Tuesday, January 15, 2013

Online euthanasia debate: Canadian Medical Association Journal

The following letters represent an online debate between Dr. Will Johnston, the Chair of the Euthanasia Prevention Coalition BC (EPC-BC) and Dr. Gregory Robinson a board member of Dying with Dignity Canada.

After reading these letters, you should write your own letter and submit it online.

The online debate began when Dr. Johnston responded to an article by Dr's Flegel and Fletcher entitled: Choosing when and how to die: Are we ready to perform Therapeutic Homicide that was published in the CMAJ on Dec 11, 2012. The first letter was titled: More on Assisted Suicide. Gregory Robinson then responded to Will Johnston with a letter titled: Assisted Dying in Canada. Will Johnston recently responded to Gregory Robinson with a letter titled: Re: Assisted Dying in Canada.
Dr. Will Johnston
Dr Will Johnston - CMAJ Dec 11, 2012, EPC-BC (Chair)

I agree with Drs. Flegel and Fletcher that we must speak up now regarding assisted suicide and euthanasia.1

On June 15, 2012, in the Carter decision, a provincial judge rejected the Supreme Court’s Rodriguez precedent and purported to legalize assisted suicide and euthanasia throughout Canada.2 I am not a lawyer, but a plain reading of the decision reveals questionable assumptions and a lack of understanding of the needs of patients.

The linchpin of the decision is that suicide is not illegal in Canada and is therefore a right.2 But Canadian laws strive to prevent suicide and even authorize forcible treatment for those who are suicidal. The judge in the Carter case admits that “suicide and attempts at suicide are serious public health problems that governments are trying to address.”2 Thus, the idea that suicide is a right that society must assist with, as long as it is not a crime, is confused.

The judge then declares that the law prohibiting assisted suicide discriminates against people who are too disabled to kill themselves. She also speculates that the law might prompt the plaintiff to commit suicide sooner, while able, which would shorten her life.2

This Orwellian reasoning, presuming a right to die based on the right to (unshortened) life, ignores the fact that anyone, including the plaintiff, who commits suicide will suffer from a shortened life. How many years of life would Canadians lose if a legal assisted suicide risk lurked constantly in home and hospital?

A friend of mine recently died from a brain tumour. He said that when he first received the diagnosis he might have opted for assisted suicide, had it been available. Two years later, he was an activist against legalization. In the last article he wrote, he states “[Canada’s] laws exist to protect me and people like me from abuse when we are at our lowest and most vulnerable.”3

As a family doctor, I see elder abuse. Sadly, a desire for money or an inheritance is often involved. Worse, the victims protect the predators. An older woman knew that her son was robbing her blind and lied to protect him. Why? Perhaps family loyalty, shame or fear that confronting the abuser would cost love and care.

Predators take their victims to the bank and to the lawyer for a new will. With legal assisted suicide, the next stop could be the doctor’s office for a lethal prescription. How are we going to detect victimization? A troubling survey,4one of several which uncovers nonconsented euthanasia deaths in foreign jurisdictions, failed to alarm the judge in Carter v. Canada.2

1. Flegel K, Fletcher J Choosing when and how to die: Are we ready to perform therapeutic homicide? CMAJ 2012;184:1227. FREE Full Text

2. Carter v. Canada (Attorney General), 2012 BCSC 886. No. S112688.

3. Coppard J. From Afghanistan to activist against assisted suicide: “These things are worth fighting for.” Vancouver (BC): Euthanasia Prevention Coalition; 2012. Available: www.epcbc.ca/2012/06/from-afghanistan-to-activist-against.html#more (accessed 2012 July 17).

4. Chambaere K, Bilsen J, Cohen J, et al . Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ 2010182: 895–901.Abstract/FREE Full Text

Dr. Gregory A. Robinson - CMAJ Dec 24, 2012

Board member of Dying with Dignity Canada.
Dr. Gregory Robinson
Dying With Dignity
Response to Dr. Will Johnston MD - Letter to the CMAJ Dec. 11, 1012, page 2018. In his incendiary letter, Will Johnston cherry picks his facts and colours his comments to provide a stunningly false portrait of medically-assisted dying, or as the study he references calls it "therapeutic homicide". The use of language this inflammatory is surely our first clue that we are not reading something that is reasoned and rational.

Will Johnston notes that suicide is a major problem in our society. And I wholeheartedly agree. Of course suicide is a major public health problem. But that is not germane to this discussion. Advocates of the right to die with dignity deliberately distance themselves from the word suicide because it is simply not what we are talking about. Suicide is about individuals, generally suffering from mental health issues, who tragically cut their lives short. There is a world of difference between those tragic situations and those of individuals who face the prospect of horrific suffering at end of life and knowing they are going to die, who are simply asking for the right to humane assistance to die peacefully. Will paints an Orwellian picture of victims being taken to doctors offices where they are coerced to die against their will. Frankly I don't know of any physician - nor can I imagine one - who would be complicit in such an act. Peer reviewed studies show that the safeguards work, and reporting tells us that over two-thirds of requests for support in The Netherlands are declined. The picture Dr. Johnston paints is nothing but a caricature of the real situation where compassionate health care providers work with patients who are suffering greatly and asking for assistance to die as a very last resort. Publications which have purported to show shortcomings in other countries (1) have been shown to be seriously flawed and riddled with errors (2).

I find it in keeping with the rest of this letter that the well researched, well reasoned and well written decision of Justice Smith of the BC Supreme Court is summarily dismissed. After hearing expert testimony from Canada and around the world and seeing experts from both sides cross-examined, a process that did not go well for many of the crown's witnesses, Justice Smith was able to reach the carefully considered conclusion that she did. And she has clearly reached this decision after a careful and thoughtful weighing of the evidence - evidence and conclusions that she carefully lays out in her 300 page decision(3). Anyone who takes the trouble to read her careful decision with an open mind - which I encourage you to do - will undoubtedly reach the same conclusion.

How will these laws impact our profession? A fascinating study out of Oregon reports that nurses characterize doctors, 5 years after the Oregon's Death With Dignity Act was passed, as better on a number of fronts include more knowledgeable about pain medications, more competent in caring for hospice patients and more interested in caring for hospice patients(4).

There are those who worry about the adequacy of safeguards and the criteria for eligibility - and we should listen and ensure we address these concerns in any legislation that is written. But when we have someone such as Dr. Will who argues, as I have heard him publicly do, that there are no possible safeguards that we could put in place to make this process safe, then we know we have left reason behind and should be very wary of his words.

Gregory Robinson, MD MHSc CCFP FCFP FRCPC Board Member, Dying with Dignity Canada

(1) Pereira, Jose, Legalizing Euthanasia or Assisted Suicide, the illusion of safeguards and controls, Current Oncology, Volume 18, no 2, 2011.

(2) Downie, Jocelyn et al, Pereira's attack on legalizing euthanasia or assisted suicide: smoke and mirrors, Current Oncology, Volume 19, n0 3, 2012.

(3) Carter v Canada (Attorney General) 2012 BCSC. Please contact info@dyingwithdignity.ca to request a link or pdf.

(4) Goy, Elizabeth R et al, Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years, Palliative and Supportive Care, 2003, Cambridge University Press, 215 - 219.

Dr. Will Johnston
Family Physician - UBC Family Practice Clinical Assistant Professor

I would like to thank Dr. Greg Robinson for his interest in my letter of Dec. 11, 2012, page 2018. His comments are a bit excited, and so I will begin by pointing out to the reader that "therapeutic homicide" was the phrase used in a CMAJ editorial a few months ago. [1] If Dr. Robinson finds that usage "inflammatory" perhaps he should take it up with Drs. Flegel and Fletcher, who wrote it, rather than concluding that he can't trust my reasoning any further because of it.

My letter [2], in reponse to that editorial about the Carter assisted suicide case, pointed out that far from the "right to suicide" declared by Justice Smith we have laws that struggle to deal with the suicide problem, and that concocting a "right to suicide" out of the Charter Section 7 "right to life" was not sound thinking. If you kill yourself, we call it suicide, and only "assistance in dying" if we are trying to spin the issue.

This spin is particularly misleading because assisted suicide and euthanasia as proposed by some "right to die" activists are not necessarily just about someone who is dying. Jocelyn Downie, the brains behind the pro-euthanasia strategy in Canada, put it this way in 2008: "[T]here are many individuals whose lives are no longer worth living to them who have not been diagnosed with a terminal illness.... There is no principled basis for excluding them from assisted suicide. "[3]

If we are not interested in the fate of each and every person who has died anywhere inside a regime of assisted suicide or euthanasia, we have abdicated our duty as physicians and citizens. It is irresponsible to wave off the thousands of unconsented deaths described objectively in Europe [4,5], as though they were just so much acceptable collateral damage in the quest for new social norms.

We should likewise be wary of bland reassurance arising out of the Oregon experience where there is no requirement for oversight at the time of lethal ingestion, no recording of disability status of the victims, and yearly destruction [6] of the application paperwork and death reports which rely on the recollections of the prescribing physician - who showed up for the death only 8 times in the 71 deaths under the Oregon Act in 2011. Only 1 of those 71 people was referred for formal psychiatric or psychological evaluation. [7] The operation of the Oregon Act is, if not shrouded in secrecy, deficient in transparency: even the police cannot find out if a particular death was an arranged suicide or who was present. [8]

If Dr. Robinson had the patience to read Justice Smith's judgment (which is not 300 pages as he reports but rather 395 pages long) he would have found her, toward the end, designing a suicide system with safeguards that would show the world how Canadians would avoid the mistakes of others. Sadly, after announcing that any acceptable assisted suicides would be "stringently limited", the judge offers eligibility criteria so subjective in nature as to open the field for further litigation and expansion, and authorizes the attending physician to misstate the cause on the death certificate to avoid mentioning assisted suicide.

This misrepresentation is at immediate odds with the sort of rigorous oversight which would be needed to minimize abuse. Our inaugural assisted suicide system appears to have been an instant failure of rigor and transparency.

Finally, Greg tells us that he is pleased to see that Oregon's assisted suicide laws have made doctors better at caring for hospice patients. In his referenced source [9] , nurses noticed some Oregon hospice care improvement (though more nurses thought physician comfort with opiate use had deteriorated) over a five year period during which there were surely similar improvements throughout the modern medical world.

Again, this is not about people who have to be dying - this is about you and me and our loved ones, and our skepticism about radical changes to health care that could see some Canadians steered not away from suicide but toward it. Parliament has rejected the idea as bad public policy, let us hope the courts soon reject it as bad law.

Will Johnston MD Vancouver
Chair, Euthanasia Prevention Coalition - BC.

[1] CMAJ August 7, 2012 vol. 184 no. 11 First published June 25, 2012, doi: 10.1503/cmaj.120961

[2] http://www.cmaj.ca/content/184/18/2018.1.full

[3] Downie, J and Bern, S, "Rodriguez Redux" (2008) 16 Health Law Journal 27 p 49

[4] Van Der Maas PJ, Van Delden JJ, Pijnenborg L, Looman CW. Euthanasia and other medical decisions concerning the end of life. Lancet. 1991 Sep 14;338(8768):669-74.

[5] Kenneth Chambaere, Johan Bilsen, Joachim Cohen, Bregje D. Onwuteaka-Philipsen, Freddy Mortier, and Luc Deliens ,Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey CMAJ June 15, 2010 182:895-901; published ahead of print May 17, 2010, doi:10.1503/cmaj.091876

[6] http://www.choiceillusionoregon.org/p/oregon-data-access-retention.html

[7] See top of page 3 at: http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx

[8] http://www.choiceillusionoregon.org/p/oregon-data-access-retention.html

[9] Goy ER, Jackson A, Harvath T, Miller LL, Delorit MA, Ganzini L., Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years. Palliat Support Care. 2003 Sep;1(3):215-9.

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