Physician-assisted death

 “If you don’t have liberty and self-determination, you’ve got nothing… and this is the ultimate self-determination, when you determine how and when you’re going to die when you’re suffering (People v. Kevorkian, 2001).” Nearly 15 years after Dr. Jack Kevorkian’s infamously spoken words, physician-assisted dying remains a controversial issue in Canadian society. In 2013, polls demonstrated that 32% of Canadians were either ‘somewhat opposed’ or ‘strongly opposed’ to physician-assisted death (PAD), and only 29% ‘strongly supported’ PAD (Environics Research Group, 2013). However, in 2015, the Supreme Court of Canada ruled in favour of PAD, citing: “the prohibition on physician-assisted dying infringes upon the right to life, liberty, and security of the person in a manner that is not in accordance with principles of fundamental justice (Carter v. Canada, 2015).”

Advocates of PAD have invoked several theories to expound their position, namely those of an ethical and practical nature. The ethical argument essentially holds that s.7 of the Charter of Rights and Freedoms, whereby everyone shall be granted “life, liberty, and security of the person,” mandates the right to choose PAD, particularly when suffering from a grievous or irremediable condition (Charter of Rights and Freedoms, 1982). Rejected is the philosophy of the ‘absolute’ sanctity of life, where life in all states is considered superior to death. Rather, patient autonomy is considered superior; life is continued as long as it is considered worth living by the patient (National Health Service, 2014). The practical argument holds that an absolute prohibition on PAD provides only two options for those patients with irremediable conditions: 1) committing suicide prematurely in a dangerous and often undignified fashion, or 2) suffering through the progression of their disease until death. Therefore, PAD is the more practical and reasonable option, when appropriate (Carter v. Canada, 2015). The practical argument extends further to question the distinction between: a) treatment cessation; b) pain management; c) terminal sedation (e.g., severe burn victims nearing death); and d) assisted death. When informed consent is provided, we are justified in administering treatments a), b) and c) in order to prevent suffering, even if this treatment may hasten death, and these treatments certainly are not prohibited (Carter v. Canada, 2015). If no absolute prohibition against a), b) or c) exists, should not d) be permissible, as justified by the same merciful moral principle?

Arguments in opposition to PAD have emerged in the form of three positions: 1) religious opposition; 2) the slippery-slope theory; and 3) medico-ethical arguments (National Health Service, 2014). Subscribers to religious arguments prohibiting PAD invoke several tenets to justify their opposition. Many religions consider human life a ‘gift from God’ and a sacred, unique endowment; thus no individual possesses the authority to violate the inherent dignity and value of human life by taking the life of another, notwithstanding intent. Perhaps the most commonly cited argument in opposition to PAD is the ‘slippery slope’ theory. Subscribers to the theory affirm that permitting PAD to the terminally ill initiates the descent down a ‘slippery slope,’ whereby the permissibility of PAD is extended to those who are disabled, mentally ill, or ‘tired’ of life (British Broadcasting Corporation, 2009). Indeed, an ominous tone reverberates among those who decry PAD as heralding the end of palliative care. Such pessimism need not exist, however. Several countries (e.g., Netherlands, Belgium) and American states (e.g., Oregon) have drafted legislation legalizing PAD. These regions have not identified any patterns legitimizing the slippery-slope theory (Carter v. Canada, 2012). In fact, in assessing the legitimacy of PAD, Justice Lynn Smith stated: “the evidence from other jurisdictions shows that the risks inherent in legally permitted assisted death have not materialized in the manner that may have been predicted (Carter v. Canada, 2012).” Additionally, “After legalization, the number of LAWER [termination without explicit request] deaths has significantly declined in both jurisdictions [Netherlands, Oregon]. This evidence serves to allay fears of a practical slippery slope (Carter v. Canada, 2012).” Citers of medico-ethical arguments maintain that existing foundational medical codes of ethics (e.g., Hippocratic Oath) prohibit taking the life of a patient, notwithstanding intent. However, the erudite scholar will recognize that the most commonly cited ‘first do no harm’ principle does not appear in the Hippocratic Oath. Moreover, the modern Hippocratic Oath states: “If it is given me to save a life, much thanks. But it may also be within my power to take a life. This awesome responsibility must be faced with great humbleness and awareness of my own fragility,” thus rendering the argument irrelevant under these circumstances (Johns Hopkins University, 2015).

PAD is a public health issue, particularly with regards to the fundamental principles of social justice and equity, as well as the allocation of health resources. Public health ethics advances a consequentialist perspective, whereby ‘good’ health outcomes are promoted and ‘bad’ health outcomes are prevented. Therefore, the public health perspective seems a glaring contraindication to PAD (Faden, R., Shebaya, S., 2015). However, such conflict is mitigated if one considers the principle of social justice, emphasizing the significance of the individual citizen’s right to make medical decisions regarding his/her own body, as well as the equitable access to medical resources (Faden, R., Shebaya, S., 2015; Canadian Public Health Association, 2016). Importantly, conscientious objection to PAD by public health institutions, whereby the result is the complete denial of service, undeniably constitutes an inequitable barrier to accessing health care, and therefore violates several founding principles of public health ethics, including social justice and equitable care (Incardona, N., Bean, S., Reel, K., & Wagner, F, 2016). Moreover, the application of ethical public health principles extends further to question: 1) the moral threshold necessary for conscientious objection (i.e., can public health institutions, akin to individual citizens, conscientiously object to PAD?); and 2) whether public health institutions receiving governmentally allocated financial resources have an obligation to provide access to all the legal health care options available to Canadians (Incardona, N., Bean, S., Reel, K., & Wagner, F, 2016).

Notably, I have not once in this paper applied the term ‘physician-assisted suicide.’ This is not insignificant; rather it signifies my perspective on the issue more broadly. Not only do I reject the notion that PAD is a form of ‘suicide’ rather than dignified death, I also strongly believe in patient autonomy, freedom of choice, and in those patients who express discontent with the grievous progression of their illnesses and the quality of their lives. As a future physician, I believe it is my duty to both perform and provide PAD as a legitimate treatment option for appropriate patients.