now feel pressured, by friends or the medical system itself, to choose euthanasia regardless of their personal preferences.

Assisted death creates possibilities of abuse for elders. Many, many years ago, Eskimo elders were placed on an ice flow and pushed out to sea to die. Are elders in this era figuratively speaking, being placed on ice flows and pushed out to sea to die?  

Giving doctors the legal authority to bring about the death of their patients will never be totally safe and no amount of so-called safeguards will protect those who live with depression or are subjected to abuse by others who will benefit from their so-called loved one’s demise. There will always be people who will abuse such power to bring about the death of others under the heading of euthanasia.  

The prohibition on physician-assisted dying has the effect of forcing some individuals to take their own lives prematurely for fear that they would be incapable of doing so when they reached the point where their painful suffering becomes intolerable.  The current ruling of the Supreme Court of Canada has resolved that problem. 

However, what happens if a patient who has a terminal illness and is suffering from never-ending intolerable pain actually wants to die but cannot inform anyone of his or her intentions to die. Well, even if he or she can’t speak or write those intentions, they can blink their eyes. One blink is yes and two blinks is no. Of course, while they are competent to make decisions, they can write and sign a Living Will in which they will state that if they are suffering from intolerable ongoing pain and there is no hope for them to survive their illness and they cannot communicate their wishes,  then they want to be euthanized. However, before they are euthanized, they must ask the patient if that is their wish. Remember; one blink is yes, and two blinks is no. Of course, if they are deaf and blind, that will cause a real problem for everyone. That’s why a Living Will will solve that problem

The Supreme Court also said; “We do not agree that the existential formulation of the right to life requires an absolute prohibition on assistance in dying, or that individuals cannot “waive” their right to life.  This would create a “duty to live”, rather than a “right to life”, and would call into question the legality of any consent to the withdrawal or refusal of lifesaving or life-sustaining treatment.  The sanctity of life is one of our most fundamental societal values.  Section 7 is rooted in a profound respect for the value of human life.  But Section 7 also encompasses life, liberty and security of the person during the passage to death. It is for this reason that the sanctity of life “is no longer seen to require that all human life be preserved at all costs.” unquote 

Now there are religious zealots who will say that patients who are suffering from intolerable pain and are facing a terminal illness, are committing a sin by asking that they be euthanized. Such a statement puts hogwash at a much higher level than that of outright stupidity.

Catholic teaching condemns euthanasia as a “crime against life” and a “crime against God”. The teaching of the Catholic Church on euthanasia rests on several core principles of Catholic ethics, including the sanctity of human life and the dignity of the human person. For this reason, a patient that asked to be euthanized and is euthanized, cannot be buried in a Catholic cemetery or their funeral be presided over by a Catholic priest.

Protestant denominations vary widely on their approach to euthanasia and physician assisted death. Since the 1970s; Evangelical  churches have worked with Roman Catholics on the sanctity of life approach, though some Evangelicals may be adopting a more exceptional opposition. While liberal Protestant  denominations have largely protested against euthanasia however many individual advocates for euthanasia and euthanasia society activists have been Protestant clergy and laity. As physician assisted dying has obtained greater legal support, some liberal Protestant denominations have offered religious arguments and support for limited forms of euthanasia.

It is one of the prevalent assumptions of Western religious culture that the Bible clearly and emphatically forbids suicide. Inspection of biblical texts shows that this is by no means the case. There is no explicit prohibition of suicide stated in the Bible. Actually the biblical texts do describe a number of cases of suicide: eight in the Old Testament, two in the Apocrypha and one in the New Testament. None of these passages offers explicit comment on the morality of the act: nor is there anywhere in the Bible any explicit discussion of the ethical issues. So what biblical grounds to those religious zealots who condemn euthanasia base their beliefs that euthanasia is a sin against Man and God?  They are the same twits who also condemn couples who live together in a common law relationship or are saying that same sex marriages are sinful and are disobeying God’s edicts.  It is the same twaddle that all zealots spew from their mouths whose brains were formed in the Dark Ages.

My paper that I submitted to Modern Medicine was actually a report I was asked to prepare for the Toronto Anglican Diocese. The church didn’t accept my suggestion that there was need for euthanasia to bring a final end to the suffering endured by so many.

Five states in the US permit assisted physician euthanasia. They are;  Oregon, Washington, Montana, Vermont and New Mexico. Colorado lawmakers have rejected a proposal to give dying patients who are suffering intolerable pain to assisted deaths by physicians. Some doctors have argued that that there may be the possibility of recovery to some of those patients and euthanizing them cannot be reversed. That is a valid argument but should patients suffer for years before death comes eventually when the cure for their diseases come fifty years after their deaths? 

The road to physician-assisted euthanasia in Canada has been a long one filled with potholes but it appears that for Canadians who are slowly dying in agonizing pain, they are at last going to reach the end of that road and die peacefully in their beds. There will be much work still to be done with respect to guidelines being drawn up.  I believe the whole world is looking towards Canada to see how we resolve this issue. What is equally important is to find appropriate means of reducing the pain these most unfortunate people are suffering from. If we solve that problem, there will be less reason for them to seek physician-assisted euthanasia as a means of ending their suffering.