Monday, November 30, 2015

Tom Koch: Provide real alternatives rather than a fatal injection.

This article was published by the Huffington Post on November 30, 2015.
Tom Koch

By Tom Koch, who is an ethicist, author and gerontologist.

The first person who asked me to kill him was my then 72-year old father. If he couldn't work and couldn't drive, what was there left to live for, he asked. "Lots," I said in refusing his request. "I'll show you."

He died peacefully in his sleep five years later.

My oldest brother, seeing our father in decline, asked me to promise to kill him as "an act of brotherly love" if he ever became infirm. During a period of depression resulting from an adverse prescription drug reaction, he refused hospital-based treatment. Instead he put his affairs in order and killed himself, suicide by pistol.

There have been others who wanted my help in dying after amputations, cancer diagnoses, while struggling with multiple sclerosis, paralyzing strokes, and a range of other incapacities.

I told each my job was to help them live as fully as possible despite their limits. That meant fighting for the best possible counseling, palliative (pain control), rehabilitative, psychiatric and social services available. I told each of them that before they gave up, they should try a life that while different could still be worthwhile.

In striking down the section of the Criminal Code that makes "aid in dying" illegal, the Supreme Court justices argued last February for individual autonomy and choice. The courts "pro-choice" judgment made overly simple what is in fact complex. If choice is our goal, we first need to address the reasons people with limits think life has lost its meaning. That's the basis of current challenges to Quebec's law legalizing what the Dutch call physician-assisted or directed termination.

A 74-year-old woman told me she doesn't want to die in pain as others have. "If I get there, end me," she said recently. I told her (and have told others) palliative medicine has come a long way and promised her pain would be treated. And, yes, I can make that promise given the state of medications today if -- a big if -- they're administered by professionals expert in their use.

Some years ago following a stroke, a woman looked down at her body, paralyzed on one side, and said to me that she didn't want to live. I told her she would improve with therapy and time and if she wanted to die today she might not tomorrow, or next week.

She lives, ten years later, with some paralysis but without pain. She uses a cane and has other mechanical aides. She is a volunteer advising new stroke patients of the possibility of life with a body some of whose parts do not respond.

A young amputee lost his right leg in an accident and could not see a future without football, baseball or dancing at parties. It took weeks to get him to accept rehabilitation, and eventually prosthesis. He's alive and well today.

The point is two-fold. First, what we request today or this week, following a grievous injury or serious diagnosis, may not be what we'll want in a month or a year. All those paralyzed by spinal cord injuries go through a depressed period of suicidal thinking. Over two-thirds find, after two years of counseling and rehabilitation that life is at least equally good, if different.

It is not "paternalism" to insist the newly injured or diagnosed take the time to adjust. It is good care and a recognition born of experience that the depressed and fearful patients does not yet have.

The second point is there is no real choice when pain control is absent or inadequate; when rehabilitation is minimal or simply unavailable. Where counseling and support are absent depression is a constant and death seems an increasingly welcome alternative.

Canada has no national program to assure a balance between "aid in dying" and assistance in living despite restrictions. While most major hospitals provide at least some pain management the demand far exceeds the ability to provide relief. In rural areas expertise is limited or non-existent.

Similarly, we have no national rehabilitation program to assure every Canadian receives the best possible rehabilitative services to strengthen the limbs that have been weakened and accommodate to the new realities of a limited body.

Nor do we adequately support the families and friends who assist our fragile citizens on a daily basis. If the newly limited feel themselves a burden on family and friends then, like Willy Loman in A Death of a Salesman, they'll see a quick death as the honorable thing.

In law it's called a predicate act or cause. It's the context in which decisions are made. People usually seek aid in dying because we have not provided aid in living. And if we believe the Supreme Court's insistence on choice, before offering an easy death we need first to assure the support is there for a life with dignity despite restrictions.

In crafting law in this area, Parliamentarians need to insist that jurisdictions offering physician-assisted termination first assure adequate support for the fragile is in place. Where that is not in place, there will be no real choice at all.

Some will say this is simply unaffordable. It will take too long to assure the resources for all Canadians facing limiting conditions. But, if we believe in choice we have to afford it. We have no alternative if we accept the Supreme Court's call for real patient choice. Think of it as infrastructure spending, a predicate act permitting people real alternatives other than a medically delivered, fatal injection.

Without, there is no real choice at all.

If you -- or someone you know -- need help, please call 1-800-273-8255 for the National Suicide Prevention Lifeline. If you are outside of the U.S., please visit the International Association for Suicide Prevention for a database of international resources.

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