Dr Coelho: Why I oppose euthanasia (MAiD).

The following is a presentation given by Dr Ramona Coehlo on December 9, 2020

My name is Dr. Ramona Coelho and I’m a family doctor. I’m originally from Montreal. My husband is a surgeon and epidemiologist. We have 5 children.

My practice in Montreal was largely compromised of patients who I cared for in their homes. My patients were homebound because of their illness or disability.

Article: Doctors are divided on Bill C-7 (Link).

In 2012 we moved to London, Ontario and I have been practicing medicine here since. I work in one of the poorer areas of London. My practice is largely comprised of people living with disabilities, as well as refugees, men out of prison and other persons who find themselves on the margins.

Right now in Canada the government is trying to pass bill c7, which among other things, is a bill where if you are wanting to commit suicide and are ill or have a disability, a medical doctor will give you a lethal injection within 90 days of request.

I personally find it appalling that there is a suicide completion track just for my type of patients.

Healthy people’s suicidal thoughts are irrational, and those people deserve saving from themselves.. but in this bill, persons with disabilities or chronic disease don’t deserve the same interventions to save their lives.

If someone tries to hurt themselves, we usually step in to protect them and offer suicide prevention. There is nothing different about disabled and sick people that make it ok to help kill them instead of saving them.

There is no medical evidence that their suicidality is different than those of able bodies persons. The government has created a suicide pathway for people who it thinks are “ better off dead”. This bill is based on ableism. Ableism is a type of discrimination against people who are not able bodied. Like sexism and racism, ableism is alive in Canada.

This is what systemic discrimination, ableism, looks like. People look away from persons with disabilities on the street, don’t notice or acknowledge their existence, and many Canadians are so scared of being disabled, they would rather be dead.

I share the testimony of Spring Hawes, a lady who has a spinal cord injury for 15 years now:

“As disabled people, we are conditioned to view ourselves as burdensome. We are taught to apologize for our existence, and to be grateful for the tolerance of those around us. We are often shown that our lives are worth less than nondisabled lives. Our lives and our survival depend on our agreeableness.” When someone is devalued by the injustices of our society, they need help, they need care and services, they need love and support. They do not need a lethal injection. And because they suffer, they might be driven to choose death if we fail to help. Currently, most disabled persons live in poverty and are much more likely to be victims of abuse or neglect. They often lack the home supports they need and accommodations to be able to work.

I share the story of my darling home care patient Charles, who had muscular dystrophy, so he was disfigured. He had no muscle mass and so you could see his bones and his face looked very different. I sent him to the hospital once as he needed admission and the neurology and internal medicine doctors fought in front of him about who would have to take him. My husband who worked at the hospital went down and tried to intervene for Charles. Charles left the hospital. He told me that those doctors made him feel terrible and that he’d rather die than go back to the hospital.

What am I getting at?

The government and society are constantly selling this bill as a way to let people choose death. They use ideas of freedom and autonomy (my choice, my life).

I’d like to look at this idea.

Whose decisions (your and mine) are made in a vacuum, unaffected by those around them?

And whose societal choices have zero impact on others? We live and breathe and function in societal units of family, neighbourhoods, schools and communities and country.

If we thought our choices didn’t affect anyone else, we wouldn’t all be wearing masks out of courtesy and protection for the vulnerable amongst us.

I had a 70 year old lady who was asking me to die and drastically losing weight for months and it took months to learn that her son who had moved in to help her, wasn’t feeding her and was stealing her money. If this bill existed at that time, her death, which the medical community would have facilitated, would have been driven by elder neglect and financial abuse.

Gabrielle Peters, a brilliant writer with disabilities, shared that a healthcare professional sat at her bedside and urged that she consider death. This was just after Gabrielle’s partner announced he was leaving her because she was too much of a burden with her disability and she no longer fit into the life he wanted.

The idea that people freely choose to die is a lack of understanding that suicidal thoughts are a failure of our society to help them. Athough people say, “its my right to die” most often people who choose this feel they have no other options. That is not autonomy, this is death by neglect.

A recent medical study in the Netherlands looked at why people would choose euthanasia if they could. Remember there is no law in the world that would allow death on demand the way the Canadian law will. The study showed that people would choose euthanasia for poverty, lack of social supports, relationship breakdown but not for disabilities.

Also, I’d like to talk about suicidality in illness. This government wants people not to suffer and for them to be able to die within 90 days. However, medical evidence shows that suicidal ideations with new illness or disability can peak at 90 days and continues to go away until about an average by 2 years.

Kristine Cowley is a person who had a spinal cord injury 33 years ago. She now has a doctorate, is a prof at a university. She was a wheelchair track Paralympian. She is married, has three children and has travelled extensively, all done after her accident. But Kris shared that it took her 5 years after her spinal cord injury to feel great. She had to go through rehab, vocational training and living in the community to feel healed. She shares that if someone suggested MAid to her in her early years, she may not be here today.

Dr Karen Ethans is a physiatrist (that’s a doctor who helps people recover from accidents or strokes or other injuries). She works at university of Manitoba and she shared that many doctors who work in emergency and Intensive care settings are not informed about the lives of people with spinal cord injury. That means that the doctors in the hospital who appear to be experts, lack understanding of these conditions. And many doctors have made these patients feel like their life is over. She also says that many, if not most, people with new spinal cord injuries wish to end their life or “not go on”in the beginning. However, once having gone through rehabilitation and integration back into the community within a few years these same people rate their quality of life or their happiness as quite high, many in fact higher than that of the non-disabled population. Being offered death in that early period when they are vulnerable is a failure to understand the medical evidence.

Lastly: I would like to talk about conscience, especially important for students here today.

There is talk about removing people such as myself from medicine, people who refuse to become involved in killing, on grounds of our conscience.

We have people like Udo Schuklenk, a prominent bioethicist from Queens University stating that conscience objectors should be screened out of medicine by having a in medical school and if people fail, they shouldn’t be admitted.

So why is it important we cling to “the good” when there is pressure on doctors to accept the law?

Unlike some occupations, integrity applies to almost every medical act. The patient’s health is the good that we, patient and physician, are seeking. We are seeking to ensure safety, improve health and preserve human life.

As physicians we help our patients do many things in the context of a trusting relationship. Patient demands are not the unilateral force in shared decision making. We journey with our patients; we encourage healthy habits. We refuse things such as antibiotics when they have a viral infection. We pull driver’s licenses when we have concerns for the patient safety and the public good. We refuse to write mask exemptions for them just because they don’t believe it is necessary.

All of this requires courage and integrity to not betray the trust society and the patient has given to us. Society’s belief in the inherent virtue and ethics of the profession has been the necessary basis of the physician-patient trust. Would you trust your doctor if you thought they didn’t care about your safety and well-being?

We must for the sake our patients continue to only offer them what is good.

I end by offering you a simple story. It is the story of my patient who came to me for MAiD. She was a fiery lady and talented artist. She had survived breast cancer but than it returned. In her brain, in her bones...... she realized after some frank discussions that her prognosis was very poor. I have to admit I was extremely overwhelmed by her request to receive MAid. I started the conversation by fully disclosing as I would always that I would never be able to journey that road with her as I didn’t think it was good for society or her and not for anyone. She took those words in, processing them. I than stumbled through what felt like hollow arguments.. I said she was not in pain right now and we would try to ensure she didn’t have pain. I explained that palliative care was amazing with excellent pain control with pet, music and art therapy. She replied that her best friend had died in agony in the States. I said we could try to find meaning for her days and maybe there was something she could leave behind for others, like her art. She said her fatigue and the weakness in her hands made her useless and she didn’t have anything left to leave the world and was angry she couldn’t paint. I told her that maybe this was the time to seek closure with friends and family and could we explore that. She told me that she was very angry at her family as they treated her badly because of her increased irritability. She also shared that she would daily sit on a park bench and hate all the people walking around her, living while she knew she was being robbed of her chance at life at a young age. She had a cancer doctor at this point and I presumed that maybe I would never see her again. However, she kept coming back to talk. I would book her at the end of my days and give her my time. She brought an amazing gift to me in those days before she died. We talked about maybe making voice memos to describe her paintings to enrich the experience for future generations. I decreased her steroids that were mean't to be shrinking her brain tumour as they were adding to her irritability and anger. Also I suggested moving her steroids to the morning and that improved her sleep and quality of life. We switched her antidepressant. In the end, my patient decided to die at home, naturally and not by MAiD. 

Patients need our time. They also need our efforts, our creativity our perseverance and our strength. A lethal injection is easy and doesn’t require any creativity. It is met out one by one and there can be no failures as those who die will never tell.

Doctors took an oath to restore life and provide care, and we do well when we keep that oath.