By Mireille Aylwin (Contributor)
On June 5th 2014, Quebec became the first province in Canada to legalize medical aid in dying, defined as ‘an act that involves deliberately causing the death of another person to put an end to that person’s suffering’[1]. This phrasing carefully avoids the negative stigma[2] associated with the term euthanasia, which literally means ‘good death.’ Any individual who is covered by the public health system and affected by a terminal incurable disease that causes unbearable physical or psychological suffering can request alleviation of his suffering through death, providing that two physicians confirm both diagnosis and the decision-making capability of the patient[3]. But what is a ‘good death’? Our current conceptualization of a ‘good death’ is nearly universally defined as occurring in old age after a long and successful life, in one’s peaceful home environment, without any violence or pain, with a patient that is conscious and accepting of his or her situation[4]. This understanding has been highly influenced by our modern ways of dying under medical scrutiny[5],[6],[7]. The past successes of bio-medicine have created a new pattern of dying characterized by chronic diseases that can be controlled, but not cured, up until the point at which the body no longer responds to treatment. Most of the patients who have fought (or are fighting) for their right to die in Canada and the UK have been affected by a terminal neurodegenerative disease like ALS[8]. They justified their actions not out of a desire to die, but a desire to avoid living in unbearable conditions[1].
The legalization of euthanasia in Quebec has certainly been influenced by numerous such court cases in Canada over the last 20 years. These cases have helped secure a patient’s right to withdraw and withhold life-sustaining treatments[9] and have challenged the ban on assisted suicide. Gloria Taylor[10], who was affected by ALS, achieved a huge step in the advancement of the right to die in 2012, when she was granted a constitutional exemption to receive medical aid in dying on the basis that there was a contradiction between the Criminal Code of Canada, which criminalizes any form of help to suicide, and the Charter of Rights and Freedom, which secures the right to liberty and security. Canadian Prime Minister Stephen Harper’s Conservative government challenged this judgment, which was struck down by the British Columbia Court of Appeal. The case will be re-evaluated by the Supreme Court of Canada as of October 2014, nearly twenty years after Sue Rodriguez[11], another ALS victim, was refused access to assisted suicide in a tight 5 to 4 ruling.
One of the problems with the advancement of such ethically and morally important issues in court cases is that it conflates common good with the rights of individuals who are living in extreme and rare conditions of suffering. The issue of euthanasia and assisted death raises multiple questions and doubts, especially when it is brought out of the more abstract philosophical world and confronted in the concrete, real world of daily medical practice. On an individual level, I can feel sympathy for the court’s high-profile cases, and I agree with the ideals of dignity, alleviation of suffering, autonomy, and self-determination which are central to the discussion of assisting death. Hypothetically, if I were one day affected by a horrible degenerative disease that condemned me to lose my autonomy and die in a way I found devoid of dignity, I would certainly advocate for the right to die. I would want to secure myself a ‘good death,’ thus trumping the uncertainty of the timing and circumstances of my certain dreadful finality[12].
However, if I were to think about this issue as the practicing physician I am, the idea of having a patient requesting my help to end their life becomes frighteningly concrete[13]. I acutely realize how the very definition of dignity and unbearable suffering is individually subjective. What one person considers as an unbearable way of living can be acceptable to others, and vice versa. While I would feel somewhat comfortable establishing the limits of my own living and dying, how can I be comfortable acting upon someone else’s subjective evaluation of the value of their life in an ill condition? Would providing medical aid in dying make me a more compassionate doctor and human being, or would it not? What is the weight of the potential suffering of the acting physician compared to that of the suffering patient? Would injecting a lethal dose of medication to someone who wishes to die feel different from withdrawing a mechanical ventilator that is keeping someone alive? Medical aid in dying is described as being part of the continuum of palliative care, but should it be suggested to patients who are terminally ill as a physician would with any other treatment alternative, or should we wait until the patient requests it? Both options seem wrong to me: offering medical aid in dying to a patient could be perceived as a judgment that their life is not worth living anymore, but not offering a treatment means that the decision-making process is incomplete and we assume everyone is aware of this option.
The exponential improvement of medical technology has created the expectation and hope that science can control death to a point where death is not natural anymore, but perceived as a scientific failure. Bioethics, the hospice, and palliative care movements in the 1970s came in reaction to the technologization of death in an attempt to give back control to the patient over one’s death and help them to have a dying process which is coherent with their personal biography. In our individualistic world, it seems logical to want to secure such a controlled ending by any means possible. This new bill in Quebec is another success in terms of patient’s autonomy, but is it a clear win for medical practice and the common good?
Mireille Aylwin is a physician from Quebec currently reading for a Masters in Medical Anthropology. She will return to the practice of medicine in the near future.
[1]National Assembly of Quebec (2012) Dying with dignity. Quebec:National Assembly of Quebec.
[2]Hausmann, E. (2004) How Press Discourse Justifies Euthanasia. Mortality 9(3): 206-222.
[3]National Assembly of Quebec (2014) Bill 52: An Act respecting end of life care. Quebec: National Assembly of Quebec.
[4]Seale, C. and Van der Geest, S. (2004) Good and Bad death: Introduction. Social Science & Medicine 58(5): 883-885.
[5]Chapple, H.S. (2010) No Place for Dying: Hospitals and the Ideology of Rescue. Walnut Creek, CA: Left Coast Press.
[6] Kaufman, S.R. (2005) …and a time to die: How American Hospitals Shape the End of Life. Chicago: The University of Chicago Press.
[7] Green, J.W. (2008) Beyond the Good Death: The Anthropology of Modern Dying. Philadelphia: University of Pennsylvania Press.
[8]Neurodegenerative disease characterised by rapidly progressive weakness due to muscle atrophy and muscle spasticity that usually lead to respiratory failure. Also known as Lou Gehrig disease or motor neurone disease. C.f.: Diane Pretty and Debbie Perdy in the UK; Gloria Taylor and Sue Rodriguez in Canada.
[9]Dickens, B. (1993) Medically Assisted Death: Nancy B. v. Hotel-Dieu de Québec. McGill Law Journal 38: 1053-1070.
[10]Carter v. Canada (Attorney General), 2012 BCSC 886.
[11]Rodriguez v. British Columbia (Attorney General), [1993] 3 R.C.S. 519.
[12]Richards, N. and Rotter, R. (2013) Desperately Seeking Certainty? The Case of Asylum Applicants and People Planning an Assisted Suicide in Switzerland. Sociological Research Online 18 (4) 26.
[13]Doctors are allowed conscientious objection and are not in the obligation to act upon a patient’s request.