reflecting on Quebec’s bill for end of life care and doctor-assisted suicide

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Quebec introduced Bill 52, which would allow doctor-assisted suicide on June 12th, so it seems a relevant time to be reading, thinking and talking about the topic. Sarah Jones BSc, MBHL, JD, writes in the Globe and Mail that right now that doctors can administer lethal doses of medication but only for the intent of easing pain:

In 1992, the Supreme Court found that the removal of life-support (deliberately ending the life of a patient) was not murder because the underlying illness killed the patient, not the physician. The next year, Sue Rodriguez pled for help committing suicide. A slim majority of the Court found that administering pain relief was legal (even if it hastened death) but that the intention of the physician determined the issue. If the physician administered the dose with the intention of easing pain (incidentally, killing the patient), the act was legal; however, if the physician administered the same dose to kill the patient (incidentally, ending the patient’s pain) then it was illegal. The exact same act could be legal or illegal depending on the intention of the physician, under the so-called “doctrine of double effect”. Since Ms. Rodriguez was petitioning for a physician to end her life intentionally, she was denied relief (though the physician that ultimately assisted with her suicide was never charged, let alone convicted).

Bill-52 regulates the acts of physicians intentionally ending life. The Bill therefore pushes the law one crucial step past the Supreme Court’s 1993 ruling. However, judges have been picking away at the Rodriguez decision for ten years now, and it is crumbling.

A different Globe and Mail article indentifies that Bill 52 would allow not just the higher doses of painkillers but something more than that:

Under the new rules, terminal palliative sedation, that places patients in a state of unconsciousness and where they are deprived of food and water, would require consent beforehand in writing and filed in the patient’s record. Death often occurs within days but can sometimes take longer.

The end-of-life treatment proposed in the bill would provoke a much quicker death. The so-called medical aid to dying would involve the injection of a yet to be determined drug, administered by a physician after terminally ill patients who met all the strict criteria had freely complied with the procedure.

“It is not an additional dose of morphine. That is not what it is. It is a medication that is more precise. And I can’t tell you what it is exactly,” Ms. Hivon said adding that the College of Physicians and the Order of Pharmacists of Quebec were working on the protocol.

In some ways this sounds as though the issue was a quicker more effective method of doing what is already being done, with more clarity of intent. It sounds as though it would allow – or indeed require – better communication between patients, doctors and perhaps the patients families. It also sounds like by keeping the restrictions as medical questions around the proper care in end-of-life situations, they avoid the idea of giving healthy people a right to  medically assisted suicide. But I still wonder what it would look like at the bedside, and would patients feel under any pressure at all to consent so as not to be an inconvenience to their families, or to be taking up hospital beds, or anything like that. I also worry because of the people I’ve talked to who say yes, the bill is limited but that’s how movement comes, bit by bit and that, according to them, its a good thing this will pave the way for times when the illness is chronic but not terminal, and then not-chronic but still leaving the person wanting out.

Seduced by Death: Doctors, Patients and the Dutch Cure by Herbert Hendin, M.D., was published in 1997. The book is written by a psychiatrist who worked as a director for the American Suicide Foundation, so he spent a large portion of his life working with people who are suicidal, attempting to prevent them from committing suicide. The book talks about both doctor-assisted suicide (where medication is prescribed but the patient takes them his or herself) and euthanasia (where the doctor administers the medication). He talks about how doctors help shape the patients requests.

A large part of the book focuses on the idea that those with chronic or terminal illness can be suffering from depression and fear, and that the depression and fear will not necessarily be addressed and treated if death is seen by the doctor as the reasonable solution to the problems. Hendin acknowledges situations – like his mother’s last days with both pneumonia and dementia – where death coming sooner is probably a blessing and extraordinary means to keep a person alive should be forgone. But he expresses concern that the doctors who assisted in suicides end up accepting patients’ insistence that life is unbearable too readily, and that they cannot adequately help their patients overcome the fear and depression if they themselves don’t see their patients’ lives as truly worthwhile.

Another theme in the book is that the legalizing of assisted suicide and euthanasia is not for the benefit of the patients but for the benefit of the doctors. They are the ones who face prosecution, and according to Hendin’s view, they are the ones who gain more say in life and death if they are granted that ability.

The argument reminds me of the question in the United States of legalizing and regulating midwives. Does allowing unregulated midwives protect mothers’ freedom of choice, or does it protect midwives ability to pose as medical providers with little oversight or education? There are midwives who want regulation and licensing because of the respectability it will confer upon them and others who reject the idea of regulation and licensing because they don’t want it to limit what types of risks they are allowed to accept on the mother’s behalf. I doubt any  doctor would have the courage to argue against having guidelines as to when doctor-assisted suicide is acceptable but from the sounds of this book they would often argue for the guidelines to be very vague and general. Does open flexible guidelines serve the patients who might otherwise be refused an assisted death or does it serve the doctors who might otherwise be held responsible for assisting in situations where they should not have?

According to Hendin some argue that legalizing would allow it to be regulated and thus bring the illegal and unregulated practice of current American doctors in line.  Hendin says the Dutch experience does not support that since he describes numerous instances where doctors break their own guidelines. The same argument is used by midwives. Some argue that regulation and licensing will help bring the ‘rebel midwives’ who take on situations like breech births of women with two previous c-sections in line by requiring them to meet certain standards and transfer such cases to OBs rather than attempt them. Some midwives argue they have to take those extreme cases because the mother threatens to have an ‘unassisted childbirth’ otherwise, and so their assisting such a case is better than not doing so. Women are counselled on online forums such as mothering.org to go ahead and threaten the midwives with that if a midwife seems hesitant to take on their situation.  Like women threatening unassisted childbirth, patients of the Dutch doctors Hendin speaks of threaten that they will attempt suicide on their own if not assisted.

In one of the situations described the psychiatrist who was advising the doctor did not see necessary to meet the woman himself, because he didn’t want to cause her any more inconvenience or stress. Instead he just signed off on the idea of her being assisted in killing herself. In some ways that idea of not subjecting the woman to a psychiatrists evaluation to protect her from the discomfort reminds me of the questions of whether pregnant women should be forced to view an ultrasound before they have an abortion, and the argument that they should not be subjected to it because they should be able to make their own decision and not be forced through anything that might make the process harder for them. In both cases there is a question of whether we just accept people’s own judgement or whether we try to have safeguards to help people. If doctor assisted suicide or euthanasia was made legal, would people start to see it as a right whereby any efforts to screen people for seriousness of intent is viewed as patronizing and unfair?


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