Some problems with "An Act Respecting End-of-Life Care"

Quebec proposes to enact Bill 52, "An Act Respecting End-of-Life Care", as early as September 2013. The Act will enshrine "medical aid in dying", including assisted suicide, as part of the continuum of medical care at the end-of-life. 

Medical aid in dying will be available according to a set of controlled measures specified in the Act. My understanding from watching an interview with Quebec's Minister of Social Services, Veronique Hivon, is that these measures are intended to limit abuses, while providing a compassionate and caring response to those individuals who seek to hasten their death.

Bill 52 has implications for all of Canada regarding end-of life-care. The arguments are nuanced and require careful analysis.

While I recognize that Bill 52 expresses a deep concern for those who are suffering from an incurable disease at the end-of-life, I am not convinced that legislating a form of assisted suicide is the most compassionate response of a just society.

Autonomy and dying with dignity
In my view, the two most common arguments in favour of assisted suicide - autonomy and dying with dignity - are fundamentally flawed.

We rightly value and want to protect our personal autonomy. Yet, there is very little that we can ever completely control.  Our decisions are never made in a vacuum; our interactions with others, with society, and with events influence our decision-making.  The decisions we make affect not only our own self, but others as well.  

An individualistic determination to control one’s death at the end-of-life exceeds the realm of personal autonomy.  When we are well enough, we want to live; we eschew suicide.  When physical deterioration limits our self-sufficiency, we may want to die.  At that point, we may want another to do the very thing we would not do our self – take our own life. Legislation would frame this desire as an entitlement based on compassion, autonomy and dignity. 

In an earlier post, I expressed my opinion on dying with dignity. To reiterate, dying with dignity is almost always referred to in connection with progressively debilitating diseases; ALS and Alzheimer’s, for example, are frequently mentioned.  There is an underlying presumption that progressive diseases rob the individual of their dignity as suffering increases and the body deteriorates.  There is a perception that physical decline equals a loss of dignity.

The sacredness of the invidivual

We are in danger of developing a view of life that relies too heavily on the vigor of the body and its ability to function. This view limits the sacredness of the individual. It overlooks the emotional, psychological, and spiritual dimensions of the person. It excludes the possibility that the natural process of dying may also serve a metaphysical purpose.

Every individual has an innate and inviolable dignity that disease, suffering and death cannot erase.  The dignity of the individual manifests itself in the totality of body, mind and spirit. End-of-life care must always proceed in a manner that recognizes and reverences the sacredness of life and the dignity of the whole person. 

Experts in palliative care say that pain can be successfully controlled and managed. Yet, depending where we live, less than 30 percent of Canadians who are dying have access to or receive appropriate palliative care. Rather than focusing on assisted suicide, the creation of an accessible and universal palliative care program would help to ensure that the dying receive reverential care appropriate to the dignity of the human person.

Abortion should be safe, legal and rare

"For me, the child developing within the womb is not an exclusive reproductive right, but a gift entrusted to the care of both sexes."

With the recent death of Henry Morgentaler, abortion is again making its way into the public forum. Rationality is often missing from the discussion. The language from both the pro-life and pro-choice camps is frequently highly charged with emotion and vitriol.
In my most recent column, I strive to present an informed and measured approach to abortion.

In the ultrasound images, I thought I recognized the nose

I was excited about being a grandmother from the beginning, but when I saw the ultrasound images of the little one at 19 weeks, I was overcome with emotion.  We could clearly see the little feet, only millimeters long, and in the profile of the face, I thought I recognized the nose.  I stand in awe before the wondrous miracle of life.

Not everyone shares my wonder. There are some who have no compunction about terminating the life of the little person developing in the womb. For them, abortion is a woman’s reproductive right, a simple procedure as benign as removing a wart.  For me, a child developing within the womb is not an exclusive reproductive right, but a gift entrusted to the care of both sexes.

The polls

With the death of Henry Morgentaler, the famous abortion activist whose determination to provide safe abortions for women changed Canada’s abortion law, the highly divisive issue of abortion is once again attracting public attention in both traditional and online media formats.  Despite the public discussion, Prime Minister Stephen Harper refuses to allow any debate on abortion in Parliament, and a January 2013 Angus Reid poll concluded that although “Canadians have continued mixed personal feelings on abortion…the appetite for true legislative action is lacking.”   Two-thirds of Canadians polled are unwilling to re-open the debate on abortion.

The reluctance to formally debate abortion is puzzling given the interest in the topic and the findings of recent polls.  Could a lack of awareness about the absence of abortion laws in Canada explain, in part, our hesitation?

The Angus Reid poll notes “45 percent of respondents mistakenly assume that a woman can have an abortion only during the first three months of her pregnancy”.  Thirty-five percent support no restrictions on abortion, 5 percent would ban abortion, and 60 percent “express a preference to regulate abortion in different ways”: during the first trimester, in cases of rape, when the mother’s life is in danger, or if the fetus has serious defects.

A 2012 Ipsos Reid poll had similar, albeit confusing, findings: 49 percent of respondents said that there should be no restrictions on abortion, while 45 percent felt that abortion should be permitted only in “special circumstances”.  Yet, in the same poll, 60 percent of respondents favored gestational limits on abortion.

Coercion is a factor in many abortions

The Angus Reid poll reported that 43 percent of men and only 27 percent of women favor the status quo. This last finding hints at a problem with abortion that does not often make its way into the public discussion: coercion is a factor in a high percentage of abortions. 

While it is not always men who force a woman to have an abortion, the male partner plays a critical role in the decision.  Others who may exert pressure on a woman to abort include her mother, her father, a doctor or another medical professional. 

A 2004 study, reported in the “Medical Science Monitor”, found that 64 percent of women who had an abortion in the United States did so because of pressure from others. This was despite the woman’s desire to have the child.  Coercion is something to bear in mind when extolling abortion as a woman’s prerogative over her reproductive rights.

Coercion may also play a role in female feticide, which is becoming a cause of concern in Canada. Sex selective abortion is another area where the majority (60 percent of Canadians overall and 66 percent of women) believes there should be laws to “outline whether a woman can have an abortion based solely on the gender of the fetus” (Angus Reid poll on gender based abortion).

Not a rare procedure

Abortion in Canada is not a rare procedure. In 2012, the Canadian Institute for Health Information reported 64, 641 documented abortions in Canada, excluding Quebec.  Since 1979, there have been an estimated 3.5-4 million abortions in Canada.

Still, we remain ambivalent. Harper has read the mood of Canadians correctly. Collectively, we lack the political will to address the legislative vacuum created when the Supreme Court reversed Morgentaler’s conviction and struck down the abortion law in 1988.

Legal, safe and rare: its time to work on the latter

While I would prefer that we treasured and protected the miracle of life at every stage, Canada cannot go back to the days when the criminalization of abortion forced women into back alleys. Abortion, to paraphrase Hilary Clinton, should be legal, safe, and rare. Canada has the first two covered; it’s time to work on the third.