Wednesday, July 3, 2013

Reflection needed on whether Bill 52, on ‘medical aid in dying,’ (euthanasia) would result in abuses in Quebec

The following letter was written by Margaret Somerville and published in The Montreal Gazette on July 3, 2013.

Margaret Somerville
Margaret Somerville, Montreal Gazette - July 3, 2013

Re: “ Véronique Hivon’s long battle” (Gazette, July 2)

Bill 52 would not just extend access to “end-of-life care”­ which includes “medical aid in dying,” a euphemism for euthanasia­ to “dying patients,” as your reporter states, but to all “end of life” patients who fulfill the necessary criteria.

Among other requirements, those criteria require that a person “suffer from an incurable serious illness; suffer from an advanced state of irreversible decline in capability; and suffer from constant and unbearable physical or psychological pain which cannot be relieved in a manner the person deems tolerable.” The bill also provides that “a person may not be denied end-of-life care for previously having refused to receive a treatment or procedure or having withdrawn consent to a treatment or procedure.”

In other words, the person being euthanized might not have exhausted all reasonable pain and suffering management treatments; seems to have a complete discretion to decide whether they regard their pain ­or it might be the pain management interventions ­ as tolerable; need not be terminally ill; and might be mentally, but not physically, ill. Many disabled, old, frail and vulnerable people would fulfil these latter two criteria, in which regard it merits noting that Bill 52 provides that “medical aid in dying” may be administered in “residential and long-term care centres” or a person’s home.

Your reporter, in painting what I regard as an unrealistically reassuring picture of the effect of Bill 52, also states that a “second doctor must also agree (with the treating doctor that “medical-aid-to-die”) is the best course (for the patient).” In fact, the second doctor need only “confirm that the criteria (for access to “medical aid in dying”) have been met.” In light of the fact that Bill 52 reflects a values stance that gives priority to radical individual autonomy, it would be inconsistent with the spirit and goals of the bill for doctors to override a patient’s wishes to have access to “medical aid in dying,” with their own view of what is the “best course” for the patient.

For reasons such as I describe, we need to consider deeply whether Bill 52 would create a very serious danger of the abuse of vulnerable people, especially those who are old.

Margaret Somerville
McGill Centre for Medicine, Ethics and Law


Winston said...

Why should palliative care be mandatory, Margaret?

Winston said...

Somerville's secular case dismantled on Amazon:

"Her "Case" is Sorely Lacking. Vapid, Hollow Assertions Aplenty.

Somerville begins her behemoth case against assisted dying with a quote from Jeff Kennett, the former Premier of Victoria, Australia. Not only is this a completely fringe statement that is a red herring, but it does nothing to support her case (which is supposed to be against VOLUNTARY deaths between consenting individuals). Kennett claimed that the elderly should be "escorted out of life" with a minimum of fuss. Aside from Kennett (and the anti-choice lobby) I could not find any evidence of anyone else advocating such an extreme position. But I suppose it would be too much for Margaret to recognize the extreme irony of her own position. Anti-choicers are the ones who want to mandate a "natural" death on everyone.

In her first chapter, The Song of Death, Somerville acknowledges that at least some hard cases do warrant assisted dying, but legalising it will change our norms. In doing so, she is advocating a continuation of the status quo, in which a privileged and wealthy minority can choose when, where and how to die, but everyone else is caught and seized by a system that mandates a "natural" death upon them (usually while being medicated to the gills with analgesics and utterly torpid, unable to even use their mental faculties).

I do give Margaret credit for understanding that the modern trend is for most people to die from chronic and/or painful illnesses (including MND, some cancers, full-blown AIDS, `natural' deaths from locked-in syndrome, quadriplegia, metastatic cancer, etc). But her claim that "society has rejected killing for two thousand years" is patently false. Wars were frequent, those who didn't profess belief in the dominant religion of the time were killed either directly or through social ostracism. The death penalty was taken for granted as a requisite instrument of society (even though evidence has shown that it does not deter heinous crime, at least in the US).

Winston said...

On pages 35-36 she lambasts Derek Humphrey's Final Exit, citing the "colossal risk" that such practical instructions regarding suicide methods is likely to somehow instigate a rash of suicides among the depressed. This is absolute bunkum. The suicide rate in the US did not increase after the tome's publication. The only real difference was in the methods of suicide. While all would wish to reduce suicide rates, a blanket prohibition on assisted suicide will do little but encourage hangings and DIY helium kits (to say nothing of one-way voyages to Switzerland). I think we can all agree that overdosing on morphine or other analgesics is far preferable to hanging or placing a shotgun in one's mouth and pulling the trigger with a toe.

The distinction Somerville tries to draw between withdrawing life support and giving an overdose of barbiturates is thinner than spider's silk and hardly as sturdy. It is, however, filled with convolution and a fog of extraneous language and specious rambling. Would Margaret find it acceptable for ill-intentioned doctors or unscrupulous family members to unplug patients from respirators without their consent? Should paramedics be allowed to "let" traffic accident casualties die from their wounds? I certainly wouldn't find this behaviour acceptable, but Somerville has given no reasons as to why she would find this immoral. Perhaps she is simply grasping at an ever-shrinking quantity of straws. She does expend at least a modicum of effort in trying to do so in chapter 3 (The Song of Death: The Lyrics of Euthanasia). According to Somerville, euthanasia does not occur if 1) the primary intention is to relieve suffering, rather than cause death (a troublesome distinction at best, and nigh impossible to verify), or 2) when medically futile treatment is withdrawn. This second instance is defined as "having no useful physiological effect." This is incredibly vague and open to interpretation. Who decides whether a treatment has a "useful physiological effect"? Would it be "useful" to keep a young quadriplegic hooked up to a ventilator for 60 years until their natural death at age 80? Perhaps for the anti-choice onlookers in society, but not for the patient him or herself (unless they consented). Surely it would be best for everyone to let the patient decide what treatments are beneficial and which are not?

This position also takes the (unwarranted) view that life is always worth living (a stance disproven by every suicide that takes place).

Winston said...

In an unexpected act of respect for autonomy, Somerville does concede that refusing treatment can be valid, but does not consider this to be suicide or assisted suicide. This is nonsensical. No one refuses a respirator or feeding tube unless they wish to die. It does, though, leave me extremely concerned at how she feels morphine should be prescribed (since patients can endure pain for weeks or months in order to stockpile enough pills for a lethal dose). She does not make her position transparent, although I would not be surprised if she would support laws that remove all patient autonomy in this regard and require painkillers to be administered only on bureaucratic say-sos."

Margaret states that the only time when taking another life is justified is in self-defense. What she inadvertently does here is encourage patients to commit suicide by cop (kill enough people, or otherwise act in a patently hostile manner until the police kill you). Obviously, this would be barbaric for all, but what do the terminally and incurably ill have to lose (save several weeks, months or years of state-mandated torture?)? Another avenue would be to get sent to death row in a state that has a low average conviction-to-execution duration.

The remainder of the book's introduction is spent on spirituality, and its importance and connection to how humans deal with life and death. I may be cynical, but this is likely to disguise her Catholic-based opposition to end-of-life choice. Her claim that voluntary euthanasia and assisted dying would preclude proper closure between patients and their loved ones is utter, nonsense.(see Helga Kuhse's Willing to Listen, Wanting to Die for a detailed example of how planned deaths can bring families and loved ones closer). Under the current system, premature suicides are prevalent, and success GUARANTEES a lack of closure between the patient's families and friends.

Winston said...

Later in her 800-page glob of nano-sized text, she emphasizes the difference between terminal sedation (which intends to relieve suffering) and a mass overdose of barbiturates that causes death much more quickly (which is murder, according to her). Major problem - intent is almost impossible to determine with any degree of certainty (the delay between the administration of morphine and death would be one way), but the patient is not able to request this at present (as it would be seen as hastening death and therefore assisted suicide). So, while Somerville does not intend to do so, she is advocating a system that promotes nonvoluntary euthanasia and involuntary euthanasia (i.e. murder) while steadfastly opposing a regulated, compassionate and fair system where the affluent and serendipitous are not the only ones who are guaranteed a peaceful and painless death. Oregon studies have repeatedly shown that simply having the means to exit life painlessly, on one's own terms, is enough for many patients. About two thirds of patients who receive the barbiturates never use them.

The "slippery slope" argument ignores the prevalence of non-voluntary and involuntary that already exists (and goes unreported and unlooked for). To suggest that increased scrutiny will lead to more abuse, rather than less, is not only prima facie absurd, but flies in the face of empirical evidence to the contrary (as evidenced in anonymous doctor surveys).

Clearly, laws against assisted dying are like laws against abortion - they only make the practice WORSE. They force practitioners underground and make a merciful death inaccessible to many people who need it most. They don't do diddly squat to make things better for anyone (except murderers seeking loopholes).

Lastly, Somerville is very fond of using the word "kill." I can understand why she would be deferential to this term instead of, say, "assisted dying", due to the connotations the pejorative verb carries. But to conflate VOLUNTARY euthanasia with murder is to deliberately cloud the issue, which is the exact charge she levels at the liberal/libertarian stance on this issue.

(Magnusson, Angels of Death)

(Kuhse H, Singer P, Baume P, Clark M, Rickard M End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-6.)

(Luc Deliens, Freddy Mortier, Johan Bilsen et al. End-of-life decisions in medical practice in Belgium, Flanders. The Lancet 2000; 356: 1806-11. Comment by H. Kuhse on the latter article was published in the Belgium journal Ethiek & Maatschappij, le trimester 2001, Jahrgang 4, Nr. 1, April, pp. 98-106.)

(Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001)

(Death Penalty Information Center)"

Will Johnston MD said...

The question is not whether the person who is killed in a highly publicized poster case for euthanasia is subjecting themselves to the death "voluntarily." The only important question for the purposes of the proposed Quebec euthanasia law is whether it would do more good than harm. The law, if passed, would mean the possibility of suicide through euthanasia will be constantly dangling before the patient, the family and the doctor. Literally thousands of unconsented and illegal deaths have been documented in jurisdictions which allow this. The claim that there is more, not less, scrutiny of the medical systems which allow this to go on is completely unfounded. Research which euthanasia societies call reassuring tends to be based on anonymous, voluntary, easily falsified questionnaires ignored by a large portion of the doctors being sampled. My thirty plus years of experience on the front lines of medical care leads me to believe that euthanasia infiltrated into the Canadian system would be a public safety issue and would subvert, not improve, the quality of life for thousands.

Will Johnston, MD