Re: Euthanasia

In the article “Legalization of euth­anasia violates the principles of competence, autonomy, and beneficence” [BCMJ 52(2):92-94], we are given a conclusion before an argument. 

Some cases from the Netherlands and Canada (only) are examined, and Ms Ho then reaffirms her somewhat emotive premature conclusions and goes on to imply that somehow euthanasia violates the very moral principles that a Canadian doctor aspires to.

I do not think it is that simple. Euthanasia differs from the abortion issue in that termination of pregnancy is now legal in Canada, but euthanasia is not, at least not yet. So are we looking at an issue that is perhaps one of religious leanings, or purely of moral principles of Canadian doctors? 

Perhaps it might be necessary to declare one’s religious affiliations at the end of such articles, as we do with potential conflict of interests with pharmaceuticals. I have no difficulty in de­claring that I am an atheist, and a strong supporter of Mr Robert Lati­mer, and have been an advocate of his release from jail on legal and moral grounds. This is my bias, and you may judge my arguments accordingly.

The word euthanasia means “a gentle and easy death.” Many opponents, as can be seen in the aforementioned article, fall prey to the so-called slippery slope principle. This implies all sorts of bad things can follow if you allow such and such. So, the implication continues, any act of mercy killing permissible will lead to wanton abuse and pick on “socially vulnerable” victims. 

This fallacy was made infamous by one of the judges at the Nuremberg Trials. However, moving from the starting point that we might accept that there are some lives so miserable—from pain of one sort or another—that assisted suicide is considered to the assumption of wanton abuse is unjustified. 

There are many examples already of advances in medicine changing social norms, and again Ms Ho falls prey to the slippery slope in her conclusion, “Worst of all, legalized euthanasia puts people who are suffering and vulnerable at risk, and no legal safeguard can prevent abuse against this group in the name of a ‘right to die.’”

Society is not that simplistic and many aspects of seeing a doctor imply trust and risk, and that is why we have lawyers specializing in medico-legal issues and why we have various professional colleges across this country to place checks and balances on that very trust and risk. 

Calling euthanasia homicide may be correct, but is not abortion a now-accepted and legal form of homicide? If we have allowed the definition of legal life to be a fetus over 24 weeks (due to a certain legal interpretation that a fetus under 24 weeks is not really a live human being) and therefore an accusation of homicide is no longer justified (though pro-lifers would argue that point) then surely we must also allow a rational, legal, and perhaps dispassionate discussion of the definition of a life worth living at the other end of the scale—always with a patient’s best interests at heart. 

In some ways the legal aspects of euthanasia should not present as much difficulty as abortion, as the former considers the rights of a patient to decide his or her own fate, whereas in the latter a life is terminated due to social and personal reasons of another person. So what we may wish to conclude is that not all homicide is wrong and enlarge the principle of justified homicide. That idea is not new; countless wars have used it.

Ms Ho quotes Sneiderman’s paper on euthanasia in the Netherlands, but she fails to inform us of his conclusion, which is that we should provide the optimal care and the best pain control, but if the patient is still plagued by unbearable and unrelievable suffering and asks for release, then, at a carefully predetermined point (by living will and various mechanisms that determine competency and autonomy) “we will abide by your request because there is no other way that we can show you our compassion.”

It is my personal opinion that “assisted suicide” already takes place more often than we can know. There is no example of a Canadian doctor being convicted of assisted suicide of a terminally ill patient by administering massive doses of narcotics or analgesics. (There have been charges laid but none have ended with a conviction.) 

Some surveys have been conducted anonymously, but I am not aware of the conclusions as to how many doctors would admit (with full immunity from prosecution) to assisting one of their suffering terminal patients to a less painful and more dignified death. 

As family doctors we face this situation not infrequently, but if we do help such patients we probably do not even mention it to our closest colleagues. This is one very good reason why this subject needs a more open and rational discussion than that presented in Ms Ho’s article. My initial reaction after reading it was, “just wait until you have sat and watched patients who you have become close to over the years suffer beyond the legal limits of your pain control, and then continue to argue that it is wrong to step in and help the patient speed up his or her death, with some dignity.” 

I do not wish in this letter to enter into a full discussion of all the legal ramifications, but only to imply that for reasons of humanity it behooves us as Canadian doctors to start the discussion more openly, just as I strongly believe that we should now legally pardon poor Mr Latimer on grounds that he has suffered enough for an act of mercy.

Assisted suicide is legal in Belgium, the Netherlands, Luxembourg, Switzerland, and Albania, as well as in the states of Oregon, Washington, and Montana. New Hampshire is examining the subject. Australia reversed its euthanasia ruling but is currently discussing it again. 

South Africa, Japan, Germany, France, and Colombia are all countries where euthanasia is coming under serious discussion or involved in legal challenges of one sort or another. There are several or­ganizations throughout the world that will assist terminally ill adult patients in the sense of directing them to appropriate resources. Dignity in Dying, in the United Kingdom, is one such organization. There are also some organizations of a disreputable nature.

It is imperative that we in Canada do not stick our heads in the sand on such a critical issue. What we do not need is a rather shallow dismissal of the whole subject. Our primary objective of “do no harm” as physicians should propel us to more open discussions of this issue. 

In the future, with genetic engineering available for treatments, we are going to face far more difficult moral and philosophical issues. We need to start looking at legal and societal protective mechanisms that will avoid abuse of euthan­asia. 

I still remember and admire Ms Sue Rodriguez’ bravery and eloquence in her moving speeches on her right to a dignified assisted suicide due to her ALS. I am not sure I would have had the courage to risk being disallowed to practise medicine if I had been asked to help her, but I would have been glad to do so were our legal circumstances altered. 
—John Dale, MD
Nelson