James Downar is a Critical Care and Palliative Care physician with a Master’s degree in Bioethics. He is an Assistant Professor in the Department of Medicine at the University of Toronto, and co-chair of the Physicians’ Advisory Council for Dying with Dignity Canada, a group that advocates for the legalization of Physician-Assisted Death.
Physician-Assisted Death (PAD) is a controversial subject in Canada, but it shouldn’t be. The latest polls show that Canadians support PAD almost as much as they support sunlight and clean drinking water. PAD is now legal in many jurisdictions, and we have a large body of evidence to address fears about slippery slopes. When PAD was legalized in Europe, it did not become the default option for dying patients; it generally remained stable while Palliative Care grew dramatically. According to the Economist, the 5 countries that have legalized PAD are world leaders in the “Basic end-of-life healthcare environment”, while Canada sits in the middle of the pack. According to the Center to Advance Palliative Care, all three US states that have legalized PAD by statute rank in the top 8 for availability of palliative care services in hospitals. The vulnerable do not appear to be pressured into accepting PAD - on the contrary, the patients who receive PAD appear to be disproportionately wealthy, educated, and well-supported by family members and health insurance. I would almost call them “privileged”, but then I remember that they were suffering enough that they chose to end their lives.
I don’t support death. I enjoy my life, and I work very hard as a Critical Care physician to keep patients alive when I can. But I accept that there are times when I can’t. And there are times when I can keep people alive, but not in a state that they would value. When patients (or their families, when they are incapable) tell me that they want to forego life-prolonging therapy, I respect their decision. I don’t insist that we continue the ventilator until they die a “natural” death. I don’t try to convince them that continuing dialysis will help them find meaning in their suffering. I respect their right to know when they’ve had enough, and I don’t see why they should only have this right when they are dependent on life support.
My support for PAD is based on an ethic of care, therefore, and the desire to help people achieve the death that they want. I’m not advocating for universal PAD, but universal choice. I was disappointed when I read a previous post suggesting that my support for PAD might be due, in part, to a lack of contact with terminally ill patients, or a lack of knowledge about symptom control. Rest assured that there are many renowned Palliative Care experts on both sides of this debate, and that ignorance and inexperience are likewise equally distributed. This debate calls for humility and a willingness to listen to our patients.
As the Supreme Court of Canada prepares to consider PAD again, I hope that the medical community can continue a productive dialogue on this issue. I know that many Canadian physicians still oppose PAD, and I respect them because I used to feel the same way. I honestly believe that your opposition stems from genuine compassion and concern for your patients, and I wouldn’t have it any other way. But we have a professional obligation to ensure that we are prepared for any eventuality. If the Supreme Court decides that the laws against PAD violate the Charter of Rights and Freedoms, we may, as I argued in a CMAJ commentary earlier this year, be called upon to develop rules and policies very quickly.