Author: Shawn Whatley

Physician assisted suicide (PAS) is fundamentally confused. Other societies throughout history have supported physician assisted suicide, euthanasia, abortion, infanticide and much more. That does not mean Canada should. We might consider the following irreconcilable issues:

1. Doctors spend massive amounts of time and energy convincing patients to not kill themselves. It is materially impossible to differentiate nihilism from depression from hopelessness. The Dying-With-Dignity crowd promotes a false image of the typical patient requesting PAS: idealistic, articulate, and simply looking for relief when faced with the prospect of death.

2. Physicians take the Hippocratic Oath. They do it for two reasons. First, they want patients to know what they stand for, to offer patients a standard of accountability. But more importantly, the oath rests on the presupposition that moral neutrality does not exist. No one can pretend to stand as an objective oracle of medical wisdom devoid of cultural interpretation and nuance.

3. Assisted suicide can fail or not go far enough. Assisted suicide necessitates laws to support euthanasia so physicians can intervene to complete the suicide for patients left near dead from their attempt. Is that what society wants?

4. The rhetoric supporting PAS sounds exactly like abortion. Initially, abortion required special outstanding circumstances, second opinions and was supposed to happen rarely. Now, abortion is routine, uncomplicated and no reason seems slight enough to get one. The Netherlands experienced the same change in frequency, approach and reasoning over the years since PAS became legal.

5. Most patients do not want suicide. By orders of magnitude, the majority wants great end of life care. Those who pretend that frail elderly patients will not feel pressured to pursue PAS in the face of huge burdens placed on their families for elder care mislead to the point of cruelty.

6. What do patients want? Do they want physicians who hold to strong moral values and will share those views graciously? Do patients want physicians who will remain a source of strength, support and encouragement when their own resources run out? Or do patients want physicians who pretend to be objective, morally neutral and blind to the issue? Do patients want a physician who can care for them even when the physician sees the world differently?

7. After the media about forcing physicians to provide or refer for any and all publicly funded services, what protection do we expect for physicians’ own human rights? The College of Physicians and Surgeons has already taken direction from the Toronto Star to consider forcing physicians to act against their moral judgment.

As the libertarians, individualists and death-with-dignity celebrations die down, I hope Canadians will consider the consequences of legalizing physician assisted suicide. Let your MPP know what you think.

For most doctors, physician assisted suicide will not change almost anything in day-to-day practice. It will happen away from the mainstream of care, available but not obvious. Doctors will want reassurance that neither patients nor doctors get coerced. But beyond that, most physicians will not get passionate either way.

Doctors usually avoid social activism. As a group, they support social movements but rarely create movements of their own.

Doctors agree on one moral absolute: Thou shalt not express a moral opinion about the behaviours, beliefs or decisions of thy patient. Everyone is a potential patient. Ergo, doctors should not express opinions about anyone’s choice. Society expects this – demands this – of their doctors. Modern medical trainees learn objectivity before all else.

People used to expect doctors to toddle the streets offering wisdom for healthy living and good character like the sheriff on the Any Griffith show. Those days are gone. Post war individualism promoted maximal freedom in personal morality.

Doctors focus on medical problems, not emotions or ethics. Doctors learn to separate morals from medical tasks. I’m often surprised when my wife takes the opposite approach on a medical issue. Doctors can separate medical problems from their social context. Physicians often turn a scientific lens onto social problems to see how social issues impact human organisms. But doctors do not care about social issues in the same way they care about surgery and pap smears.

Physician assisted suicide will probably develop like abortions. Doctors usually hear about abortions after the fact. Patients decide with their families then go to a clinic. Physicians rarely have to agonize over termination. MDs help before and after the event but do not discuss it much in between.

Doctors live as a tiny part of the social fabric just like everyone else. We work hard and try to help people where possible. We enjoy our family and buy lots of stuff. We don’t want to die with unfulfilled dreams. Counter-cultural revolutionaries are rare.

Politicians will probably set up physician assisted suicide like abortion. It will happen in discrete clinics with staff that want to be there. No provider will be forced to participate. Family doctors won’t write referrals.  Doctors will carry on looking after all the other medical problems relieved that the courts took care of things.

Physician assisted suicide will be a non-issue for most doctors. That’s what society wants. Or does it?

Please share a comment or read “Bad Idea – Physician Assisted Suicide” (next post).

 

Everyone knows to avoid politics and religion in polite conversation.  Not any longer. The Supreme Court’s unanimous decision to rescind the ban on physician assisted suicide promises to make politics and religion very popular topics. Here’s some of the coverage so far:

•  CTVNews
• Toronto Star
• Globe and Mail
• National Post

Last summer, the media exploded after a walk-in clinic doctor refused to give a young woman birth control pills. The Toronto Star said that “Doctors who play God can be pastors not physicians.” The Star rocked the College of Physicians and Surgeons of Ontario (CPSO) with, “If the college fails to reassert itself as a self-governing authority, let the provincial government step in to defend patient rights under the Ontario Human Rights Code. Queen’s Park could do that by de-delegating the college’s authority and re-regulating medicine on our behalf.” De-regulation scares the CPSO more than anything. It immediately tackled a rewrite of its 2008 policy, “Physicians and the Ontario Human Rights Code”.

A number of doctors agree with the Star. They insist physicians must submit their personal beliefs to their patients’ requests. If a patient wants a legal, available treatment, then a doctor shall comply or refer the patient to another doctor. Noncompliant doctors should face discipline. In other words, refuse the pill; lose your licence.

These same doctors usually emphasize the role of evidence, science and objectivity in medicine. In their view, medical practice is crisp, uniform and evidence based. There’s little need for doctors to rely on personal ethics or morality in their decision making. In fact, aside from the Georgetown Mantra (Principles of Biomedical Ethics), doctors should leave their personal morality at the door (which is, of course, a moral position of its own).

But experts tell us that medicine isn’t crisp, uniform or even as evidence-based as we would like. Sherwin Nuland, author of the best seller How We Die: Reflections of Life’s Final Chapter, New Edition, also wrote about uncertainty in The Uncertain Art: Thoughts on a Life in Medicine. Whether people call it art, wisdom or clinical judgment, medicine appears less black and white and more often frustratingly grey. It makes medicine an intrinsically moral profession. Even with solid, evidence-based treatment guidelines, doctors still must work to explain, encourage and support patients to carry through with what’s good for them.  Governments started paying physicians incentives based on how many patients doctors convince to agree with current clinical guidelines where they exist. Medicine is not crisp and clear. Physicians require acute moral sensitivity since almost everything they do involves moral agency (see Medicine as a Moral Practice).

Even if we grant that patients’ rights should trump doctors’ beliefs, does this apply to everything? Should doctors comply with every patient request so long as it’s legal and doesn’t hurt anyone else? Should doctors be forced to give narcotics for chronic pain to everyone who asks for them in the emergency department? What about X-Rays and blood work? Many investigations aren’t cut and dried, evidence-based. Should doctors always rescind their clinical judgment in favour of a patient’s demands if there’s no evidence to guide them? What if sex selection becomes legal in Canada? Should doctors be allowed to refuse to help parents choose the sex of their children?

The Supreme Court stressed that doctors “cannot be compelled to assist someone in suicide“. It seems, for now, that doctors’ beliefs might trump patients’ rights. Pending the CPSO update on Human Rights, the College might still force physicians to refer patients for assisted suicide. If patients request it, doctors might have to choose between their medical licence and their Hippocratic Oath: “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan…”

The federal government has one year to draft new legislation. In the meantime, expect to find politics and religion in conversations everywhere.

photo credit: ctvnews.ca