Monday, September 12, 2011

Support for dignified end-of-life legislation in Canada

From Globe and Mail Editorial, September 12, 2011
Canadians want to live good, long lives. And for most people, that includes an ending-of-life that is as dignified, peaceful and comfortable as possible.

Time and again, opinion polls show a large majority of Canadians support the idea that the terminally ill should be able to decide when and how they die. They believe that competent adults in unbearable pain, suffering from an illness that will never improve, have the right to die with dignity.
And yet the Canadian government is no closer to resolving how – or if – to reform the law against euthanasia; no politician is brave enough to champion such a contentious cause, or even to launch a national debate probing public opinion.

The issue remains divisive and morally fraught. Critics of euthanasia, including some Christian groups and advocates for the disabled, fear it could lead to “mercy” killings of the vulnerable and the elderly.

As baby boomers age, experts believe they will lobby for a change to the section of the Criminal Code that makes euthanasia illegal (and punishable by up to 14 years in prison), in the same way they advocated for the legalization of same-sex marriage, and for other momentous social changes....
Assisted suicide has become legal in several jurisdictions, including Oregon, Washington, Montana, Belgium, the Netherlands, Luxembourg and Switzerland. Canadian legislators can learn by example. In the U.K., the Director of Public Prosecutions recently published revised guidelines detailing factors that make the prosecution of family members who help relatives die less likely.

The Dutch law offers a six-part test (to determine the competency of the patient making the request), which must be met for a physician-assisted suicide to be legal. The patient’s request must be voluntary, they must have a lasting desire to die, and their suffering must be unbearable. The attending physician must assist the patient to weigh the alternatives, must consult with another doctor and ensure there is no chance of recovery. And a report must be filed with the coroner. Each year, many requests for euthanasia are rejected, especially in cases of depression.

Research shows that, in places where assisted suicide is legal, there is an initial spike in requests. However, the number then diminishes. “Many people, once they know that if all else fails, this is an option, they won’t make that call. The stress is gone,” says Udo Schuklenk, a Queen’s University professor who chairs the Royal Society’s committee on end-of-life decision-making in Canada. The committee will release a report this fall.

“Often when people talk about end-of-life decision-making, the assumption is, it’s about pain,” he adds. “But it’s not. The concern is more about losing control over the quality of their lives.”
In a death-denying society, any open, overt and public discourse about the state's contemplating making assisted suicide acceptable, legal and available, within prescribed parameters, is a step in the right direction. Having trained in chaplaincy services, and worked in palliative care, I have watched patients transition from consciousness with medicated pain to unconsciousness with increased pain management.
Their families are able to provide their presence, their compassion and their support in an atmosphere of some frustration that when the patient's diagnosis is finally terminal, and nothing more can be done, the option of a dignified termination is not available in Canada.
This is a case, in our opinion, where individual responsibility and choice trump the state's right to intervene, provided the conditions necessary to comply with state regulations have been met. In other words, having set the requirements, in a deliberate, "conservative,"  researched and publicly debated process, the state can and should then not be involved in the individual decision. That decision, following a clear and documented set of answers available to the immediate family similar to the list of questions posed by the Dutch, must then be left to the patient and his/her doctor(s).
We already have DNR orders in palliative care, where patient and family or patient advocate have determined that "Do Not Resussitate" (do not take extraordinary measures) to keep the patient alive have been issued and implemented.
We also have a growing acceptance of the limits of medicine among the public, meaning that many already believe the evidence that many human conditions, and especially combinations of different conditions, are beyond the ken of medical cure. That growing realization and acceptance is healthy for both the profession and the patients. Hence taking this step back, after careful consideration, would be less traumatic for both doctors and patients.
With respect to professor Shuklenk's observation that once the option is available, the patient's stress level drops, I can attest to that truth, in an analogous situation. When required to attend an autopsy, as part of chaplaincy training, I was quite agitated. Here was a class of five theology students going to attend this procedure, in my view invading the private space of a recently deceased person, under the supervision of the pathologist and the assistant. Not only that but would I be able to observe calmly and without even passing out (I had already passed out in the Operating Room witnessing abdominal surgery), in order to fully appreciate the awesome complexity and profound life-changing experience?
My supervisor, noticing my anxiety, advised, "Please just to and give yourself permission to leave whenever you feel you must."
That was all the support I needed; I attended, tentatively at first, but eventually fully participating, fully observing and fully integrating the facts with my own "awe" at the miracle of human life. In both the experience of attending the birth of two of three daughters and the autopsy, I felt and believed that I was privileged to experience nothing less than miracles and nothing less than sheer amazement at the profound and transcendent gift of life, both at the beginning and at it's end.
There are dangers, of course, to any proposal for end-of-life legislation that include things like mercy killings of the disadvantaged, especially when health care resources are limited and removing some patients from care would, conceivably, make more room for others less disadvantaged. However, that, along with the religious fears of such legislation destroying the "right to life" ethic of some religious groups, can and should be confronted within both the debate and the design of the legislation that is finally put to parliament for a vote.
It is in support of the courage and the relatively cautious approach recommended by the Globe editorial that this piece is written in the hope the public discourse will continue, and political hearts and minds will come to the view, calmly and without religious or psychological or societal fears so that the political decisions that must prevail can be made for the health and wellbeing of all Canadians.

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