It's still not over, Debbie

I had been in practice for a few years, and had been involved in the management of quite a number of women with ovarian cancer, when "It's Over, Debbie" appeared in JAMA in early 1988. In that anonymous essay, a gynecology resident described how, after being woken during a night on call to attend a distressed 20-year-old woman with terminal ovarian cancer, he (or she--it was never specified which) had administered an excessive dose of morphine. The woman died within minutes. From the tone of the essay, the resident seemed to feel that doing this was the only reasonable response to horrific suffering (the resident described the patient's room as "a gallows scene"). But many of us felt that this was a disturbing rush to judgment and just plain wrong. The resident was tired, did not know the patient, was not familiar with her circumstances, and interpreted the patient's statement "let's get this over with" as a plea to accelerate her dying. During residency we become familiar with the idea that patients die, but this familiarity should not mean that hastening death becomes just another management option. I found the resident's hubris chilling.

Needless to say, publication of this essay provoked a storm of responses, some praising the resident's actions and many condemning them. Local authorities petitioned JAMA's editorial offices with a view to prosecuting the author, but the editor of JAMA refused to disclose the author's name. Nor was it known when this incident took place--or even if it took place at all. What publication of the essay did, though, was reignite discussion of euthanasia and physician-assisted death.

Lawyers, ethicists, sociologists, religious experts, and physicians all weighed in, and the debate has continued--with some excellent and thoughtful opinions expressed in the BCMJ earlier this year. Just about all of us have opinions on the morality (and potential for legality) of physician-assisted death, and most of us are convinced that we're right and those who think differently are wrong.

Earlier this year, the CMA released an update of its policy on euthanasia and assisted suicide. In the document the CMA confirmed that it was not opposed to palliative sedation or withdrawing or withholding life-sustaining interventions when these were no longer wanted or indicated, but repeated its opposition to euthanasia and assisted suicide. However, the CMA subsequently softened its position to support physicians who follow their conscience "within the bounds of existing legislation." Very shortly, the Supreme Court of Canada will hear arguments that the law banning assisted suicide is unconstitutional; the BC Supreme Court has already decided that it is, but the law in BC has not changed. Quebec, however, has very recently made physician-assisted suicide legal; the province has circumvented the federal law by specifying that their legislation is an extension of existing health services, which are a provincial responsibility. So the ground is shifting.

If the federal law changes, will physicians readily agree to assist? When the CMA canvassed Canadian physicians, 16% to 20% indicated that they would be prepared to participate in physician-assisted death if it were to become legal. But I wonder--when push comes to shove, how many of those 16% to 20% will have the nerve to make good on their intention? Can a physician switch easily from efforts to maintain quality of life to a quick action that takes life away? 

As has been stated repeatedly, our efforts for the terminally ill should be directed ceaselessly and tirelessly toward maintaining their quality of life, with the aim of allowing an easeful death. Agreed, there are countless reports of terminally ill patients having a peaceful death by their own hand or with the assistance of a physician. But I am still haunted by the feelings I had when I first read "It's Over, Debbie." If I assist someone in taking his or her own life, I cannot possibly know--whatever the circumstances--whether it was the right thing to do. And there is no going back.
--TCR