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Can Fam Physician. 2010 June; 56(6): 527–528.
PMCID: PMC2902936


Be aware of moral harassment.

I thank Dr Leiva for his thoughtful response; however, I beg to disagree with some of his statements.

After spending 18 years in palliative care, I have come to see things differently than he does. As I am but a retired palliator, I will ask illustrious people to answer for me, while adding some comments of my own.

I do not deny that a request for euthanasia is a call for help and I recognize that 95% of those requests respond to compassion and eventually pursue a natural death. But to not see that some lucid requests beg only to end a life of senseless, inescapable, unrelieved suffering is unacceptable.1 As Paul Tillich says, “They are more numerous than we think, stoic people for whom the notion of suicide applies not to those overcome by life but to those who have overcome life and who are equally capable of living and dying and are able to chose freely between both”2 (freely translated).

Dr Leiva writes that in accepting euthanasia “we … [lose] the opportunity to try harder … [and] to offer hope.” Some physicians are often blamed for “therapeutic harassment.” Not to accept occasional failures of the best palliation speaks to a lack of experience and, to some degree, of pride—“moral harassment.” How long must one try while the patient is assailed by unendurable suffering? Marcia Angell wrote the following about the hospice and palliative care movement: “[It comprises] a professional pride that borders on hubris and rigidity.”3 Eric Cassell, the “father” of suffering, wrote, “In the care of suffering patients, even the best physicians sometimes (and not rarely) find their abilities insufficient; the suffering of some patients seems beyond reach,” while about those patients, he affirmed that “their request [for euthanasia] should be honored.”4

In terms of believing that agreeing with euthanasia means agreeing that “some lives are not worth living,” I can only tell Dr Leiva that if he listens humbly with all his heart, that is exactly what some patients are saying. It is never the physician’s assessment. Reading Paul Tillich would help.2

As well, without any supporting data, Dr Leiva attests that “troubles of human relationships within families become accentuated.” This is surprising, given that the British Medical Journal’s special issue on end-of-life care reported that such families had an easier period of bereavement,5 and given that the families of departed loved ones considered euthanasia to mean “compassionate assistance” and thought that it would be “inhumane to withhold assistance.”1

Two last points: 1) In a study by Battin et al6 published in the Journal of Medical Ethics, there was no evidence that “legalised [physician assisted suicide] or euthanasia will have disproportionate impact on patients in vulnerable groups” (eg, the elderly, women, the uninsured, people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities),6 and 2) patient-physician relationships are not endangered when euthanasia is an option—Dutch physicians came in first out of 9 European countries regarding “trust in your doctor.”7

I fully recognize the immense service rendered by palliative care efforts in Canada, but as the evidence goes, unacceptable situations at the end of life occur,1 and it is the patients who suffer, not the physicians. “[T]heir request should be honored.”4

Before the Senate Special Committee on Euthanasia and Assisted Suicide, ethicist E.H. Kluge quoted C.S. Lewis: “Of all the tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive.”8 An excellent definition of paternalism.


1. Wilson KG, Chochinov HM, McPherson CJ, Skirko MG, Allard P, Chary S, et al. Desire for euthanasia or physician-assisted suicide in palliative cancer care. Health Psychol. 2007;26(3):314–23. [PubMed]
2. Tillich P. Le courage d’être. Paris, Fr: Les Éditions du Cerf; 1999.
3. Angell M. The quality of mercy. In: Quill TE, Battin MP, editors. Physician-assisted dying: the case for palliative care and patient choice. Baltimore, MD: Johns Hopkins University Press; 2004. pp. 15–23.
4. Cassell EJ. When suffering patients seek death. In: Quill TE, Battin MP, editors. Physician-assisted dying: the case for palliative care and patient choice. Baltimore, MD: Johns Hopkins University Press; 2004. pp. 75–88.
5. Swarte NB, van der Lee ML, van der Bom JG, van den Bout J, Heintz APM. Effects of euthanasia on the bereaved family and friends: a cross sectional study. BMJ. 2003;327(7408):189. [PMC free article] [PubMed]
6. Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007;33(10):591–7. [PMC free article] [PubMed]
7. Tallis R. Why I changed my mind on assisted dying. London Times. 2009. Oct 27, Available from: Accessed 2010 May 7.
8. Senate Special Committee on Euthanasia and Assisted-Suicide [35th Parliament, 1st Session] J Senate Can. 1994;(2):10.

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada