Health Canada hasn’t reported numbers since April, when it estimated assisted suicide deaths accounted for 0.6 per cent of all Canadian deaths between June 17 and Dec. 31, 2016. There won’t be another report until fall, but extended for another six months, it’s likely that last year’s 970 legal assisted deaths may hit 2,000 over the past 12 months.
Beneath the raw reality of the numbers lies a medical community that is still grappling with its own ethics and the changing nature of the doctor-patient relationship, as well as a society that must deal with its most vulnerable.
Ottawa psychiatrist Sephora Tang is certain the practice of euthanasia is set to expand. She talks about “when” and not “if” eligibility for what is called medical assistance in dying (MAID) includes psychiatric patients. She worries about whether her patients are already censoring out their dark thoughts of suicide when they talk to her, if only because they believe she could make it happen in a legal and socially acceptable medical procedure in less than two weeks.
Her whole practice depends on patient trust. Is trust threatened?
Tang isn’t primarily worried about Ontario doctors being forced by their College of Physicians and Surgeons to play a role in a process aimed at causing their patient’s death, though that does infuriate, frustrate and depress her. Her first thoughts are for the vulnerable. She sees patients who don’t know their own mind, who have never experienced their lives as anything valuable to themselves or to others.
“As a community, we need to be more embracing of those who are vulnerable, who are isolated,” she said. “The weak, the sick, the frail among us — we have a call now to all people in the community, not just doctors, to go out, to outreach, to show more love to these people.”
For Tang, one certain result of legalized medically assisted death is that society can no longer safely off-load its responsibility for the least among us on a professional class of carers. However magical their powers may be, doctors can’t bear that burden alone.
“This (legal euthanasia) is entirely, from a secular perspective, a capitulation to a market model of medicine,” said medical ethicist and paediatric cancer doctor Sr. Nuala Kenny. “We have rejected the long-standing, actually pre-Christian, Hippocratic notion that there is a central, moral reality to medicine. The nature of medicine is different from the relationship with the guy who fixes your car.
“What you see is what I call the perfect storm of the loss of morality in medicine, the rise of commercialization and commodification in medicine — medicine is now big business — and the dominance of the belief in technology to relieve every one of our distresses, to provide every one of our dreams, to provide assurance of the avoidance of even suffering,” Kenny said. “That is what this is. It is the medicalization of human suffering.”
Kenny, author of the upcoming Novalis book Rediscovering the Art of Dying, wants the world to know that she’s a doctor.
“I am not a Wal-Mart clerk,” she declares.
The 73-year-old Sister of Charity is distressed by how readily the medical profession rolled over and accepted a redefinition of their ethics by political pressure groups and national media too easily fascinated by the tale of high-achieving, strong-willed individuals choosing the time and manner of their deaths in defiance of moral codes.
“Irresponsible journalism,” she calls it.
But she’s even more worried by Catholics who think there’s no issue here.
“Medical assisted death is a direct refutation of the paschal mystery,” said Kenny. “It is the medical equivalent of Jesus at Gethsemane saying, ‘I’m sorry Father, I’m not going to do it this way.’ ”
Dr. Doug Mark thinks of himself as an ordinary family doctor, in practice 31 years. The problem he faces is the very idea of the remote, lawyer-dominated, bureaucratic College of Physicians and Surgeons intruding on the doctor-patient relationship. He’s having conversations with patients that he never imagined.
“One patient said to me — I talked to him about this, and he says, ‘You’re not going to try to off me, are you doc?’ ”
The question was offered as a sort of joke, but not really.
“Realistically, you have to ask that question though,” said Mark. “What if a doctor were to say to a patient, ‘I think there’s nothing else we can do. Why don’t you explore this?’ ”
Mark thinks assisted suicide is the easy way out — not for the patient, but for the doctor and the health system.
“Patients don’t really need medical assistance in dying. They don’t need medical suicide,” Mark said. “They feel out of control and they’re desperate. They’re fearful and they don’t have a comforting person to help them through their pain and through their worries and so on.”
Referring for a MAID assessment allows the doctor to move on to the next patient. Whatever happens next is somebody else’s responsibility. For the broader health system, assisted dying saves money.
“We have to be realistic here. Caring for people at the end of life, that’s where the greatest costs are. There would be huge cost savings if these patients say, ‘OK, that’s it. I want to pack it in now. Thank you very much. Let’s have a party for going away,’ ” said Mark.
Just before legal assisted death hits the one-year mark, the Christian Medical and Dental Society of Canada will argue in an Ontario Divisional Court room that they shouldn’t be forced by the CPSO to provide an “effective referral” for MAID assessments. It’s a legal fight almost certain to wind its way to the Supreme Court of Canada over the next couple of years, but it’s not about the legality of doctors injecting patients with lethal doses of drugs. It’s just that last, little shred of resistance from a few Evangelical and Roman Catholic doctors who think they shouldn’t have to open that particular door to death.
South of the border, Georgetown University ethicist Dr. Daniel Sulmasy looks at what’s happening in Canada and sees the gathering storm.
“It’s terribly frightening to me,” said Sulmasy. “I think it must be frightening to you as well, just how rapidly this is expanding, and being carried out with a kind of secular vengefulness.”
Americans have long lived by a code of personal freedom. Arguments for patient autonomy will be massively seductive in the U.S., where euthanasia is legal in six states. As the debate wends its way from one state legislature to the next, Sulmasy hopes somebody will speak up for the medical profession and the tradition represented by the Hippocratic oath.
“In a healthy, liberal, pluralistic, democratic republic, professions have to have an autonomy to set their own ethical standards, independent of popular opinion, the state and the market,” he said. “We do have a 2,500-year-old Western tradition, with good reason, to be opposed to making this part of medical practice.”
So far, all the major medical societies in the U.S. oppose any form of voluntary euthanasia, just as the Canadian Medical Association had until 2015. But advocates for medical suicide have produced guides and handbooks instructing friendly doctors on how to get involved in medical bodies and shift their positions from opposed to neutral.
Sulmasy wonders at the irrationality of this politicized, false argument for compassion.
“It’s almost as if they are railing at the ominous and metaphysically unsurpassable reality of death, over which they have no control,” he said. “They’re saying, ‘I will get the better of you, I will kill myself.’ They don’t even see how pathetic that is in the face of the enormity of the metaphysical reality of death — to say that this is actually control. It isn’t.”
In Ottawa, Tang thinks Canada’s legal landscape now calls her to a higher, more exacting standard.
“For those people who affirm the dignity of life at all stages, we’re just going to have to be really, really good at our craft now and to take care of our patients as best as possible,” said Tang. “Usually, if a patient sees that you care about them and that you are working your hardest to try to alleviate their suffering and their symptoms, they are going to be given a new sense of hope. That will allow you to work more with them, to give you a second chance. This may help us to hone our skills for those patients who want to continue working with you and not have their lives cut short.”