Physician-assisted suicide

Belgium, the Netherlands, Switzerland, Oregon, Washington State, Montana and, most recently, Vermont have all legalized physician-assisted suicide or euthanasia. (Reuters)

As a doctor I can’t help but wonder what I would do in a situation where physician-assisted suicide was legal. Given all my training to make patients healthier, could I assist in a patient’s death with a clear conscience? To the contrary, if it helps a patient die with dignity, why wouldn’t I help?  

As the right-to-die debate picks up, recent surveys of doctors are raising an unsettling question: What happens if physician-assisted suicide becomes legal, even as most doctors remain deeply opposed to it?  

Only 16 per cent of Canadian doctors would be willing to take part in assisted suicide, according to a March survey by the Canadian Medical Association. A New England Journal of Medicine survey in September found only 36 per cent of doctors in 74 countries were in favour of assisted suicide.

This places most doctors firmly out of step with public opinion. An Environics Institute survey in October showed that 69 per cent of Canadians support physician-assisted suicide, the highest recorded approval since 1992.  

The gulf between popular support and doctors reminds some of how the abortion debate has played out in some regions where the procedure is legal but inaccessible. As with abortion, many doctors will refuse to participate, says Dr. Donald Boudreau, an opponent of physician-assisted suicide who is a respirologist and the director of medical curriculum development at McGill University. 

Suicide is not illegal in Canada, but assisting in it is. Last year, the Supreme Court of British Columbia ruled against the ban on assisted suicide, saying it was unconstitutional. The B.C. Court of Appeal overturned the ruling in October. Quebec’s Right-To-Die Bill 52 has added more fire to the debate. Before Toronto’s well-known microbiologist Dr. Donald Low died from a brain tumor in September, he recorded a public plea for the right to die with dignity — prompting Ontario Health Minister Deb Mathews to suggest, "it’s time to talk about assisted suicide."

Canada is joining a debate that has erupted across the world. Belgium, the Netherlands, Switzerland, Oregon, Washington State, Montana and, most recently, Vermont have all legalized physician-assisted suicide or euthanasia.  
Many doctors who oppose assisted suicide have major ethical concerns about killing a patient, Boudreau says. The act is inherently against a physician’s "do no harm" principle, he adds. "How can I teach medical students about healing when I have to prepare them as euthanizers?" he asks.  

Vulnerable populations?

People become doctors to support human beings in their darkest hour, says Dr. Margaret Cottle, a palliative care doctor from Vancouver and vice president of the Euthanasia Prevention Coalition. "There is something so deeply human about that connection, and to take it away with a lethal pill, instead of supporting patients through these difficult periods, will destroy us," she adds.  

'We cannot always ensure that they will die without symptoms.'- Dr. James Downar 

Some doctors also worry that assisted suicide laws could be misused. In the Netherlands and Belgium, euthanasia is being administered to patients with mental illness who do not necessarily have a terminal illness, Cottle says. She highlights the recently publicized case of Nathan Verhelst, a 44-year-old who was legally euthanized in Belgium after a botched sex-change operation resulted in “unbearable psychological suffering,” according to reports in the media.  

Opponents also worry that vulnerable populations, such as the elderly and poor, may be pressured into a duty-to-die as opposed to a right-to-die. "Having been at the bedside of dying patients for 25 years, I can tell you that these patients are extremely vulnerable and depressed," Cottle says. Opening up the possibility of assisted suicide will pressure patients to choose to live or die — in many cases as a result of financial or emotional burden on their families, she fears.

Doctors who support the decriminalization of assisted suicide, such as Dr. James Downar, a palliative and critical care doctor at Toronto General Hospital, have a different view. Doctors can often treat stable symptoms such as pain, but some patients develop sudden complications, and "we cannot always ensure that they will die without symptoms," Downar says. He adds that  most people who request assisted suicide are concerned about the loss of independence and control, something that can't be treated. 

Downar does not believe that misuse will occur with carefully thought out laws. "There is always a potential for abuse of the law, but data from Oregon and Washington don’t support this. It remains an option taken by less than one per cent of the population, most of whom are educated, white men," he says.  

Cottle disagrees. Even in Oregon and Washington, the laws allow for abuses to occur, she says. There is no oversight of the lethal medications — once patients pick up their drugs, they take them home and can use them whenever they please, she says. When a patient dies, there is no recall of the lethal drugs by the pharmacy, making it uncertain what killed the patient and where the drugs ended up, she says. There will be abuses, it’s just not reported, she adds.

'The end of life experience is like being on a tightrope with no net, if there is no wind, you can stay on that rope for quite a long time.'- Dr. Margaret Cottle

If assisted suicide is legalized, disagreeing doctors could be pushed into a corner. While laws allowing physician-assisted suicide also let individual doctors refuse to participate, most require doctors to refer patients to others who will perform it.   

This obligation to refer could force doctors into an ethical quandary, Boudreau says.  And doctors may be hesitant to work in hospitals that offer assisted suicide. "Ask yourself, how would I feel if I were all of a sudden working in a hospital that … started to do something that I found morally reprehensible?" Boudreau asks.  

Because so many doctors oppose assisted suicide, it’s already tough to find doctors willing to assist in it — even where it’s allowed.   

In March 2012, the Netherlands euthanasia lobby NVVE set up mobile clinics to provide assisted suicide to patients who had been refused by their doctors.  Compassion and Choices, a U.S. non-profit organization, has launched campaigns in Montana, Washington State and Oregon using poignant pleas from patients to pressure doctors into assisting suicide.  

Switzerland may have found a way to avoid unwilling doctors and hospitals altogether. Organizations such as Dignitas, founded by Swiss Lawyer Ludwig A Minelli, recruit volunteers to help people commit suicide. Willing doctors still have to prescribe the lethal drugs but don’t participate directly. Dignitas performs the procedure in private clinics outside hospitals. From 1998 to 2012, it provided assisted suicide to 1,496 people.  

Some observers propose removing doctors completely from the equation. Alternative methods, such as using non-doctors to assist in suicide though a centralized government body, need to be considered, Boudreau says. "Why do doctors need to be the ones performing this?" he asks.  

Dr. Lisa Lehmann, director of the Center for Bioethics at Brigham and Women’s Hospital in Boston, touted this idea in the July 2012 New England Journal of Medicine. She suggested that physicians could certify a patient’s diagnosis and prognosis, and patients could then use an independent authority to get a prescription for suicide drugs.  

When Cottle is asked by patients to assist in their suicide, she tells them that today they may not feel like living, but who knows how they will feel one month from now. "What if a grandchild is born, or a graduation happens, or someone close to you gets married, wouldn’t you want to be there?" she asks.  

Determining prognosis is never easy, so providing patients with a definite timeline to death is near impossible, Cottle says. "The end of life experience is like being on a tightrope with no net, if there is no wind, you can stay on that rope for quite a long time," she says.