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Tom Koch is a Toronto-based consulting ethicist and gerontologist. His latest book is Ethics in Everyday Places.

A recent and well-publicized poll of 61 Laval, Que., physicians reported that, while a majority of respondents supported the idea of physician-assisted termination (PAT), "59 per cent of the recalcitrant doctors in Laval said they struggled with the emotional burden of ending a life."

Commentators found this surprising and discouraging. I found it surprising (and shocking) that the percentage was so low. As Gerrit Kimsma, a Dutch physician and long-time PAT advocate has said many times, ending the life of a patient in care is for him always emotionally burdensome.

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Canadians should want their physicians to struggle with PAT requests. Abandoning the caring struggle for procedures whose sole goal is to silence a still beating heart should be an emotional issue. I distrust those who think PAT is just a simple procedure, termination of the patient an easy thing.

I have been asked to terminate family members or patients five times. In each case, I have struggled to find a way to improve that person's life and care so that early termination is no longer a response to pain, depression or isolation.

Yes, the Supreme Court has made it legal. What the court ignored was the need to balance a presumed right to early death with a prior right to live, as long as possible, with dignity in challenging circumstances. For 30 years, I have argued in articles, books, journal papers and as consultant to Justice Canada, that PAT only becomes appropriate when we have done everything possible to assure the fullest possible life for the fragile person.

That means having palliative physicians and nurses who can attend to pain, psychological support for those struggling with limiting conditions, rehabilitative specialists who can assure maximum engagement and social services that guarantee a person's care is not an impossible burden on his or her family. Until and unless those things are in place the choice to die prematurely isn't balanced and fair, it's just a choice made when other, better alternatives are not available. And for many, they are not.

We have spent so much time focused on "dying with dignity" that we've ignored the right to life with dignity despite restrictions. While 96 per cent of Canadians support hospice care for patients with end-stage illnesses, fewer than 30 per cent of all Canadian patients have access to them. Not all communicative and assistive devices are covered by provincial health plans. Home support is in many areas inadequate. Persons who otherwise might live comfortably for months or years may choose PAT because the services they need are unavailable.

The number of registered palliative-care medical specialists in Canada, make up a tiny percentage of all Canadian physicians. These are physicians skilled not only in pain control but in the provision of all that might make a restricted life easier. Palliative care focuses on the whole person, and often that person's family, as well as the precise treatment of underlying chronic conditions. Without them, late-stage care is necessarily limited.

Time and again studies have shown that most people are understandably depressed and sometimes suicidal after an adverse diagnosis, a debilitating stroke or a traumatic injury. Of course they are. The life they lived is over and the life they might still live seems terrifying and limited.

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For decades, my studies – and those of others – have shown even those with extremely limiting conditions may, with appropriate support and after a period of adjustment, find meaningful and useful lives. Yes, at first, an early death may seem preferable. But we who struggle with these situations know that many if not most people will find, with time and support, a life still worth living. We've seen it. We've been there.

Yes, people have to the right to choose. But a real choice only occurs when the necessities of life with dignity despite restrictions first is assured. Without that, "choice" is an empty promise.

PAT should be the last option presented, never the first. It is not something to be taken lightly. It may have its place after we first assure everyone the option of living with dignity despite limits, free of pain, and with support. When everyone is offered that option, then those involved in their care perhaps will feel less burdened when premature death is a person's stated option.

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