Recent events suggest that the assisted-suicide movement has gained momentum; reports from the Royal Society of Canada, the Quebec National Assembly and the British Columbia Supreme Court all support legalization of physician- assisted suicide. But the case is not closed.
Confusion reigns. Doctors opposed to physician-assisted suicide are sometimes labelled as paternalistic, disrespectful of patients’ autonomy and blind to certain aspects of human dignity. These are inaccurate and offensive descriptions of who we are and what we do in the sick room.
The public must be reassured that the needs of dying patients can be met within current legislation and practices. It must realize that we are able to have conversations about halting futile life-supporting interventions; we are able to “unplug” ventilators and be a compassionate witness to death; we are able to relieve physical and emotional suffering with an increasingly sophisticated array of medications, up to and including progressive terminal sedation. All the while, we are not ready to act upon “requested death.”
What is it about euthanasia and assisted-suicide that frightens doctors?
Madam Justice Lynn Smith, of the B.C. Supreme Court attempts to assuage our concerns by suggesting that it would be a matter of a few isolated cases and that safeguards have been proven effective in other jurisdictions. These predictions are highly debatable. Even if this wishful thinking were correct, it misses the point.
Our angst is not limited to cases of assisted-suicide. It is rather that engaging in it alters the mission of medicine. It strikes at the very core of our beings as healers. It would leave an indelible imprint on dialogues with all patients. Our worry is anchored in the deep recognition of the vulnerability of sick persons and the power differential that exists in the doctor-patient relationship.
Doctors can become angry with patients. Patients can desire to please their doctors. Such feelings, and many others, can profoundly affect decision-making in directions contrary to patients’ best interests.
The risk is too great. The medical profession is able to make mistakes and to act from dishonourable motives; its members are far from infallible. To apprehend these facts one need look no further than the German Medical Association’s May, 2012 apology for the complicity of (many) doctors under the Third Reich in abrogating their obligations as healers.
There is much cloudiness swirling about this issue – even within the profession itself. A recent editorial in the Canadian Medical Association Journal entitled, “Choosing when and how to die: Are we ready to perform therapeutic homicide?” may have inadvertently perpetuated the confusion. The authors argued that the euthanasia debate has been largely theoretical because of the “tacit assumption that doctors do not kill people.” I object to the suggestion that “do not kill” is a tacit (i.e. a silent) feature of medical practice. The voices in favour of maintaining this cornerstone-of-medicine have been persistent, noisy and unambiguous.
The Hippocratic Oath includes a stern injunction: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” This constraint has guided medical doctors for more than 2,400 years. For example, it provides the inspiration and motivation for the steadfast refusal of the vast majority of physicians from participating in capital punishment. We do not administer the lethal injections that kill convicted criminals. Neither should we accept to administer it under scenarios envisaged by Judge Smith.
Physician-inflicted death is unnecessary and potentially harmful and I do not want to teach medical students how to end their patients’ lives. If society concludes that it is advisable, it must not foist it lock, stock and barrel onto the medical profession. Physicians must not become the agents of implementation. Euthanasia and assisted-suicide must not become “medical” acts.
Palliative-care physicians are among the staunchest opponents of euthanasia. Professionals who are most often in the thick of things must be heard. If Canada is to disregard the consensus opinions of palliative-care physicians and look askance at our collective anxieties then let it confer responsibility for assisted-suicide on a non-physician group.
Nothing would prevent society from mandating responsibilities to a new profession; I have called it euthanatrics.
Its practitioners – euthanologists – could ensure that society-sanctioned suicides are carried out expertly, with transparency and accountability. It would provide a mechanism to meet new legislative demands while protecting the medical profession so that it can continue to fulfill its ancient mandate of healing.
J. Donald Boudreau is Arnold P. Gold Foundation Associate Professor of Medicine at McGill University.