by Raphaella Friedman:
The ability to determine the time and manner of one’s own death was once thought of as supernatural, a power reserved for the fates, not the government. But advances in medicine and technology that allow physicians to extend life almost indefinitely are changing perceptions of mortality. People are living longer, and as religiosity gives way to more secular societies, public policy options like euthanasia and assisted suicide are becoming more attractive to those suffering from terminal illness.
While touted as the most humane approaches to death by their advocates, euthanasia and physician-assisted suicide challenge many deeply engrained notions about the sanctity of life, the obligations of the state, and the patient-physician relationship. Some of these policies have taken hold in more secular societies, but they are not without controversy.
For Quebec, a province that has long been linguistically and culturally distinct from the rest of Canada, the adoption of a progressive approach to end of life care may prove to be yet another factor that sets it apart from the rest of the country. And if the current trend holds, Quebec may be the first province in Canada to grant citizens the right to die.
Quebec is not the first place to grapple with the debate over the legalization of euthanasia and doctor-assisted suicide. Such practices are legal in four places around the world, though each has its own approach. Oregon has legalized doctor-assisted suicide, in which a physician prescribes a pill or tells the patient which button to press to end his or her life. Switzerland too allows assisted suicide, but does not require a physician’s presence. The Netherlands and Belgium have both adopted euthanasia as an end-of-life option, allowing doctors to inject medications or press a button themselves, actively ending their patients’ lives. This form of assisted suicide is most controversial, as it gives power to the physician. For some, it amounts to little more than consensual murder.
Those who fear paternalism and the marginalization of minority groups look no further than the Netherlands when defending their argument. Involuntary euthanasia rates are uncomfortably high in the Netherlands, prompting concerns about lax restrictions and vulnerable populations. Out of the 9,700 annual requests for euthanasia or assisted suicide, 3,700 are granted, only 300 of which are assisted suicides. Of those euthanized, approximately 1,000 were involuntary: The patient did not or could not consent to the procedure. If a similar system makes its way to Quebec, “we’re in serious danger of losing our respect for human life and human dignity,” said Margaret Somerville, ethicist and founding director of the McGill University Centre for Medicine, Ethics and Law.
Despite the controversies surrounding end-of-life care in other countries and a reluctance to address the issue in Canada as a whole, a special provincial governmental commission in Quebec entitled Mourir dans la Dignité, or Dying with Dignity, has begun to tackle end of life issues ranging from palliative care to euthanasia. It has been accepting presentations and written statements from experts since 2009, and now the commission is conducting public hearings in 11 cities on the subject of death. They plan to file a formal report sometime in 2011.
The head of the commission, Member of the National Assembly of Quebec Geoffrey Kelley, said that the commission’s facilitation of complex discussion of life and death boils down to a single question: “We’re asking, if you’re in pain and suffering at the end of life, can government do something about it, yes or no?”
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It is not a question that other provinces are comfortable with addressing. Dr. Yves Robert, the secretary of the Quebec College of Physicians, acknowledges that Quebec stands alone from the rest of Canada in promoting this conversation: “We are in some ways a distinct society, being mostly French, with values which are probably closer to Western Europe, where there are already some countries legalizing euthanasia.”
In fact, while the College of Physicians has actively endorsed a conversation about euthanasia and the right to die, the Canadian Medical Association (CMA) has closed the topic. Official policy is made explicit by the CMA’s 2007 statement: “Canadian physicians should not participate in euthanasia or assisted suicide.”
“In Quebec, they have been most willing to challenge public policy,” explained Susan Eng, advocacy chair for the Canadian Association of Retired Persons (CARP) and board member of the Canadian Civil Liberties Association (CCLA).“They have the most willingness to challenge the idea that there should be only public pay medicine. They are actually prepared to deal with the issue of private paid medicine.” And now they’re taking on end-of-life care.
In Quebec, what was once an intensely religious society has slowly evolved into one of the most secular in the world. The Catholic character of Quebec began to erode in the 1960s, when the province transferred the responsibilities of health care and education from the Roman Catholic Church to the new government and created a welfare state. As religion waned, a sense of Quebec nationalism grew.
In 1991 a separatist political party, the Bloc Québécois, was founded. It is this party, which continues to advocate for an independent Quebec, that has raised the issue of euthanasia, one which politicians in other provinces have shied away from.
In April 2010, Bloc Québécois MP Francine Lalonde introduced Bill C-384 in the Canadian House of Commons, which called for the legalization of assisted suicide and euthanasia for those experiencing extreme physical or mental suffering. Despite Lalonde’s concerted efforts, the bill was soundly defeated 228-59. Bill C-384 falls in line with the Bloc’s history of taking controversial stances on issues, promoting Quebec’s unique values, needs, and interests. While euthanasia is certainly not grounds for a separatist movement and the Bloc does not purport it to be the party’s main issue, there is no doubt that the acceptance of euthanasia would further distinguish Quebec from the rest of Canada.
The last time Canada broached the topic of end-of-life care was in 1993, when a woman named Sue Rodriguez brought a case before Canada’s Supreme Court. Rodriguez suffered from Lou Gehrig’s disease and was told she had three years to live. In 1993, well into the later stages of her illness, she begged the Supreme Court to grant her what no other court would: the right to die.
Rodriguez’s lawyers made the case that prohibiting someone to help Rodriguez end her own life when she was no longer physically capable of doing so herself deprived her of her right to personal liberty and security. They also posited that it constituted cruel and inhumane treatment, also forbidden under Canadian Civil Code.
Her appeal was denied. The Supreme Court ruled that the state’s obligation to preserve the sanctity of life conflicted with her request. Canada has maintained this position ever since; current law bans assisted suicide, and accessories to an assisted suicide face up to 14 years in prison. In 1994, Rodriguez took her life with the help of an anonymous physician. Her case is not an isolated one.
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“He asked me to come around on a Sunday; he said he wanted to die at 2:00 in the afternoon,” said Dr. Phillip Nitschke, an Australian physician and pro-euthanasia activist who administered the world’s first legal, lethal injection in 1996. “He wanted the drug to be injected. It was very hard. I built a machine where I could press the button on my little laptop computer that would deliver the drugs, which took me out of that immediate space. He was able to hold his wife and he died in her arms … It was quite difficult. Obviously I’d fought hard to get the law in”—Nitschke had actively fought to have a legal euthanasia law passed in Australia’s Northern Territory—“but then the time came when it had to be used.” Nitschke has hardly looked back since. By the time that the Northern Territory repealed its decision to legalize euthanasia in 1997, Nitschke had already administered lethal doses to four patients, earning him the less-than-affectionate nickname “Dr. Death.”
That same year he founded Exit International, an organization devoted to presenting and promoting end-of-life options, including assisted suicide and euthanasia. The organization holds workshops in Canada, as well as in Britain, the United States and Australia. In these workshops, Nitschke teaches his audiences about specific methods that will ensure a peaceful, painless death should their health or physical condition deteriorate irreparably. Where the government refuses to bend the rules of end-of-life medical care, Nitschke believes he provides a valuable service in teaching a medical approach to painless suicide.
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An elderly man with dark circles under his eyes sits on a bed. He talks about the choices he’s made in his life, from what car he drives to the woman he chose to marry. He then stares at the camera intently: “What I didn’t choose was to be terminally ill. I didn’t choose to starve to death because eating is like swallowing razor blades. And I certainly didn’t choose to have to watch my family go through this with me.” He concludes pleadingly, as the camera zooms in, “I’ve made my final choice, I just need the government to listen.” Exit International’s logo flashes at the end.
The ad has been banned from Canadian airways, but thanks to Youtube it has been viewed more than 43,000 times. The Television Bureau of Canada refused to air the ad, not because of the potentially disturbing subject matter, but rather because of the Exit International logo: It cannot direct traffic to an organization or website that promotes suicide by teaching suicide techniques. While the ad itself does not undermine societal values protected under the Civil Code and, in fact, represents a balanced account of the dilemma of a terminally ill patient, apparently the organization does. Lose the logo, make some other minor changes, and it’s back on the air, the Bureau said.
Nitschke found their logic absurd. “People are very surprised that these ads attracted any censure whatsoever. It’s very soft, very mild, and one would hardly find that it’s a confronting ad,” he said dismissively. “And to try and argue that it might somehow or other convince people to go off and commit suicide—which is really why it’s restricted, the fear that it might encourage suicide—is bizarre.”
In light of Canada’s strict legal repercussions for accessories to assisted suicide, Nitschke’s goal is to make sure that family and friends don’t have to go to jail just because their loved one didn’t prepare an exit strategy while still physically able to do so. But his personal views on euthanasia and assisted suicide go beyond the constraints of the law.
“[Assisted suicide] is not an option that should just be reserved for people who satisfy strict criteria. I believe that any adult who has a considered and rational perspective should have access to the best ways and means of carrying it out,” said Nitschke. “Now, that is a view which upsets some people in the movement because they say it will upset politicians and make it harder to bring about legislative change.”
However extreme Nitschke’s views, this question of self-determination and individual liberty is at the heart of the legal debate.
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Beyond public policy, the moral consideration of whether one citizen should be allowed to take another’s life proves to be thorny. By making suicide easy and accessible to nearly all who seek it, Nitschke’s organization departs from other pro-euthanasia groups. Most countries have rejected the view outright. However, in Belgium, assisted suicide and euthanasia are available to those with unbearable mental conditions, as well as to people who are simply tired of life, despite being physically healthy. This is individual liberty at its most extreme.
“Do you really have no moral problem with a doctor killing patients?” asked Somerville. Like Nitschke, Somerville is an Australian. She too has joined the argument over euthanasia in Canada, and the two have debated each other in the past.
In her written submission to the Quebec Commission on Dying with Dignity, Somerville argued, “We need to explore not only the practical realities, such as the possibilities for abuse, that allowing euthanasia would open up, but also, the effect that doing so would have on important values and symbols that make up the intangible fabric that constitutes our society.”
Somerville argued that the physician-patient relationship would be severely damaged by allowing doctors to kill patients. Physicians are denoted as healers, and also have more opportunities than the average citizen to kill, claimed Somerville. She refuses to use the words euthanasia or assisted suicide. “The danger of euphemism is that it blocks out moral intuitions about what is right and what is wrong. It makes us feel differently,” she said. “If we describe doctors as warm and fuzzy you have one reaction; you have a different reaction when you talk about doctors killing people.”
While the Quebec College of Physicians does not endorse euthanasia, it does not rule it out entirely either. It simply wants law to more accurately reflect the realities in the field. “In our criminal code it’s a black-and-white issue. There is no other way to interpret it in the criminal code other than it being a murder. But there may be exceptions,” said Robert. He points to the problem of technology extending life past its expiration date.
“Is this the best way to handle care for a person?” he asked. “We may have to change the usual way of thinking that medicine has to prolong life as long as possible.” Eng agreed, pointing to the problem of the high cost of extreme end-of-life care. “That kind of medical intervention is extremely expensive, and the cost-benefit of it needs to be re-examined, especially as that intervention is painful,” she said.
In the absence of assisted suicide, there is the alternative of simply ending treatment, in which case “the person is allowed to starve and dehydrate to death, which takes several days of agony. What the hell is that about?” said Eng, her otherwise professional tone abandoned in a burst of unexpected emotion. Moral questions evaporate at the bedside; dignity is the only thing clearly in focus. “You can’t blame the doctor for not wanting to take on the liability. And so, what do you do in the meantime? You’re standing at the hospital bed, what are you supposed to do?”
There is agreement on at least one thing: the importance of both the physician and patient’s role in decision-making. By presenting euthanasia as the inalienable right of the autonomous patient, the Bloc’s bill “reduced the role of the physician,” according to Robert. “It does not promote the best decision-making process. The will of the patient has to be considered, without a doubt, but professional opinion has to be considered too.”
Nitschke disagreed: “I don’t think that profession itself should stand in the way of something that the broader public clearly wants. I don’t think any profession should stand in the way of decisions people want to make about their own death.”
Somerville believes that even opening the debate about whether one human can kill another is a grave mistake in which individualism takes precedence over important societal values. When forming a position on the issue, she tells people to ask themselves the following two questions: ‘How would I not like my great-great grandchildren to die?’ And ‘What values do I want to pass on to the world of the future?’
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Despite deep-seated disagreements, official proceedings in Canada have remained surprisingly civil for a debate that entails life and death. Little fanfare or protest have accompanied the public hearings thus far.
Doctors, academics, organizations and private citizens have come out on all sides of the issue. “What’s refreshing about this debate is that it’s not a partisan debate,” Kelley pointed out. “There’s not a liberal side, not a conservative side. People are pleased that their parliamentarians are grappling with an issue that has a very direct impact on their lives.”
The discussion is holistic. A current governmental online questionnaire looks at a variety of end-of-life care options, like palliative care and the state of nursing homes, in addition to euthanasia. However, some consider the inclusion of euthanasia distracting. “I think that the debate on these issues in some ways is premature,” said Abby Lippman, a fellow at McGill’s Institute on Biotechnology and the Human Future. “We should provide people with the care that they need at the end of their life before we go into issues of how do we make that [end of life] happen faster,” she said. “Until that basic stuff is done, I consider this discussion dyslexic.”
In written statements, the Canadian Medical Association has also recommended enhanced palliative care services, better suicide prevention programs, and a Canadian study of medical decision making before considering such a “fundamental reconsideration of medical ethics.”
Others have called for special attention to how a euthanasia policy could affect vulnerable groups, like the elderly and mentally disabled. Kelley acknowledges that some of these concerns would have to be addressed in any sort of legislation. “The message you could send to seniors, that somehow their lives are no longer useful, and the notion of being a burden on one’s family, is very disturbing.” It is one that he believes the commission and Quebec’s government will ensure does not result.
The CARP, on the other hand, has urged greater public discourse on end of life options. “There are issues that people don’t like to talk about,” said Eng. “But the reality is, our people, our membership, deal with it everyday, and often privately and without much community support.”
In a CARP poll in September 2010, 71 percent of the 3,000 members who responded, all above the age of 65, supported assisted suicide or euthanasia. Eng places great weight on that number: “It wasn’t 50/50. That’s a serious amount of people.” She added, “I don’t read that as a clamor for suicide, I read it as a fear of bad death.”
Kelley also described the discussion of euthanasia as unavoidable. Many Canadians have watched loved ones become slaves to the machines that keep them alive and are struck by fear of a bad death in a sterile hospital. “There is a nostalgia for a peaceful country death, as death has become so medicalized,” explained Kelley.
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Choosing the time and manner of one’s death is, at the end of the day, a very personal issue. Putting aside the policy making, there remains the inevitable and individual struggle with mortality that every human must face. It is these encounters with death that have brought euthanasia to the forefront of the political agenda. Kelley is heading up this commission a few years after watching a hospice assist both of his parents in dying; MP Francine Lalonde’s effort to legalize euthanasia has run parallel to another struggle: her own against cancer. In September she tearfully announced at a press conference that she would not be running for reelection because of a recurrence of bone cancer.
Whether Quebec will become euthanasia’s beachhead to Canada and North America remains to be seen. While some might say that Quebec has opened a Pandora’s box, the question of dying well and what that entails is universal. As Eng put it, “This is the kind of thing society has to grapple with.”
Raphaella Friedman ’12 is a Political Science major in Trumbull College. Contact her at raphaella.friedman@yale.edu.