Say No to Euthanasia and Assisted Suicide

Say “No” to Euthanasia and Assisted Suicide:
No Special Circumstance Can Justify Them

Abridged version of a brief presented to the Collège des Médecins du Québec, August 30 2009, by Joseph Ayoub, m.d., André Bourque, m.d., Catherine Ferrier, m.d., François Lehmann, m.d. and José Maurais, m.d.. The brief has also been endorsed by a significant number of physicians in the province of Québec.

The issue of decriminalizing euthanasia and assisted suicide has reared its head over and over again in Canada and Quebec for the past 20 years. The proponents of euthanasia justify their position on the need to respect the autonomy and “dignity” of the individual. In recent years some cases have gone before the courts, and the Supreme Court of Canada has reaffirmed the intrinsic value of human life and the limits governing an individual’s freedom to decide to end his or her own life. So the pro‐euthanasia lobby has turned to its only possible legal recourse: an amendment of the Criminal Code by the Parliament of Canada. Bill C‐384, introduced by Bloc Québécois MP Francine Lalonde, is the latest attempt.

 

Passing Bill C384 would make euthanasia and assisted suicide legal in Canada.

As we are all going to face death one day, this issue is at the heart of how we understand being human. It concerns society as a whole. Opinion polls on euthanasia are hard to interpret, but there is one constant: people’s desire to be surrounded and supported at the end of life, and spared pain and suffering. No doubt most people will answer Yes if asked whether they are in favour of euthanasia in cases where someone is suffering terrible pain that cannot be relieved. This question puts the respondents in a position where they have to choose between euthanasia and an absence of adequate, appropriate care to manage pain; in other words, they choose euthanasia as a means of pain management. Over the past few years, while the debate on euthanasia has been going on, thousands of patients have died of different terminal illnesses under the care of competent medical professionals and with the support of family and volunteers. Over the last 30 years, our hospitals and other health institutions have developed unprecedented palliative care services. More remains to be done, especially for the chronically ill who have only a few months or years left to live. The ethical questions surrounding proportionate care, life‐prolonging treatment, cessation of treatment and pain management are all part of the daily discussion at institutions where medicine is taught and practised.

The overwhelming majority of patients in a state of physical and mental decline come to the natural end of life in a much fuller environment of support and palliation than ever before. We are still far from reaching the limits of what can be done in palliative care. Pharmacological advances and methods of radiation and surgical oncology allow us to relieve patients of much suffering and distress for which we formerly had few options.

No doubt pain control can sometimes be imperfect in terminal states and it does happen that it cannot be achieved without secondary sedating effects that the patient does not want. The use of opiates and the entire available analgesic arsenal to relieve the patient’s pain as much as possible until the end is considered to be good medical practice, even an obligation, and this even when the medication’s secondary effects shorten life (which is rarely the case).

In recent years, techniques of inducing sleep have been added to the therapeutic repertoire for the very rare cases of pain that cannot be adequately managed. To echo ethicist Margaret Somerville, it is the pain that should be killed, not the patient.

Pharmacology and other medical and surgical methods and procedures will continue to make advances in pain relief, but the existential suffering of a patient with a terminal illness is and always will be a phenomenon that belongs to our humanity, to our desire to make sense of our present misery, to our beliefs in something beyond—the suffering and humiliation of watching our own physical and mental decline, finding ourselves dependent and seen as a burden by others, the indignity of having to submit to having our personal hygiene needs looked after by someone else, the difficulty of leaving our loved ones or seeing the grief of those we love. More than the “intractable” pain, it is this suffering that can cause the patient whose days are numbered to sink into despair and depression and demand that his or her life be cut short. The great majority of patients find comfort in their pain from the care of those around them, and sometimes from antidepressant medication. Practice shows that the request to die is a kind of cry from the heart that is more often a call for sympathy than a genuine request for euthanasia.

The problem of people afflicted with severe terminal or degenerative illness who foresee the onset of their illness’s complications, who are not necessarily depressed and who have lots of support, but who want to end their life at a particular place and time and cannot do it alone, will always be with us. These people no longer see any meaning in what is left of their natural life, and the wait for death is sometimes very long. In our society, there are not many people who request euthanasia in these circumstances, and the majority of those with a similar physical condition have absolutely no desire to end their days. It will never be possible to draw distinctions based on age, severity of affliction or life expectancy with this group of people, because what is really at issue here is the right to commit suicide. For excellent reasons, our society has decided that a suicidal person who is capable of carrying out the act may be kept from doing so.

It is the situation of these people, who are driven by their suffering to ask for assistance in ending their lives, that motivates the proponents of euthanasia and assisted suicide. We should not, must not, deny that such situations exist, nor affirm that such people are all depressed or incapable of giving informed consent to their request. They must be listened to and helped to the maximum extent possible, but for us their request remains absolutely inadmissible.

There is another group of patients whose situation is of great concern: patients whose dying seems to drag on interminably. For some people, the last months and weeks of life is a slow attrition, where the organs collapse one after the other, the skin breaks down, consciousness fades and the vital functions are holding on by a thread. Care in these cases places extreme demands on the medical personnel, and families exhausted by the vigil and desperate for it to be over sometimes ask the physician to intervene. In such situations there is a great temptation to authorize the doctor to put an end to the patient’s dying process. To some, the line between palliation and euthanasia can seem tenuous, because the distinction between them lies in the intention of the act, and not in what it entails. Nevertheless, even in situations like these, the prohibition on euthanasia must remain.

In conclusion, we present nine arguments why euthanasia and assisted suicide should never be decriminalized in Canada

  1. Medical practice teaches us that patients who express the wish to die usually do so because they are in need of comfort, they are depressed or their pain and symptoms are not being well managed. For the great majority, good medical care, treatment for the depression and a palliative approach are the solutions. Patients who ask to die often change their mind with time. Often the request comes not from the patients but from their exhausted families; the patients themselves have not asked that their death be hastened. Mostly, when the families get more support, the demand disappears. In the face of suffering, it is far better to look for meaning in the life that remains, develop strategies to face existential questions and strive for optimal care, than to seek shortcuts to death.
  2. Ending the patient’s life is not a humane solution to tragic situations of pain and suffering: the physician’s duty is always to kill the pain, not the patient. Proposing euthanasia shows a lack of confidence in the progress of medical science. There are no limits imposed on the physician’s means of relieving pain. The means are many, accessible, increasingly sophisticated and constantly developing. In extreme cases, heavy sedation that puts patients to sleep can even be a last resort to sustain them through their suffering, until death takes place from natural causes. In treating terminal cases, there are no obstacles to ending or foregoing treatments considered useless or disproportionate by the patient or the physician. There is always a way out, even in the most complex cases. There are no taboo issues about death in the medical profession. The questioning of life‐prolonging treatment, the withdrawal of useless or disproportionate treatment and the refusal of treatment by autonomous patients are daily events in clinical practice, addressed calmly and openly by practising physicians and in training programs. Doctors clearly understand the line between pain relief and euthanasia.
  3. 3. There are individuals who seriously or insistently ask for euthanasia or assisted suicide. They are very few in number. These requests are usually rooted in their personality and the need they feel to control their life—and their death. The vast majority of people in similar situations do not ask for life‐shortening intervention. Individual freedom and autonomy end where they impinge on the freedom of other members of society. Changing the law to satisfy the demand of such a small number of people would imperil the lives of a much greater number who initially were not even aimed at. The experience of the few countries that have taken the route of euthanasia and assisted suicide shows that these practices soon become ungovernable despite the controls and guidelines put in place: protocols are not respected, consents are not obtained, the pressures exerted by families are strong and difficult to manage. People who have not asked to die are put to death.
  4. Decriminalization of euthanasia is a slippery slope that will inevitably lead to a much steeper slide, hard to control. Physicians in countries where euthanasia is legal know this from experience. Once it is accepted that patients in a terminal state who so request can be put to death, physicians find themselves confronted with the requests of the disabled and the chronically ill, then with the requests of patients with psychological problems and then with the fate of severely handicapped new‐borns—who have not asked to die. Even young people who are chronically ill invoke anti‐discrimination laws to support their request for assisted suicide. Accepting that giving death could be a solution to one problem opens the door to giving death to a hundred others. Euthanasia becomes a “treatment option” that people can turn to to relieve their suffering, when in fact there are many other options.
  5. Decriminalization of euthanasia and assisted suicide would create unwarranted pressure on the chronically ill, the severely disabled and those who require a lot of assistance or expensive treatments: they could begin to think that they are an undue burden on their loved ones or on society and that they should consider euthanasia or assisted suicide. The possibility of euthanasia would distort social attitudes toward the seriously ill, the disabled and the old.
  6. Neither disease, nor physical or mental decline, nor pain, nor suffering, nor loss of autonomy can undermine the fundamental value of the human being. A person is not valueless because she or he is chronically dependent or dying. The solution to ensure “dying with dignity” remains first and foremost a competent palliative approach, respect, support and tenderness.
  7. Decriminalization of euthanasia and assisted suicide depends entirely on the participation of the medical profession. Ultimately, it is doctors who are asked to decide whether it makes more sense to preserve a life or to end it: physicians find themselves put in the position of arbitrator. The result is a loss of patients’ autonomy and a corresponding increase in the power of the medical profession over the individuals in its charge. Giving patients the right to die means giving doctors the right to kill. An erosion of the doctor‐patient relationship must follow if the doctor is not simply the person who cures, relieves or comforts, but becomes as well the person who gives death. Putting to death becomes just another treatment option available to the profession, along with various medical or surgical alternatives; this would erode people’s bond of confidence in the profession as a whole.
  8. Even though it is sometimes asserted that suicide is a freedom, it is above all a personal tragedy that is fundamentally contrary to human nature and a failure on society’s part. Suicide is never without repercussions on other people and society as a whole. The medical response to a person’s attempted suicide has always been to come to the person’s aid; it should remain so. The physician who participates in suicide is promoting suicide at a societal level.
  9. The Hippocratic prohibition on euthanasia and assisted suicide is more than a millennial tradition. It has been a core value for the generations of physicians who have adhered to it. It is imbued with wisdom and compassion and deserves to be vigorously defended.