Cure sometimes; Treat often; Comfort always; Kill frequently?
A Canadian perspective on Voluntary Euthanasia
As a school-kid I would wait in the car as my father visited house-bound patients in our village. Dad would tell me snippets about the local people whom he admired for their hard-working, honest character. Sometimes he quoted Hippocrates: “Cure sometimes, treat often, comfort always!”
I followed Dad’s medical footsteps to University College, Dublin and emigrated to Canada where I have been a rural family physician for over 30 years. Voluntary Euthanasia is the only state-sanctioned homicide routinely occurring across Canada. Between 2016 & 2019, 13,946 Canadians died by Medical Assistance in Dying [MAiD]. Canada has ~38 million people.
Medical Assistance in Dying
After the 2015 Supreme Court of Canada Carter decision was legislated by Parliament in 2016, it was no longer a crime to provide a poison—or to directly kill—a patient meeting the criteria. The vast majority of the ~14,000 cases have been through the direct administration of IV drugs, in other words, by Voluntary Euthanasia [VE]. MAiD includes provisions for Assisted Suicide [AS].
The Supreme Court [SCC] declared sections 241(b) and 14 of the Criminal Code “void insofar as they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life; and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”
Their decision was based on the autonomy of the individual and the wish to avoid people suffering ‘intolerable’ pain. They also voiced the fear that sufferers might take their lives prematurely or be incapable of doing so at the time of their choosing.
Human Rights
The Canadian Charter of Rights and Freedoms says, “everyone has the right to life, liberty and security of the person.”
The Universal Declaration of Human Rights declares that “everyone has the right to life, liberty and security of person.” Importantly, the United Nations defines Human Rights as being "universal and inalienable…everyone is born with and possesses the same rights."
Former President of the Supreme Court of the United Kingdom, Baroness Hale of Richmond, commented on the dignity of the individual: “Democracy is founded on the principle that each individual has equal value. Treating some as automatically having less value than others not only causes pain and distress to that person but also violates his or her dignity as a human being.”
Voluntary Euthanasia
As human beings we have free will—The Freedom—to kill ourselves. I believe we do not have a Right to kill ourselves and definitely we do not have a Right to mandate a person or group to kill us on-demand. As human beings we have the responsibility to prevent someone from taking their own life in despair.
Compassion for the appellants in Carter might have blinded the Justices to the dangers of legalizing the intentional killing of a segment of the population—however willing they may be. Curiously the SCC is very opposed to Capital Punishment when the arguments against the Death Penalty hold fast against Euthanasia. MAiD/AS/VE can:
be coerced,
kill incompetent people,
irreversible when applied in error,
deny the intrinsic value of human life,
brutalize patients, children, family & friends, providers,
promote cost reduction through the premature killing of the sick,
not be a “treatment”,
not ascertain those who “deserve” death or not,
glamourizes death and can cause the Werther Effect (suicide contagion),
kill the mentally ill rather than treat them appropriately,
collude with delusions rather than preventing suicide,
have complications from the administration of toxic medication.
Evidence from Oregon shows the most frequently reported reasons for requesting Assisted Suicide are: “Loss of autonomy (87%); Decreasing ability to participate in activities that made life enjoyable (90%); and Loss of dignity (72%).” Physical pain (or the fear of it) did not even make the top 5 reasons for requesting Assisted Suicide. In addition, the vast majority of Assisted Suicide cases in Oregon in 2019 were white people. The cultural differences need investigation because there were very few Hispanic and Asian recipients and no African-Americans, Pacific Islanders or American Indians.
Another curious statistic from Oregon is that up to 1/3 of those receiving a prescription for the fatal medication never take it. (In a private communication, it appears that few withdraw from MAiD once the application has been approved.) Patently, there is some different dynamic between killing oneself and having another person administer the poison to you.
The march of ‘Progress’
The SCC agreed with the original trial judge: “…that a permissive regime with properly designed and administered safeguards was capable of protecting vulnerable people from abuse and error.” Based on this permissive opinion, Canada mirrored much of the system from the Netherlands where Euthanasia was made legal in the 1970’s. Startling statistics from the Netherlands reported in The Province (Vancouver) showed: “In 1990…2,300 people asked doctors to kill them; 400 asked doctors to provide them with the means to kill themselves; 8,100 died when doctors deliberately gave them an overdose of pain medication to kill them (for which 4,941 patients didn’t consent); 1,040 people died when doctors euthanized them without their knowledge or consent (72 per cent of those never having given any indication they would want their lives terminated).”
There are many egregious cases. The Supreme Court of the Netherlands just exonerated a doctor who ordered the family of an elderly woman to hold her down so he could administer the lethal injection. A Dutch nun was dying painfully of cancer and her physician felt her religion prevented her from agreeing to euthanasia, so he felt both justified and compassionate in ending her life without telling her he was doing so. (Psychiatric Times). The Journal of the Canadian Medical Association has shown that up to 30 per cent of assisted suicides occur without consent in one region of Belgium.
The SCC noted that “minors or persons with psychiatric disorders or minor medical conditions” do not fall within the Carter decision. It is only 4 years since Bill C-14 and yet there are persistent calls to extend MAiD/AS/VE to Mature Minors, for psychiatric illness and by Prior Directive.
Then there is the tough issue of “intolerable suffering”. If, as shown in Oregon, the suffering is primarily “the loss of autonomy, the decreasing ability to participate in activities that made life enjoyable and loss of dignity” then people with prolonged existential distress will eventually become candidates for MAiD.
MAiD has even become a “therapeutic option.” In 2018, then 42-year-old Roger Foley from Ontario wanted to live despite having a serious neuro-degenerative disease. He was in hospital because he felt the home-care being provided was inadequate. He claims he was offered Euthanasia as the alternative to a forced discharge or the $1,800 per day charge.
If Human Rights as "universal and inalienable…universal because everyone is born with and possesses the same rights…" then logically all Canadians have a “Right to Die”. Suicide-on-Demand will be a disaster for any society.
The Dead don’t complain
By conscripting two caring professions and by making MAiD “A Right”, Parliament and the SCC avoided a lot of opposition to Euthanasia in Canada. A doctor or nurse should not be a MAiD/AS/VE provider but remain the patient’s independent advocate, counsellor and caregiver. We should be a shield against coercion and should minimize the risk of involuntary euthanasia.
Most, if not all, MAiD applicants should have palliative, psychiatric and social services consultations. A difficulty is that here an applicant can refuse all valid treatment (including curative treatment) and still be approved for MAiD.
In light of possibility suicide contagion there should be proper longitudinal studies especially of the young children of MAID recipients. (“New figures from the Netherlands have shown that suicide numbers went up by 34% in that country after assisted suicide was legalized –at a time when the numbers of deaths by suicide fell in neighbouring countries in the same period.”)
Despite the SCC stating: “Nothing in this declaration would compel physicians to provide assistance in dying” there are jurisdictions like Ontario where physicians are required to provide an “effective referral” for MAiD/AS/VE. This, when Alberta has a proven self-referral route for patients involving the patient making just one phone-call.
Humanist Dr. Donald Boudreau, McGill University, said “My personal belief is that healing and euthanizing are simply not miscible.” It is only a matter of time before job postings in Geriatrics / Palliative Care / Family Medicine (etc.) specify the need for the applicant to be a MAiD provider. Medical students are already being taught how to kill patients before they are fully taught how to heal them. Indeed, there are calls to screen Med School applicants likely to hold Hippocratic views. That could exclude many good doctors including some Humanists, Muslims, Jews, Sikhs, Buddhists and Christians, amongst others.
An Bille um Bás Dínitiúil, 2020 / The Dying with Dignity Bill, 2020
“Dignity” is an emotive argument used to support Euthanasia though it mostly refers to a lack of self-determination and a personal loss of control. It seems evident that being killed due to a perceived lack of self-worth “…violates his or her dignity as a human being.” [Hale]
Whatever their physical/mental status or position in life, we must see the dignity in every person.
Dr. Kevin Hay
Kevin is a UCD grad & now a rural Family Physician in Alberta, Canada. He has been writing on Medical Assistance in Dying in Canada for the past 3 years. This article takes information from several sources including his previous articles in The Province (Vancouver) and The Hamilton Spectator. You can follow him on Twitter @kevinhay77.