Assisted suicide is not the only answer to suffering

"We operate under a false premise when we equate the suffering arising from disease, illness or disability with a loss of dignity."

The Supreme Court of Canada rules in favour of physician assisted suicide

It is eloquent, persuasive and based in law; it almost had me convinced that physician assisted dying is the correct response to suffering.

In the Carter decision, the Supreme Court of Canada ruled that a competent adult who consents to death, and has a “grievous and irremediable medical condition (including illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition” has a right to physician assisted dying.  The ruling does not restrict physician assisted dying to those who are terminally ill.

The Court found that a total ban against physician assisted dying is broader than necessary to achieve its objective of protecting  “vulnerable persons from being induced to commit suicide at a time of weakness”.  In the view of the Court, the consequences of the prohibition impinge on the individual’s right to life, liberty and security of the person.

In the words of the Court, “the prohibition deprives some individuals of life, as it has the effect of forcing some individuals to take their own lives prematurely, for fear they would be incapable of doing so when they reached the point where suffering was intolerable. The rights to liberty and security of the person, which deal with concerns about autonomy and quality of life, are also engaged. An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.”

As I read through the lengthy decision, it was difficult not to let the logic of the Court inform my belief on the matter.   It is hard to argue against the individual’s right to autonomy and dignity when I like to make my own decisions, and have no wish to endure suffering, nor watch someone else endure it.

Still, I have issues with physician assisted dying.

A different view of suffering

My attitude towards suffering differs from the negative approach towards suffering implied in the term “dying with dignity”, and endorsed in the Carter decision. In my view, the human person is created in the image and likeness of God. This divine stamp on the individual sanctifies every human life, and gives each of us an innate and inviolable dignity.

We operate under a false premise when we equate the suffering arising from disease, illness or disability with a loss of dignity. I have known people to endure each of these with great dignity, allowing their suffering to transform them, and in the process, their relationships and those who cared for them. Rather than losing their dignity, they grew in graciousness.

Archbishop Antonio Mancini of Halifax-Yarmouth, in a homily I happened to hear while visiting Halifax a few days after the Supreme Court decision, addressed our struggle to make sense of suffering.  “When there is no meaning to suffering, it is only pain, and of course people are afraid… But where there is meaning, where there is love and proper care, where there is community support, suffering can become sacrifice. Sacrifice is not just another word for ‘put up with’. It literally means…to make something “sacred”. To take suffering and to transform it with meaning is to make the reality of suffering a manifestation of the holy and the sacred.”

While this view of the relationship between suffering and dignity differs from that of the majority of Canadians and of the Supreme Court, there is the same desire to act compassionately towards those who suffer. From this standpoint, the compassionate response begins with a willingness to share, not to avoid, the suffering of another, and encompasses support and care.

For those who do not applaud this decision as one giant step forward for Canadians, and who seek an alternate response, the Canadian Conference of Catholic Bishops has issued a statement that may be helpful. The bishops recommend that legislators interpret the decision as narrowly as possible so as not to open the door to euthanasia. They urge governments and professional associations to implement policies that will protect the freedom of conscience of health-care workers who oppose physician assisted dying. And, they renew their call for universal access to quality hospice-palliative care.

Undergirding these action points is an unshakeable belief in the sanctity of human life as a reality that defines the human person, and in the power of love to ease the transition from life to death in even the most difficult of situations.

Let's talk about dying ...just shoot me is not a plan

According to a 2014 Dying with Dignity Ipsos-Reid Survey, 84% of Canadians agree “a doctor should be able to help someone end their life if the person is a competent adult who is terminally ill, suffering unbearably and repeatedly asks for assistance to die”.  While the push to legalize physician-assisted suicide has Canadians passionately debating the right to die and what it means to die with dignity, the debate has had little effect in motivating those who are healthy to prepare for their own eventual date with the Grim Reaper.

We communicate our fear of dying in subconscious ways

Research indicates that most people are fearful of suffering during the dying process. I think we communicate this fear subconsciously through actions that let us believe we can cheat death. These actions are not necessarily bad for us, and may even motivate us to continue living life to our fullest, but they do nothing to ease the way into death or make our dying easier for those we love.

One way we may communicate our fear of dying is to pretend that we are not getting older, obsessing over aging, or jealously guarding our independence, symbolized in our reluctance to surrender our driver’s license, or downsize our home.

We avoid taking practical steps to make our death and dying easier for others. Only 56% of adult Canadians have a signed will, and less than 29% have appointed a power of attorney; fewer have designated a substitute decision-maker for personal care and health matters.  We are highly unlikely to preplan our funeral, even though 75% of us believe doing so would make things easier for our family.

Even our spiritual preparation for death can be limited to our last days when our families seek out the priest to hear our deathbed confession and administer the last rites. 

We think we have lots of time to prepare ourselves to meet our maker and to get our affairs in order, even though death is the one certainty in life and the Grim Reaper lurks in the shadows.

Creating an Advanced Care Plan

The Canadian Hospice Palliative Care Association, partly in response to the public discussion about euthanasia and physician-assisted suicide, wants to shift the public conversation towards the importance of quality hospice palliative care and away from some of the more negative views of death, which, in my view, have played a significant role in shaping Canadian support for physician-assisted suicide. The organization has a suggestion that can help us prepare for our own death and dying.

It recommends that we start talking about end-of-life issues with our family, friends and health-care providers, and suggests that individuals create an Advanced Care Plan (ACP) that will provide direction for our care when the time comes. An ACP can guide us in articulating our personal beliefs and values, and can help us clarify our own attitude about dying and what constitutes a good death. It gets the discussion moving about the types of medical interventions that we would accept or reject if faced with a chronic illness, or a life-threatening illness or injury. And, it provides information on the legal requirements and documents that will enable others to act on our behalf.  An ACP is not a sign-up sheet for physician-assisted suicide or euthanasia; it is a comprehensive plan that can help us live out our life until its natural end.

While the public discourse has Canadians talking about the death and dying of a small minority, most of us skirt around the topic of our own mortality. We avoid planning for that unavoidable dance with the Grim Reaper.

The Grim Reaper can be a motivating image

The Grim Reaper, incidentally, became embedded in the European psyche during the bubonic plague of the 14^th century, when no one could forget the reality of death. It was sometimes depicted in an embrace with a young woman to symbolize that death is an integral part of life. Rather than frighten us, it is an image that can remind us to live well, to never give up on the journey towards wholeness and holiness, and to follow confidently in the footsteps of Jesus who embraced the world from the cross and shows us the way through suffering.

The conversations I have with others about death are largely superficial because the topic can become morbid and depressing. We talk about avoiding suffering, and we would prefer to die in our sleep after a long, healthy and happy life. And, should we become decrepit or senile, we joke about telling our kids to “just shoot me”, which really is not much of a plan when it comes to preparing for death and dying.

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.

Dying with dignity is more than physical

The province of Quebec has responded to the report of its  "Dying with Dignity" commission. The Quebec proposal is recommending that euthanasia/assisted suicide be decriminalized in limited and rare cases. The province is proposing that terminally ill individuals be allowed to request the help of a doctor to end their life. 

Under Quebec's proposal, an individual could make the request providing the individual is:

• suffering from an incurable disease, with no hope of improvement
• experiencing intolerable physical or psychological pain
• receiving palliative care

The proposal places euthanasia/assisted suicide within the realm of medical care; in this context, euthanasia/assisted suicide would be considered an appropriate, and compassionate level of “medical aid in dying”.

Definition

In euthanasia, a third party, such as a doctor, takes the action that ends the individual’s life, while in assisted suicide the dying person takes the final action that causes death.

Those who express support do so from a place of compassion

A recent call in show on CBC Radio debated the issue of euthanasia/assisted suicide. Callers from both sides of the debate shared their experiences.  The callers had journeyed with people they loved through debilitating diseases, and the process of dying. It was evident that this experience had profoundly affected each one of them, and influenced their opinions. Those who expressed support for euthanasia/assisted suicide were responding from a place of compassion and love.

While I do not support euthanasia or assisted suicide, I understand why many people favor the Quebec proposal, and hold the opinion that euthanasia/assisted suicide is a compassionate, and humane response to dying. We do not want to watch someone we love suffer, especially when that person is dying from a painful and debilitating disease that robs the body of its ability to function. We have a collective aversion to pain and suffering. Out of compassion for the dying, we want their suffering to end.

Equating human dignity with a properly functioning body

The discussion of euthanasia/assisted suicide is often framed in terms of human dignity, and we hear frequent references to ‘dying with dignity’.  There is a perception, and a fear that we can lose our dignity in the dying process. As a society, we are developing a vision of dying with dignity that, in my view, relies too heavily on our physical capacities.

We have come to equate human dignity with a properly functioning body. In the euthanasia/assisted suicide debate, when we talk about human dignity, we are most often referring to things like the terminally ill person’s ability to communicate, and to control bodily functions, especially eating and elimination.  A body that is in decline is seen as undignified, and an affront, robbing the individual of ‘quality of life’, and causing unnecessary suffering to the dying and those with them.

Human dignity depends on more than the vigour of the body

Most Canadians would agree that human life is precious. Many of us consider human life to be sacred.  In the Christian worldview, which I share, the human person is more than a physical body. In the teaching of the Catechism of the Catholic Church (# 364), we are animated by a spiritual soul, and we share in the dignity of the image of God. Body and spirit, precious and sacred, the human person has an innate and inviolable dignity.

A view of human dignity that relies solely on the vigour of the body takes into account only one dimension of the human person. It overlooks the psycho-spiritual dimensions of the person.  Human dignity depends on the whole person, and should never be restricted to the physical.  We do not lose our dignity when our body breaks down.

Death may be a moment of exceptional grace

Medical care, especially when caring for the terminally ill, should consider the whole person. Suffering and death, more than any other experience in life, reveals the spiritual dimension of our existence. A comprehensive debate on euthanasia/assisted suicide must include a rigorous discussion on the concept of human dignity. While death is the disintegration of the body, it may also be a moment of exceptional grace, when we discover fully and completely our imperishable dignity, and meet its author face to face.

Euthanasia: a slippery slope

Youth in Asia?

It was 1978.  The teaching assistant of my Russian Literature seminar entered the room. He sat down at the table and said, “Today we are going to talk about youth in Asia.”  My classmates and I looked at one another, puzzled. Sensing our confusion, he stood up and wrote ‘euthanasia’ on the chalkboard. “Mercy-killing,” he said. The debate was on. More than three decades later, the debate is heating up.

Last week, the Royal Society of Canada (RSC) released its report, “End-of-life decision making.” The Parliamentary Committee on Palliative and Compassionate Care also released its report. And, there is presently a legal challenge before the Supreme Court of British Columbia that seeks to decriminalize euthanasia.

Link to RSC report: http://www.rsc.ca/creports.php

Link to Parliamentary Commiteee Report: 

http://pcpcc-cpspsc.com/wp-content/uploads/2011/11/ReportEN.pdf

Euthanasia, an act of compassion or moral confusion?

Euthanasia, which literally means “a good death,” has come to be defined as “the intentional killing by act or omission of a dependent human being for his or her alleged benefit.”

The proponents of euthanasia seem to value life, just as those opposed to it do. At the heart of the push for the decriminalization of euthanasia is the desire to ease suffering for the dying or the terminally ill and their family. Some would argue that euthanasia is a compassionate action because the elimination of suffering helps people experience a good death. 

But, enshrining euthanasia in law is a dangerous path for a society tread. It can lead to the slippery slope of moral confusion regarding the value of a particular individual’s life. Who decides when a person’s life no longer has value or meaning? Who judges the quality of that life, and on what criteria?

The RSC report recommends that Canada adopt a “permissive yet carefully regulated and monitored system with respect to assisted death.”  Based on evidence from other countries, the RSC dismisses the slippery slope argument. The report states that the decriminalization of euthanasia is not a threat to vulnerable people, nor does it lead to non-voluntary or involuntary euthanasia. 

The Netherlands

These two claims are debatable. The experience of the Netherlands, where voluntary euthanasia has been legal since 1984, suggests otherwise. In 1999, the “Journal of Medical Ethics” published a paper reflecting on the results of a 1995 survey of physicians. The survey found that in 20%, or 900 of 4,500 reported cases, patients did not request or consent to having their life ended. Some of these patients were mentally competent at the time of their death, while others were not. In two-thirds of these cases, the patient and physician had never even discussed euthanasia as a possibility.

The study also revealed that physicians withheld or withdrew life-prolonging treatment in 41 % of 1000 cases of infants under one year of age because they felt the baby’s life would be unbearable. In 20% of these cases, parents were not consulted.

The paper concluded that “the practice of voluntary euthanasia remained beyond effective control,” despite regulated guidelines and the duty to report enshrined in law. Although it was illegal, physicians were carrying out involuntary and non-voluntary euthanasia.

The physicians surveyed were not bad, evil people. They believed they were acting in the best interests of their patients. They were deciding which human life had value, meaning, and quality.

Belgium 

A study published in 2010 in the "Canadian Medical Journal" looked at physician-assisted deaths in Belgium, where voluntary euthanasia has been legal since 2002. That study also found that involuntary and non-voluntary euthanasia was occurring.

Dutch Physicians Association

The Dutch Physicians Association (KNMG) released a position paper on euthanasia this fall. The KNMG paper recommends that non-medical reasons, like loneliness or financial difficulties, should qualify a person for euthanasia. The rationale is that non-medical factors also cause unbearable suffering and affect an individual’s quality of life.

It's a slippery slope

All of this points to moral confusion; the slope seems slippery to me.

In the Christian worldview, life is sacred from conception to natural death. End-of-life decisions flow from this premise. Ordinary medical interventions and treatments must always be taken to preserve life.  Therapies that deliver compassionate and palliative care are essential to preserving the dignity of the dying person and contributing to a good death.

The RSC report acknowledges that Canadians are not preparing adequately for death, and that quality palliative care is not readily available.  The Parliamentary Committee Report makes recommendations for establishing a national system of compassionate and palliative care.  This is the direction in which we should be moving.

If we want to avoid the slippery slope, we need to choose a path based on the spiritual principle that life is sacred, from conception to natural death.