Scenario 1: A 64 year old patient is suffering from advanced Lou Gehrig’s disease – she cannot perform her own activities of daily living, and can do nothing but watch her own body deteriorate until the slow release of death. She wishes to have the opportunity to control how she passes, with the aid of her healthcare providers. Sound reasonable?
Scenario 2: A 64 year old patient is suffering from severe depression – despite multiple medication and behavioral regimes, his illness prevents him from doing even basic activities of daily living. He is cognitively competent, and has balanced the pros/cons of continuing to live with this illness. He wishes to have control over how he ends his life, and wants to proceed with physician-assisted suicide.
How are the two scenarios different…and why does the latter leave a nagging feeling in the pit of our stomachs?
BC Supreme Court’s Justice Lynn Smith and her recent ruling, which found the law banning physician-assisted suicide to be unconstitutional, has opened the gate to both relief and fear from the general public. It is true that there is no law against suicide itself, and in reality there already exists various degrees of accepted medical practices in end-of-life care, such as administering large doses of pain medications to hasten death. For patients like Gloria Taylor (ie Scenario 1), an official removal of an all-encompassing blanket law against physician-assisted suicide would give her the power to write the ending to her battle with an incurable disease:
“To die screaming at the top of my lungs because the pain is so great that I can’t stand it is something I try not to think about,” Taylor, one of the plain-tiffs in the landmark court case, told reporters Monday in her first public comments about the ruling. “Now, thankfully, I don’t have to fear that kind of death, an ending to a life that’s been full of so many good things and challenges. I can do dying, but I can’t do major suffering to get there.”
The counter-argument of course, is that if the prohibition against physician-assisted suicide was removed, vulnerable members of society such as the aged, the cognitively impaired, and the disabled, might be at risk. Opponents to the recent BC decision are using emotionally and politically charged terms to express their concerns: “Euthanasia! Mercy killing! State-sanctioned murder!”
Like most things, the truth probably lies somewhere between the two black-and-white extremes. Physician-assisted suicide is not the ultimate salvation to all patients with incurable diseases, and it is also certainly not the catalyst for a mass murdering of the elderly.
Going forward, the actual tricky part really lies in figuring out exactly where we wish to be in the grey area – how do we as a society define who qualifies for physician assisted suicide? Who gets to decide if Scenario 1 or Scenario 2 is more appropriate for doctor-mediated death? Granted, the recent decision in BC clearly stipulates some conditions that must be met, but one can easily think of clinical situations where controversy will arise even within these guidelines:
“(a) There is an existing physician-patient relationship;
(b) The assistance is provided to a fully-informed, non-ambivalent competent adult patient who:
(i) Is free from coercion and undue influence, is not clinically depressed and who personally requests physician-assisted death; and
(ii) Is materially physically disabled or is soon to become so, has been diagnosed by a medical practitioner as having a serious illness, disease or disability, is in a state of advanced weakening capacities with no chance of improvement, has an illness that is without remedy by acceptable treatment options, and has an illness causing enduring physical or psychological suffering that is intolerable and that cannot be alleviated by any acceptable medical treatments.”
We will soon find out if the governments of Canada and BC will appeal. Personally, I suspect we may never get perfect directions from the Criminal Code – this may be too complex an issue to be addressed by any one set of rules. Perhaps the rigid trappings of law and politics make them the wrong tools to tackle something as emotional, spiritual, and personal, as choosing how any one person passes from life to death.
At the very least, let us hope we can arrive at something that doesn’t lose sight of the patient in the process, and instead puts them first in our journey towards real patient-centered care.
What do you think about physician-assisted suicides? How/who should govern its practice?
Edmund Kwok
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