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Assisted Dying: A medical student’s perspective

Assisted Dying: A medical student’s perspective

I would like to introduce you to June Duong, Meds ’19. It was a pleasure to invite her to write a guest blog to share her thoughts on assisted dying.

 

I first became aware of the debate surrounding assisted dying six years ago for a high school law course. The task was to choose a court case that went all the way up to the Supreme Court of Canada and provide arguments both for and against the decision made, while taking a personal stance on one side of the issue. Six years ago, there was no Kay Carter or Gloria Taylor. The case that I studied, analyzed, and wrote about was that of Sue Rodriguez in 1993.

Rodriguez was a 42-year-old woman suffering from amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. She challenged Criminal Code Section 241(b) which criminalized assisted dying. Rodriguez argued that it infringed on three sections of the Canadian Charter of Rights and Freedoms, making it unconstitutional. Section 7 of the Charter includes the rights to life, liberty, and security of person. Does Section 7 also include the right to choose how one ends their life? Who does this life belong to: myself or the state? Section 12 of the Charter ensures the freedom from cruel and unusual punishments. Is being forced to live out a menacing and degenerative illness a form of cruel and unusual punishment? Is our healthcare system inflicting this fate on our patients? And lastly, Section 15 of the Charter guarantees equality. With suicide having been decriminalized in Canada since 1972, does leaving Section 241(b) in place discriminate against those who are physically incapable of taking their own lives? Is having no assisted dying options for the physically disabled an acceptable safeguard? These were the questions that the Supreme Court faced and there was no easy answer, with the final decision coming down to a 5-4 split1.

The arguments against legalizing assisted dying gave me pause, as they should have and still do, but many countries have managed to legalize assisted dying successfully without any evidence of compromising the safety of vulnerable groups2,3. So it wasn’t like Canada was venturing into completely unchartered territories (no pun intended) because there was plenty of legislation that we could have turned to for help in writing our own. Ultimately, at 16-years-old, I sided with Rodriguez. I truly believed then, and I still do, in the importance of autonomy. Now that I am a physician-in-training, my understanding and appreciation for autonomy has only grown. As medical professionals, we are here to help the patient make their own decision, not make it for them. A lot of these decisions aren’t easy to swallow, such as a patient who refuses treatment. Aren’t we supposed to do everything we can to save a patient? Isn’t that what our profession is sworn to do? Maybe back when the medical field was still paternalistic was it acceptable for a doctor, the one who knows all and knows best, to impose their will on their patient. But now it would be wholly unacceptable. You are not saving the patient, you are condemning them to a life they did not want to live. We are not in this profession to make the easy choices, we are here to make the right choices.

On April 14, the government introduced Bill C-14 to address the Supreme Court ruling that Section 241(b) did indeed infringe on the rights and freedoms guaranteed by the Charter. This new ruling was quite simply a reflection of changing public opinion. In 2015, 77% of Canadians support assisted dying for those who are terminally ill, up 10% from just four years ago4. The Supreme Court had seen this case before: the Taylor case was a revival of Rodriguez’s. Canadian society wasn’t ready in 1993, but we are now. Lawmakers didn’t have a choice, the law must keep up with public opinion. And so must the healthcare profession else we let our patients down.

Dean Reznick already covered what the new legislation entails in his blog: https://meds.queensu.ca/blog/?p=3335. My personal opinion is that it is a good starting point for assisted dying legislation. If this bill were to pass, I am not confident that it will last long before another court challenge, maybe by a 17-year-old or maybe by someone with dementia who wants to leave an advanced directive. However, the reason why I think this is a reasonable bill is because of the circumstances surrounding it. The Supreme Court decision that knocked down Section 241(b) of the Criminal Code was made on February 6, 2015. The ruling would not come into effect for another year, giving Parliament some time to come up with legislation to regulate assisted dying. But during this time, there was a handover of power from the Conservatives to the Liberals, who were left with a very limited time window to come up with this bill. An extension was granted, giving the Liberals until June 6, 2016 for the new bill to pass. Conjuring up new legislation to regulate a very sensitive topic is not easy, and I think the Liberals did what they could. It was either play it safe in hopes of getting legislation in place by the deadline, or risk having the Criminal Code section knocked down with nothing in its place.

Physicians, right-to-die advocates, patients, and just about everybody else interested in this debate have been holding their breath since the Supreme Court decision. And I feel like some of us still are even after the bill was revealed. The narrow scope of the bill almost guarantees a challenge in the future, but as with every task that seems insurmountable, all we can do is take it one step at a time.

I hope that you enjoyed reading June’s perspective as much as I did. As always, I invite you to share your thoughts by commenting on the blog, or better yet, drop by the Macklem House…my door is always open.

  1. http://publications.gc.ca/Collection-R/LoPBdP/BP/bp349-e.htm
  2. http://www.nejm.org/doi/full/10.1056/NEJM199611283352227
  3. http://jme.bmj.com/content/33/10/591.short
  4. https://www.thestar.com/news/gta/2015/08/28/77-of-canadians-support-ass…

Kay H. Bransford

Thu, 06/22/2017 - 13:59

It’s encouraging to read your post. When my mother, in a moderate stage of multi-infarct dementia, broke her hip and the doctor told me I had to lift the Do Not Resuscitate (DNR) before she would preform the surgery to alleviate mom’s pain, I was flummoxed. I knew mom would most likely return with broken ribs and in a deeper stage of memory loss. Thankfully, a geriatric consult helped me navigate my choices. However, I felt the doctor was more worried about their stats then the right options for my mom. This is a complicated issue indeed. Here’s to one step forward.

Kay H. Bransford

June Duong

Thu, 06/22/2017 - 13:59

No decision is an easy one which is why open discussion, such as you had with the geriatric consult, is so important. Thank you for your comment!

June Duong

Elizabeth Hopkins

Thu, 06/22/2017 - 14:00

Thank you for your post…I’ve been a proponent of the right to die since the mid 70’s when the name I read about was http://www.nytimes.com/1985/06/12/nyregion/karen-ann-quinlan-31-dies-focus-of-76-right-to-die-case.html?pagewanted=all Karen Ann Quinlan. I watched my parents both suffer horribly and die of bowel cancer; I watched my next door neighbour die of ALS.

Now I have my own battle with Assisted Dying. I’ve been suffering with the consequences of preventable medical errors that left me with an ostomy, severe emotional and physical complications and severe PTSD and depression.

I thank you for writing this thoughtful piece.

Elizabeth Hopkins

Craig Goldie

Thu, 06/22/2017 - 14:00

Thank you for the post, June. Autonomy is an extremely important ethical consideration in medical decision making. I would encourage you and your classmates to also focus on the CanMEDS role of health advocacy to ensure patients are all able to access appropriate healthcare, particularly palliative care. We want to ensure that assisted death decisions are not made due to the inability to get adequate help for symptom management but rather the intractability of suffering as defined by the patient themselves, despite access to the best care possible.

I certainly hold no illusions that I can alleviate all suffering in all of my patients, but I do believe people have inequitable access to care (particularly in rural locations) and that absolutely needs to be addressed in conjunction with medical assistance in dying. Hopefully the newly-formed Ontario Palliative Care Network (OPCN) will help to reduce this inequality and ensure all Ontarians (and all Canadians) have access to palliative care expertise at home and in outpatient and inpatient settings. This needs to include physicians as well as many other professionals such as nursing, social work, dieticians, occupational therapists, physiotherapist, spiritual care practitioners and of course centered around the patient, their family, and their community. In many ways, this is a public health issue.

We also hope to educate our colleagues and other health-care professionals (and the public) in the important tenets of palliative care – both in symptom management but advanced care planning, to allow people to live as well as possible until they die. Previously that was until they died naturally, now it may be under circumstances of their choosing.

I hope that June and her classmates will excel in caring for patients in all stages of life, including those with terminal illnesses.

Craig Goldie

Hi Dr. Goldie,

I couldn’t agree more with what you have said. What is encouraging though, is that the focus on the assisted dying bill has also generated a lot of discussion about palliative care and end-of-life decisions in general. I am hopeful (maybe naively) that patients won’t be choosing between assisted dying or inadequate symptom management, but rather that this is another option for those patients who are truly and immensely suffering despite the best possible care.

June Duong

Donna Marie Letourneau

Thu, 06/22/2017 - 14:01

Thank you for your well spoken words June. I am one that agrees with assisted death although many that I know disagree with me, especially those friends of mine that also attend church. I have conflicted feelings however having watched my grandmother and mother both suffer with Huntington’s disease. No amount of medications would help to prevent the suffering they endured. I watched as they progressively lost their ability to walk, talk, swallow, function. But through it all the chorea movements were non stop. I felt like my mother was running a marathon every day but without the ability to adequately hydrate or nourish her body to sustain the calories she burned. I wonder how much pain was she really in? she cried all of the time, she was depressed and she felt extreme guilt that she may have passed this on to us. (she didn’t, we are all negative) My mother wanted assisted death, she said that would be her wish over going into a nursing home but she didn’t get her choice. What I have are memories of years of suffering.

Donna Marie Letourneau

Hi Donna,

Nobody wants to watch their loved ones suffer and it’s unfortunate that the medical profession couldn’t grant her wish of assisted dying at the time. This topic will always be controversial and there will always be people (physicians included) who disagree, but it is an option that must be available and discussed. I am hopeful that in the future, patients won’t be forced to endure the immeasurable suffering you speak of. Thank you so much for your comment and your personal story.

June Duong

Stephen McNevin

Thu, 06/22/2017 - 14:02

To be truly autonomous and to consent competently is an ideal that is rare in real life in my experience when individuals are in a moment of great suffering. This is most evident in those who contend with mental illness and for those vulnerable adults and children with cognitive differences. Why would we allow those vulnerable souls to die with far less due process than we used to apply as a state when we condemned others to death. Indeed the process was so error prone we stopped the death penalty long ago.For me these are deep waters and the potential for abuse is so great that PAID should be an extraordinary act only after a full judicial review which is as it is now.

 

Stephen McNevin

Hi Dr. McNevin,

I think that physician-assisted dying will always be viewed as an extraordinary act. The decision to end a life will hopefully never come easy. My personal opinion is that a physician, who has built a relationship with the patient and gotten to know who they are as a person, is in a better position to discuss end-of-life care than a judicial review. The feeling of having strangers determine your fate with full authority can’t be pleasant. However, your concerns are extremely valid and there isn’t a single solution that anyone can provide, which is why I believe the narrow scope of the bill is a good place to start. Thank you for thoughtful comment.

June Duong

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