Assisted Suicide, Suffering, and Slippery Slopes

Are we playing God, or just relieving suffering?

Note: This post exceeds the length that can be contained in an e-mail, so please click on the title to get the full version via the website…

I own several scythes. And I have a dark grey bug suit with a hood that I wear in the spring and early summer when I’m cutting weeds during black fly season. Julie has noted that I pretty much look like The Grim Reaper. Not a great look for an ER doc. Is euthanasia (euphemistically called “MAID”—medical assistance in dying—in Canada) a good look for doctors?

Mr. O

My very first real job as a doc was as a family doctor in a small village. As a typical rural doc, I did everything from well baby checks, to pap smears, to removing moles, to palliative care. And so it was one day—a Friday, at suppertime, after a long day in the office—I got a call that one of my palliative care patients (we’ll call him Mr. O) was struggling. I headed over.

Mr. O was elderly and had been diagnosed with pancreatic cancer, too advanced for any treatment. He knew what it meant—death. Sooner rather than later. At that time (late 90’s) palliative care was in the process of being cleaved off from the main body of family medicine to become a “specialty”. The area where I worked had a palliative care nurse, who had visited and provided the family with advice and had left meds which could be given if needed. But I was the quarterback for the palliative care team.

I arrived at his house and was immediately ushered into his bedroom by his wife, who was somewhat frantic, although trying to be stoic. The man was suffering. Horribly. It was awful to watch. His abdominal pain had become extreme through that day, he was emaciated, and he had told his wife that he wanted to be gone. He had become somewhat obtunded (“out-of-er”, in Cape-Breton-speak) over that day. He was writhing in pain, despite having had a fair amount of morphine already administered by the nurse who had left not long before I arrived.

I suggested she take him to the hospital. I could call an ambulance. Maybe something had started bleeding internally? But he had made her swear not to let him die in hospital. He wanted no more treatment, just pain relief. He wanted to die at home. Please just treat him here, she asked.

There was morphine and there were syringes. I knew how to use them. I gave him some. We waited, he writhed. “Please give him more,” Mrs. O said. I did. Still more writhing, although he was sleepier. “Please don’t let him suffer”, she said. “I’m worried if I give him more he might stop breathing”, I explained. She looked me in the eye in a way that I will not ever forget, put her hand on my shoulder, and said “Don’t let him suffer. Give him more”. I took a deep breath and gave another dose. I stayed another hour. He was finally comfortable. Snoring, finally peaceful. Her sister was on the way over. I excused myself, gave my cell number. Call me if you need me or if anything happens.

I was only 30 minutes later my cell rang. It was her. “He’s gone,” she said tearfully. “Thank you so much for what you did doctor.” I took care of the death certificate, and she called the funeral home.

I lived the next months in fear that the College of Physicians and Surgeons would come knocking. I had given him a LOT of morphine. I had almost certainly shortened his life. Was I a killer? Mrs. O didn’t seem to think so. She gave me a high-end bottle of Scotch every Christmas for the 4 years I practiced there.

The fine line between alleviating pain and hastening death

Just a couple of years before that, one of my teachers—a wonderful doctor and person —had run afoul of the medical regulators, and actually been arrested by police for hastening the death of a terminal patient. The case was highly publicized. Was I next for giving morphine to Mr. O?

The line between preventing suffering and hastening death becomes fuzzy in the last hours or even days of life for many of us. Unless you are lucky enough to die peacefully in your sleep like my dad, many patients have extreme pain, anxiety, or discomfort produced by their terminal condition.

I was also influenced by Svend Robinson and his support of Sue Rodriguez in 1993. I heard him talk at a small public event, along with several other speakers who had experienced the uncomfortable and ignominious deaths of loved ones.

One story that stuck out for me was a daughter, who had found her elderly father behind the barn. He had killed himself with a shotgun blast to his face, distraught due to a penile cancer (found on autopsy) that must have been intensely painful. She (perhaps correctly?) felt that if assisted suicide were available, it would have spared him his pain and suffering, and spared her and her family the trauma of having to find a loved one who died in such a horrific manner. (Coincidentally, Julie’s step-grandfather killed himself under cosmically coincidental circumstances, for a cosmically coincidental cancer).

Slippery slopes and mea culpas

I pictured “MAID” as something that would be done rarely, and only at the very end of life. It would be used for situations like Mr. O’s. Those already at death’s door. No possible joy ahead of them. Suffering immensely.

I didn’t want doctors to be so frightened of overdosing their patient that they didn’t adequately relieve suffering. MAID seemed like the answer. I was very vocal in my support when euthanasia was in the process of being legalized. It’s a view that I’m now much less strident about, and am embarrassed about how supportive I was. Chalk it up as one of the many things in my life where old me shakes his head and rolls his eyes at naive younger me.

What happened to change my view?

I realize now how how right people were to caution me about the slippery slope.

The first sign that we were sliding was that even by the time the first legislation was developed, it was determined that a patient had to be competent AT THE TIME OF THE ASSISTED SUICIDE. To me this was completely contrary to what I had pictured euthanasia being legalized for. Mr. O was not competent. He was near comatose. But he had spelled out his wishes clearly in advance. By the time I gave him morphine he was well beyond being able to lucidly explain to me that he wanted it. If he was well enough to do so, I would not have been comfortable in giving him something that I thought might shorten his life. This is a Catch-22: where the only people who can choose to die are those who are completely lucid and able to communicate. Which means that they can still have quality of life and may not be ready to die.

It did not take long to see clear evidence that the medical profession had indeed slid down the slippery euthanasia slope. A perfectly lucid, in fact articulate, cancer patient in Halifax chose death when she still clearly had more life to live.

"While her death was the beautiful, end of life experience she wanted, it was earlier than she would have liked,"

A Canadian couple had a physician kill the 2 of them, together, after gathering and joking with family.

The next morning, at eight o’clock, Chris and his siblings arrived at the house as their parents finished their game, and the family sat together, drinking coffee. They cried, but they also laughed. Soon the doctors arrived, and one of them, Dr. White, took Noreen and Bob aside separately to assess their mental states. At 9 o’clock, the two shuffled their way into the house, their kids behind them. At the last minute, Noreen called for a family picture, everybody laughing at the absurdity of the moment. The couple lay down on their bed, Noreen on the right and Bob on the left, and clasped their hands between them. They were given a moment of privacy to say their last words to each other, then, with their children at their feet, were first put to sleep, and then, after the family stepped out, the doctors helped them leave the world together.

This is NOT what I argued for when I supported euthanasia. Or at least it was not what I had meant to argue for. Like many situations, what was said and what was heard were perhaps different.

The greatest meaning comes from the darkest times

My great aunt died recently, almost 97 years old. She was quite a lady. She had worked a full career as a nurse in Toronto before retiring back to Liverpool, N.S. I got to spend a few days with her as she was dying of a terminal cancer (for which she had chosen not to be treated). Although she was drowsy, often nauseated, weak, and uncomfortable, we had some wonderful moments. We had some memorable hugs and laughs. She told me some stories from our family that I had never heard, that maybe I can pass on down through the generations. I cherish that time with her. Time we never would have had if she had decided to be euthanized before her natural end.

My mom, too, died of an extremely painful condition (on my top 10 list of things I don’t want to die of), but being with her at the end was one of the most meaningful experiences of my life. I held her hand as she slipped away over several hours. I whispered in her ear that I loved her. That she was a wonderful mother to us. I whispered about beautiful memories. Birds we had seen. Places we had been. She squeezed my hand. Eventually the squeezes stopped, but I still whispered. A quicker death would have stopped her pain earlier. And taken that experience away from us. Would the world be better off? Or poorer for it. Would I be less traumatized? Or more barren and bereft?

How many more family parties did Noreen and Bob have in them, had they not been euthanized? Would they have passed on a story to a child that may have changed his or her life? Or a hug that would have always been remembered? Could they have passed on some piece of important family history, that is now lost?

There are numerous novels, short stories, and horror movies that explore what it would be like if we humans were to know the date of our own death in advance. The take-home message of most is that such a world would be a dystopia. We start to die the moment we are born. Our hourglass holds a finite number of grains of sand. We don’t know how many. Humans are meant to struggle until the end. To do our best for as long as we can. We are not meant to “know” when we will die any more than we are meant to know what comes after.

Not allowing patients to suffer unnecessarily is different from planning the moment they will die.

Remind me again - is my job to STOP suicide, or assist it? Should we euthanize depressed patients?

As an ER doc, I have seen many hundreds of patients who are “suicidal”. One of Milburn’s Rules of ER is “Most patients who tell you they are suicidal aren’t really suicidal. Most patients who are really suicidal don’t tell you they are suicidal”. Put another way, most people who tell me they are suicidal do so because they are looking for help. They don’t actually want to die. The ones who are seriously suicidal know that if they want to finish the job, they shouldn’t announce it in advance.

One of the worst nightmares of any physician is having a patient kill himself. It is a horrible feeling when it happens. Why didn’t we see the signs? What should we have done differently? What should we have asked? Are we even good enough to be a doctor?

Now, as we turn the page on chapter one of assisted suicide in Canada, we are set to expand eligibility to include those with mental health issues (not to mention “emancipated minors,” and possibly even newborn babies with disabilities).

Bizarrely, I may soon be in a position where if a depressed patient tells me he is fine, then goes home and kills himself, I am a terrible doctor and may face disciplinary action. But if the same depressed patient tells me he wants to kill himself, and I don’t agree to help him, I may face disciplinary action. How can these 2 things be true at the same time?

The injunction against human euthanasia is ancient

The Hippocratic Oath contains an injunction against euthanasia. It states “I will give no deadly medicine to any one if asked, nor suggest any such counsel”. Did we throw this away at our peril? Was this one of Chesterton’s Fences, one that we tore down at our peril? Was this particular fence keeping us from stepping onto a slippery slope?

I know physicians who assist suicide. They are well-meaning people. Compassionate and caring, and wanting to relieve suffering. One refers to participating in assisted dying as “the most meaningful and fulfilling part of my practice”. (I personally find this a little creepy. Euthanasia to me is similar to abortion. At best, it is unfortunate but necessary. At worst, it is a sin. I wasn’t “fulfilled” by giving Mr. O morphine. It was agonizing and heartbreaking.)

Slippery slope arguments are easy to make, and to weaponize, and are often wrong. In some ways, we live our whole lives walking carefully on slippery slopes. Never lie, but it is OK if you are hiding someone from the Nazis. Thou shalt not kill. But what about killing someone who is about to shoot your child?

REMEMBER YOUR HIPPOPOTAMUS OATH!!

That said, was assisted suicide a slippery slope that we never should have ventured out onto? Did Hippocrates understand an inevitable slide that I was blind to?

Perhaps we should note from history that the eugenics movement (of which euthanasia was a central part) was in vogue both in North America and Europe only a few generations ago. Our society rightly veered away from this after the horror of Nazi Germany, and the lessons learned during the Nuremberg investigations and trials. We forget this at our peril.

Who qualifies?

Part of the problem around assisted suicide is the folly of thinking we can create objective parameters around who “qualifies”. When we legalized euthanasia it was understood that it needs “rules” to prevent abuse. And we empowered the state to create these rules. The state now defines when a life is too miserable to continue, or else sentences an individual to keep on living even if he doesn’t want to. Bureaucrats define the value of human life.

What is a “grievous and irremediable condition” that could qualify someone for euthanasia? I have met patients with horrible arthritis who can’t get a knee replacement for technical reasons and who can barely walk, but who have great quality of life and no desire to end it. They have families, friends, hobbies, and plans for Christmas. I’ve had other patients with similar arthritis who are socially isolated, depressed, and directionless. Their arthritis is indeed “grievous and irremediable”. But if they “qualify” for euthanasia, is it really being approved on the basis of the patient’s arthritis? Or inability or unwillingness to cope with it?

All humans suffer. It is the fundamental truth of existence. The first Noble Truth of the Buddhists. Who are we to define for another when their suffering is intolerable? How can we possibly draw a legal or technical line on something that is by definition completely personal?

Who benefits?

There are already concerning signs that part of the push for euthanasia in Canada is as a cost-saving measure. Our healthcare system is in its death throes. The best way you can support medicare, the argument goes, is by offing yourself. No costly operations, medications, tests, or hospital stays. One and done. The patient stops suffering, and we taxpayers save money. Win-win!

There is a great article by The New Atlantis HERE that outlines how the poor, lonely, and disenfranchised of our society are most likely to be the ones that we euthanize. And there is an humourous take by JP Sears HERE, which is absurd (kind-of, but you will see how it connects to the New Atlantis and CBC articles).

This whole assisted suicide thing got really weird really fast. Good thing we’re going to teach kids that it’s completely normal to euthanize people. Nothing to see here! (Thanks Matt Aldred)

Is life too difficult to bear, or too precious to waste?

Life is hard. Aging is hard. We ache in our joints. We become less able. We get short of breath. We lose our teeth. We lose our loved ones. We accumulate burdens during our journey through life in the same way that we accumulate horseflies during a walk in the summer—by the end there are a swarm of them biting at us.

But in another sense, as we near our year, month, day, hour of death—life becomes more meaningful, more intense. Every moment becomes more precious as we realize we have less of them ahead of us. Those last stories, last whispers, last tears. That last hug, or squeeze of the hand is the most precious; the most indispensable.

As someone who swings toward the libertarian side of that specific political balance-beam, I support patient autonomy, which logically means supporting an individual’s right to leave life on his own terms. Does that mean it’s OK for a doctor to kill him? When we argued for “right-to-die” legislation, was the quid-pro-quo state-controlled—and perhaps state-encouraged—euthanasia? Does the pursuit of the laudable goal of autonomy inevitably lead to overuse of euthanasia? Can we discard the bathwater of state overreach while keeping the baby of personal autonomy?

Does assisting suicide make us more humane? Or does it make us less human? One thing is for certain: we have already slid far beyond where I ever thought we would venture on this slippery slope. If I could turn back the hand of time, I think I would have argued to leave Chesterton’s Fence intact.