Harvey Schipper is professor of medicine at the University of Toronto.
I am an oncologist, and I am Jewish. Fortunately, at this moment, I am not terminally ill, nor do I bear an incurable disease. By virtue of my profession and my age, death, suffering and the indignity that can go with it are familiar to me.
That is my perspective. I lead with that declaration, because when it comes to the business of assisted suicide, context is everything.
The rationale for actively ending a life is always posited on the basis of ending suffering, and hence preserving dignity. At face value, this appears both straightforward and without controversy. It is not. Whose suffering? What is dignity, and is it realistic to provide some idealized form of dignity in every instance, try as we may? Who is to judge? When to decide, and when to act? Who is to act, and on what authority?
Some years ago, at a palliative-care conference in Israel, I was riveted by a panel where Anglican, Catholic and Jewish physicians discussed suffering. The ordained Anglican, a highly respected surgeon, spoke of the purifying nature of suffering and its role in preparing people for the afterlife. For him, the total relief of pain was at cross-purposes with the spiritual transit of the end of life. For me, as a Jew, this was a striking perspective, certainly far from my understanding that pain of this sort had little redeeming value. Lesson No. 1: Cultural context is important.
More recently, I was asked to see a young man dying of cancer, whose pain seemed uncontrollable. He was desperate to go home. The complex logistics of pain management and support appeared to make this impossible. What to do? We talked, initially rather guardedly, then more openly. It turned out that more than anything else, he wanted to see his dog. That was why he wanted to go home, for the absence tormented him. We arranged for the dog to make a hospital visit. The pain went away. My patient died quite comfortably in his hospital bed a few days later. Lesson No. 2: Understand the pain. You may be able to relieve it.
Almost 30 years ago, a small group of Winnipeg cancer physicians asked what was then a heretical question: Are we treating cancer, independent of the patient, or are we treating a patient who happens to have cancer? We created the “quality of life” concept, and objective measures of it. What happened to the tumour became less important than what happened to the person – physically, emotionally, socially and functionally. We broadened our understanding of our patients, and so were born the diverse range of interventions and supports we now routinely employ to more than keep people alive. We help our patients live lives. Lesson No. 3: It’s about the person, not the disease.
“Assisted suicide,” is a euphemism for ending someone else’s life. Every civilized society holds life sacred. The idea of “Thou shalt not kill” echoes in every faith. The penalties for killing are severe, mitigated by an understanding of intent. Whenever we introduce a legal exception, we run into trouble. Similar arguments about relieving suffering were used by the Nazis to justify first exterminating the weakened and disabled, then the mentally ill, and then non-Aryans on the regime’s hell-bent descent into depravity. In order to execute the policy, a cohort of licensed killers was created. This, in a society once considered the world’s most sophisticated and cultured. Lesson No. 4: Assisted suicide is not a legal matter. It’s a moral one, and we can’t legislate morality.
So where does this bring me in the consideration of assisted suicide? Full circle, to my ancient role as physician. Not as medical technician, nor as the master of prognostic statistics, derived from groups somehow extrapolated to an individual. I am a member of the one profession whose essential role invokes individual life and death decisions, and acts on risks that necessarily include adverse outcomes causing pain, and suffering and death. I’m not doing my job unless I understand context, cause and possibility when it comes to suffering. That takes time, patience and experience. The responsibility is a great harbinger of humility.
Each dying patient has their own context and belief frame for their “suffering.” Each case has its own mix of causes, and things that make it worse or better. My contention is that when we fully understand what’s going on, it is rare that suffering can’t be greatly palliated. It then follows that the perceived need to end life to alleviate suffering is a very rare occurrence.
In this most intimate and delicate interaction between patient and physician, the physician also has context and values. I don’t think they can be legislated away.
For me, as a Jew and as a physician, I can give morphine to relieve pain, but not to end a life. I come down against legalizing assisted suicide as a product of my faith, culture, training and experience. Put as a dichotomy, I’m prepared that a few might suffer more than they can bear, rather than countenance in the name of some kind of generosity of spirit the active taking of a life. I know from history, and I have seen too much of the slippery slope of convenience, to find confidence in any permissive legislative process.
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