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It is our duty to reflect on and reevaluate our values because, as physicians, we have little or no preparation for requests for euthanasia. Indeed, we are more comfortable responding to requests for kidney and heart transplants! We must get past the “pros” and “cons” and focus on the needs of the dying. After all, we do not ask orthopedic surgeons whether they are for or against amputation!
Our society is constantly evolving and our patients reflect this evolution, with ever increasing expectations of autonomy. A few generations ago, divorce, abortion, same-sex marriage, and voluntary euthanasia were not givens. In 1970, 50% of Canadians said they were in favour of voluntary euthanasia. In 2007, this number had increased to 77% in Canada and 83% in Quebec.1 In 2003, 51% of specialists and 43% of general practitioners in Quebec said that they supported it.2 In Fall 2009, there were reports in the media that 75% of both groups were then in support of voluntary euthanasia. This is in line with the position taken by the Collège des médecins du Québec, which has acknowledged that shortening an intolerable life might, under exceptional circumstances, fall within the continuum of “appropriate care.”
The uncomfortable majority (with a single dissenting voice) in the Supreme Court ruling in the Sue Rodriguez case, whose death did not result in an in-depth investigation, confirmed the opinion issued by France’s prestigious advisory council on ethics, the Conseil consultatif national de l’ethique de France, that “the law, which considers euthanasia either murder or assassination, is extremely virtuous and severe”3 (freely translated). In recent years, convictions on charges of assisted suicide have often resulted in reduced or commuted sentences.
We must remain open. In 2010, there is no place for the paternalism of the past. “A physician’s first duty is not to save the patient’s life at all costs. It is to respect the patient’s freedom to choose for himself or herself” (freely translated). So writes the Honourable Jean-Louis Beaudoin in a report released in 2009.4
We must remain open. We now have a more thorough understanding of the limits of palliative care. According to 2 recent Canadian studies, terminally ill patients are far more concerned about existential suffering than about pain or physical symptoms. In the first study, pain ranked seventh, not being a burden ranked fifth, receiving unnecessary treatment ranked second, and being able to have complete trust in one’s physician ranked first among the concerns of these patients.5 This study shed light on the existential concerns of patients, as expressed by ethicist Hubert Doucet: “When life ceases to have any meaning, a patient suffers simply by virtue of being alive and of witnessing the degradation of his identity”6 (freely translated).
In the second study involving 379 cancer patients in palliative care with a life expectancy of less than 6 months, 63% reported that they were in favour of euthanasia, 40% reported that if their condition deteriorated and euthanasia were legal, they would consider it, and 6% reported that if euthanasia were legal, they would request it immediately. None of these patients had pain that was not being managed adequately and none was considered unfit to make decisions. The reason for their support of euthanasia was a marked deterioration in their condition that deprived them of any autonomy, rendered them a burden, and stripped their life of any meaning.7 This study demonstrates that, for some, even excellent palliative care cannot relieve existential suffering. “We thought that if we could manage pain adequately, we could make death more humane. What we are realizing is that a patient’s life is not meaningful simply because his or her pain is being managed. The real question becomes, what is the meaning of life and is it worth living if it is reduced to waiting for death?”6 (freely translated).
We must remain open because our human condition requires this of us; because we are aware that the only person who can measure the suffering is the patient. When we stand up to leave after spending an hour at a dying patient’s side, we need to remember that, in that day, the patient faces another 23 hours of this existence and is already anticipating the suffering that the next day will bring.
We need to remain open because “the ‘sanctity of life’ has to be the sanctity of personhood, not merely the possession of a body.”8 Our law on abortion illustrates this perfectly; no one questions whether a 20-week-old fetus is alive.
We need to remain open because providing access to euthanasia has been shown to be an effective way of warding off suffering and extending life. This is what American sociologist France Norwood discovered as she spent 15 months accompanying Dutch general practitioners as they visited patients dying at home.9,10
We all agree that we cannot impose our beliefs on others. This is especially true when it comes to the final wishes of a dying person. For this reason, I support the views of the Honourable Jean-Louis Beaudoin when he writes:
We can hold whatever personal opinions we like about euthanasia. Our personal opinions and feelings are primarily shaped by our moral and religious convictions. Studies conducted in Belgium and the Netherlands on euthanasia demonstrate that the systems that have been put in place to avoid errors (the main argument raised by opponents of euthanasia) are working, and that the lines are rarely, if ever, blurred. Such systems restore an individual’s freedom to choose and manage his or her own destiny4 (freely translated).
I will give the last word to Hubert Doucet, with a quote from his book on a bioethical approach to dying entitled Mourir: approches bioéthiques: “Dying with dignity, about which there has been so much debate in recent years, ought not to be conceived of as a gentle death. Rather, it ought to be conceived of as a death that respects the dying person’s personality and history”11 (freely translated).