On June 5, the province of Quebec adopted the controversial Bill 52, also known as the “end-of-life-care bill,” which would legally permit doctors to actively participate in the death of terminally ill patients suffering from physical or psychological pain. This came after a vote of 94-22 in the National Assembly, effectively making it law, and will take somewhere between 12 and 18 months to implement. So while it’s clear this is historic for Quebec, there remains an understandably charged debate amongst physicians, legislators, and citizens.
Euthanasia laws aren’t exactly a new concept. It’s legal in Luxembourg, the Netherlands, and Belgium (even for children). Physician assisted suicide (PAS) is also legal in several countries like Albania, Germany, Switzerland, and four US states: Oregon, Washington, Montana, and New Mexico. The distinction with PAS is that the doctor does not actually perform the action. It’s akin to your doctor handing you a lethal dose of morphine and looking the other way.
Euthanasia, on the other hand, requires a physician to be present, perform the procedure, and ensure everything runs smoothly, thus incorporating them into the process. Quebec would allow doctors to do the deed, but according to Quebec lawmakers it’s not euthanasia, per se.
“Medical aid in dying refers to the fact that it is always in a medical context and in the form of aid asked by the person,” Veronique Hivon, a member of the National Assembly who coauthored and cosponsored the bill, told VICE. “The term euthanasia does not imply that it only comes as a request.”
In Belgium, euthanasia is legal, and if poor old aunt Susan is on a whole set of machines and incapacitated, the family can make the decision on her behalf. What’s unique about the Quebec bill, according its authors, is that that wouldn’t be allowed to happen, as the request must come from the patients themselves. "Nobody can ask for it except the person," Hivon said.
In fact, there’s a whole set of similar ironclad restrictions and qualifications you have to meet if you want to get government-sanctioned suicide, which are outlined in section 26 of the law. For example, you must meet the legal age limit, you have to be capable of giving consent, you have to suffer from an incurable serious illness, it must be in an advanced state of irreversible decline, and you have to suffer from “constant and unbearable physical or psychological pain which cannot be relieved in a manner the person deems tolerable.” According to Hivon, the patient would also need a second independent medical opinion and—like everything else related to government—they need to fill out a form. This form can be filled out by a third party if you’re physically incapable but mentally cognizant.
These safeguards bring reassurance to proponents, but to critics they give faulty justification to a procedure they feel has no place in medicine. “It’s just not good for society to have people who are legally allowed to kill other people,” Dr. Catherine Ferrier, the president of the Physicians Alliance Against Euthanasia, tells me. For her, the issue centres on defending those most vulnerable, and laws of this kind not only endanger them, but also are inspired by fear and apprehension rather than compassion. “Euthanasia is driven by a fear of the whole dying process. How do you respond to fear? You try and control it, but you lose a lot by doing that; it’s not something you can cut off and not have repercussions.”
Image via Flickr user armymedicine.
Dr. Derryck Smith is a clinical emeritus professor of psychology at the University of British Colombia, and a board member of Dying with Dignity, a member-based charity focused on education and support for the choice-in-dying-movement. He interprets the bill as “a humane piece of legislation that alleviates endless suffering at the end of life.” He points to Dr. Donald Low, a Toronto physician who stated his case via YouTube for sensible euthanasia legislation only eight days before he eventually succumbed to a brain tumor. He also notes that these are tested waters, “It mirrors legislation that is in place in Belgium and Oregon, etc," Smith says. It’s nothing new, and it’s going to give Quebecers assistance in dying when they’re in the ravages of pain.”
Somewhat unsurprisingly, Ferrier’s opinion is the one most present in the Canadian medical community. A survey by the Canadian Medical Association found that a clear majority—44 percent—would refuse to assist a death compared to only 16 percent who said they would participate. While the bill itself is supported by a majority in the National Assembly and by the general public, the sentiment is not shared by those on the front lines.
“For many people who answer, they answer that they want it, and it’s because they or someone they know has had a bad experience,” Ferrier says. “Their care wasn’t managed properly, so they are afraid. They say ‘I’d rather be dead than go through what my aunt went through.’ We should improve care, and it’s foolish to jump to killing people.”
When asked why physicians would support the bill, Ferrier cited her personal experience, “The further you get from the dying the more likely you are to support it. If you’re in radiology you may support it, but those working close to the elderly and dying overwhelmingly reject it." Ferrier’s claims are indeed supported by statements from those in palliative care.
While medical practitioners may oppose the law, that doesn’t seem to bother supporters in the least. According to Smith, change rarely comes from medical professionals; it’s the public and elected officials acting on their behalf that alter the zeitgeist. “Physicians are nervous,” he says. "They have not yet been trained in how to deal with a request to die, or the actual procedure itself. Over time, more and more physicians will become more comfortable with it. The same thing happened with abortion. It was public pressure that brought that into the fold and not the leadership of the medical community.”
Image via Flickr user consumerist.
So public pressure may be enough, but what about dignity? For many people, this debate is less about whether it’s morally right or wrong, but about having the freedom to make an informed choice about how you die. To some, the notion of being at the mercy of the medical process and consumed with bureaucracy without a prospect of a peaceful and controlled exit sounds horrifying and undignified. Smith looks at dignity as synonymous with autonomy and individual choice. In this case, it comes from your capacity to dictate the terms of your demise, and being unable to do so is what’s undignified.
“Dignity means you are in charge of your own death at a time of your own choosing. It’s an issue of autonomy, and of being able to choose. The problem is that choice is unavailable. After all, if you were given the choice most would choose to die in their own homes surrounded by loved ones. But that’s something that’s afforded to very few people.”
Yet that’s not how critics of the law understand dignity. Many of us are going to age differently, and some of us may slip gradually into senility, or our mind may remain lucid while our bodies deteriorate. Either way, it’s inevitable that we’ll become more dependent on others. So perhaps we shouldn’t equate independence with dignity, and conversely, dependence on others as undignified. If we conclude that those who are dependent on others are undignified, what does that say about those medically disabled and living life to the fullest? As Dr. Ferrier points out, “If someone is dependent on someone else, that doesn’t mean they have less dignity. The notion that you have less dignity when you are sick and dying is a false understanding of what dignity is.”
One thing both sides can agree on is the need for more palliative care. It’s a large field with increasingly more physicians specializing in alleviating pain, keeping patients comfortable, and easing discomfort at the end of life. The practice itself was brought to North America in the 1970s by Dr. Balfour Mount, a Canadian physician, who remains vehemently opposed to euthanasia. Alarmingly, the current percentage of Canadians that have access to this type of care is about 16-30 percent. As Ferrier puts it, “we should focus on improving this type of care. Poor management at the end of someone’s life is what’s causing this push towards euthanasia.” But Smith cautions that universal access to palliative care is a long way off, “Everyone wants more palliative care, and I support palliative care. But we can’t wait for everyone to have palliative care before we get this legislation because we’ll never get it. It’ll take forever.”
Going forward, countries all over the world must cope with aging baby-boomers. So we’re left with difficult choices about how to offer dignity when we’re unsure what it means, or how to provide a semblance of personal choice to someone who may be incapable of thinking clearly. Confronting death head-on for yourself and your loved ones is a long and arduous procedure. At this rate, it’s possible you could have something similar to “medical aid in dying” on your deathbed. Just be sure to hand in all your forms in triplicate, dot your I's and cross your T's before you do check out.
Doctor-Assisted Suicide Is Officially Legal in Quebec | VICE (external - login to view)