Dr. Rene Leiva is an Assistant Professor with the Department of Family Medicine of the University of Ottawa. Part of his work includes in-patient Palliative Care and Care of the Elderly at Bruyere Continuing Care in Ottawa, ON
I read with interest the CMAJ Editor in Chief’s latest editorial about protecting the right of physicians to conscientiously object to being party to physician hastened death. Principled medicine has dealt with suffering since Hippocratic tenets were first formulated about 2400 years ago. It is only in the last fifty years that causing death has been construed as ‘medical treatment’ for suffering, which I firmly believe to be erroneous. I’m disturbed to see that while Quebec is leading the country on euthanasia only a fraction of its population has access to palliative care. Palliative Care has been around for close to forty years, but Quebec's new law on ‘medical aid in dying’ expects to make that option available to 100 per cent of Quebecers in a matter of months.
In Belgium, hastened death has become part of the culture: despite having initially focused on the competent adult who is terminally ill, it has quickly moved into euthanasia for mental suffering and dementia, and for those tired of living, as well as children; it is commonly practiced by other health professionals such as nurses despite this being illegal. Medically assisted deaths have risen by 640% in Belgium since the law was adopted in 2002 and there are a significant number of deaths without consent as well as under reporting.
When I first met Tom Mortier through mutual acquaintances, he impressed upon me his concerns about the dangers of living in a society that embraces hastened death and shared the sad and tragic account of his mother’s euthanasia under the Belgian law. Her story was the focus of a recent article in the New Yorker and part of an Australian TV documentary. He often forwards me information on euthanasia cases and events that in a different culture or time would have been unthinkable: from the doctor who euthanized his mother leading an ‘educational trip’ to the Nazi camp Auschwitz to leaders in the field celebrating euthanasia as having ‘a life-intensifying and sacred dimension’.
Not all the founders of the hastened death movement have remained convinced they were doing the right thing. Ann Humphry, the late co-founder of the Hemlock Society, now Compassion and Choices, deeply regretted her actions. She was concerned that sick and vulnerable people might feel subtle pressures to relieve their families and friends of the emotional burdens of their lingering death. Is this unrealistic? Last year, a Canadian woman committed suicide while promoting the legalization of hastened death. Part of her manifesto stated that ‘I can live or vegetate for perhaps ten years in hospital at Canada’s expense, costing anywhere from $50,000 to $75,000 per year,” she said. “Nurses, who thought they were embarked on a career that had great meaning, find themselves perpetually changing my diapers and reporting on the physical changes of an empty husk. It is ludicrous, wasteful and unfair”. Is this the message we want to communicate about the value of our parents’ and grandparents’ lives as the end approaches?
Fittingly, it was a Belgian doctor and Nazi death camp survivor who was instrumental in developing the World Medical Association position against euthanasia. He felt very strongly that ‘the natural duty of the physician is first to protect life and not to kill the patient. The main task of the doctor is to help his patient in defending his interest not only against the disease but also against any dangerous competition between the interests of the community of healthy people or society, even the family sometimes, and those of the patient’.
I, too, believe that behind the fears of existential suffering or of becoming a burden to loved ones, or feelings of hopelessness and worthlessness, there is a call for help to find meaning even in the midst of such suffering. When death seems to be the answer, we as human beings have abdicated the opportunity to go beyond our limitations, to try harder, and to offer hope to these people. To agree with patients’ requests for assisted suicide is to confirm their feeling that their life is without value. Under these overwhelming fears, a free chosen decision for hastened death is an illusion.
The most challenging clinical cases usually are the ones where patients are suffering from existential distress, or in other words, loss of purpose in life in the face of suffering. I would also name it "depression of the soul." To paraphrase a philosopher, the answer to this suffering is not a pill but a person, not a word but an act. It is an act of loving presence and being there for them. As Holocaust survivor and psychiatrist Viktor Frankl says, “Love is the only way to grasp another human being in the innermost core of his personality.” The experience of many, including mine, is that the presence of a loved one to those who are sick and fragile, and the voicing to the patient that they are being truly and honestly loved, is what gives true dignity. When suffering and loneliness arrives, if someone honestly tells the patient that they are of great value no matter what, that they are loved and needed just by being present, I think it would be very hard for them to go ahead with their plan. I can often spend only limited time with my patients, but friends and family can offer something I can’t. I can deal easily with the pain of the body, but I can’t do the same with the pain of the soul.
I commend Palliative Care doctors in Quebec who have affirmed their role, not to prolong suffering but to provide care in the spirit of their founder Dr. Cicely Saunders: "You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die." They are right to want to participate only in what they view as proper compassionate care. Their integrity demands it. Other societies have allowed this, so should ours too.