Physician-Assisted Suicide and Euthanasia
Spring 2012 - Volume 16 Number 2
Re: Boudreau JD. Physician-Assisted Suicide and Euthanasia: Can You Even Imagine Teaching Medical Students How to End Their Patients’ Lives? Perm J 2011 Fall;15(4):79-84.
Considering that physician-assisted suicide and euthanasia is a sensitive and controversial topic, the reductionism and the lack of objectivity of the question asked and of its discussion are intriguing. It is clear that the author and advisers wished no answer but their own. It is not usual for scholars to be reluctant to confront their views with others.
Surprising it is, that of those with the most experience in the field, none were consulted, namely from the Netherlands, Belgium, and the State of Oregon. Their comments would have broadened the horizon for the readership and rectified some lexical vagaries. It is generally understood that kill and murder are acts perpetrated on nonconsenting victims. Thus, the absolute moral value of “not to kill” does not apply to requested euthanasia, and “self-murder” is an oxymoron.
The experts from overseas would have insisted that euthanasia cannot be reduced to the “teaching of an act intended to hasten death”; and that what can very well be role-modeled is a humanism paving the way toward the “presence and accompaniment,” hailed by Dr Boudreau, which is the essence of the Belgian Integral Palliative Care: high-quality palliative care, open to the “act” of advancing death, when suffering cannot be relieved and proves intolerable to the desolate dying patient, who requests it.1 From the Netherlands likewise, one would appreciate how the “euthanasia talk,” over weeks and months, can be taught, along with excellent palliation and end-of-life care. In this humanistic, reassuring process, nine out of ten formal requests sublimate into a natural death.2 Only one in ten will want the request honored, as recommended by Eric Cassell, MD: “Assisting a patient in dying is not an easy way out. When terminally ill patients request assistance in dying because of their suffering, and their request meets commonly endorsed safeguards, their request should be honored.”3
In that perspective, bright and sensitive medical students, learn to develop a rich “autonomie-en-lien” (bonds in autonomy), an obbligato tandem between patient and physician, wherein both remain free, yet tied by the bonds of humanity (Marc Desmets, MD; personal communication; 2012).a The morality of an act resting on its justification and its benevolence—as per philosopher Tom Beauchamp, MD4—is in the realm of the physician; benevolence, as the answer to suffering, affirmed solely by the patient. “Only the patients know how awful their own suffering is,” wrote Cassell.3
In the above context, to entertain nightmares of “Modules of euthanasia,” taught by certified “euthanatricians” teaching evidence-based medicine, which may well be irrelevant when “The One and Only Mrs Jones” will face death,5 all belong to fiction.
Curricula, textbooks, research, hence journals, on end-of-life and palliative care abound and have been on the rise, more so where regulated physician-assisted dying has been enacted. Palliative care, including medically assisted dying are already taught in the Netherlands and in Belgium by qualified medical educators. “Palliative care education fits very well with the aims and agenda of general medical education, helping to correct the imbalance between knowledge, skills and attitudes.”6 In 2007, the Flemish Palliative Care Federation stated: “No dual track in end-of-life care by which palliative care practice and teaching on the one hand and euthanasia on the other would develop in separation” … “Each patient’s choice must be respected.”1
What is needed then is a continued expansion of those activities by mentors respectful of patients’ autonomy and for whom the faculty’s agenda is aligned with, and subordinated to, the patient’s own. Paternalism is no longer a virtue but an oppressive tyranny (vide infra). “The first duty of the physician is no longer to save life at all costs, but to respect his patient’s choices,” affirmed the Hon Baudouin.7 Dr Cicely Saunders reminded all that: “Whatever our own beliefs, we should never impose them on another person, least of all on any individual who is dependent upon us.”8
Should a ludicrous specialty of “euthanatrists” ever be considered necessary, one for “terminalists” or “sedationists” is then urgently needed to administer terminal sedation, for both euthanasia and terminal sedation end in death. The insinuated inadequacies regarding “death talk,” diagnosing depression, and pain management are still being raised. To be noted, even in reputed palliative care units, terminal sedation can last more than 10 days (in 10% of cases) and even more than 20 days (in 3.4% of cases).9 The longer it lasts, the more knowledge, skills and humanism are necessary to cope with the wide spectrum of physical, psychosocial and spiritual problems that develop, for both staff and families. Not rarely, experienced palliativists at times do poorly in such situations, as heard personally in workshops on “prolonged terminal sedations.”
Humanism and Values
Such “deep-seated personal convictions about one’s obligation to others—especially those in need” (humanism as defined in the commentary) has made the physicians in the Netherlands the most trustworthy physicians in the seven countries in the British Medical Journal inquiry, which included the United Kingdom (UK) and the US,10 whereas Belgium is second only to the UK for its palliative care activities. And contrary to unsubstantiated fears, there is no evidence of a slippery slope,7,11 no evidence that “vulnerable” persons have suffered any abuses12 and that requests for death are not less numerous from patients followed in palliative care rather than receiving standard care.13
Dr Boudreau is right, this question is not “exclusively axiologic,” nor is it exclusively humanistic, yet, it is nearly so for both these terms. The Hon Baudouin also declared: “One’s opinion (about euthanasia) and personal sentiments, depend, above all, on one’s own moral and religious convictions,”7 (emphasis added; translation by author). That represents a cunning slope towards paternalism, “a tyranny sincerely exercised for the good of its victims may be the most oppressive …” wrote CS Lewis: “… those who torment us for our own good will torment us without end for they do so with the approval of their conscience.14
As well, humanism is unevenly displayed by physicians. It has also been displaced by science and technology, premedical marks gaining in importance at admission time. Obvious to all, knowledge and skills are so much more easily taught than are personal values influenced or attitudes changed. Students soon learn to appreciate—and rate—the great and the less great humanists, all doing their best. Some cases will overwhelm the very best end-of-life care. Humility is not humiliating. In the end, students will learn that euthanasia is not a choice between life and death but a personal choice about a personal death, which should be honored.
William Osler would wonder what “Whole Person Medicine” is all about. Did the faculty ever have any other goal? Likewise, euthanasia modules and euthanatricians can only result from a misguided hypercompartmentalization, which might have suited Descartes but surely not Spinoza.15
Profoundly humanist mentors CAN teach compassion and respect, from birth till, and including, death.
Marcel Boisvert, MD
Retired General Practitioner from the Palliative Care Unit and Associate Professor of Medicine, Department of Oncology at the Royal Victoria Hospital in Montreal, Canada
a Belgian Jesuit and Palliative Care Physician.
1. Bernheim JL, Deschepper R, Distelmans W, Mullie A, Bilsen J, Deliens L. Development of palliative care and legalization of euthanasia: antagonism or synergy? BMJ 2008 Apr 19;336(7649):864-7.
2. Norwood F. The maintenance of life: preventing social death through euthanasia talk and end-of-life care—lessons from the Netherlands. Durham, NC: Carolina Academic Press; 2009.
3. Cassell EJ. When suffering patients seek death in physician-assisted dying. Baltimore, MD: Johns Hopkins University Press; 2004. p 75-88.
4. Beauchamp T. When hastened death is neither killing nor letting die. In: Quill TE, Battin MP, eds. Physician-assisted dying. Baltimore, MD: Johns Hopkins University Press; 2004. p 118-29.
5. Hoey J. The one and only Mrs Jones. CMAJ 1998 Aug 11;159(3):241-2.
6. Olthuis G, Dekkers W. Medical education, palliative care and moral attitude: some objectives and future perspectives. Med Educ 2003 Oct;37(10):928-33.
7. Baudouin JL. [Rapport de synthèse] Closing remarks: Extrapolating from Medicine [in French]. Association Henri Capitant des Amis de la Culture Juridique Française conference; 2009 Jun, Switzerland. p 12-7.
8. Saunders C, Sykes N, eds. The management of terminal disease. London, UK: Hodder Arnold Publications; 1978. p 4.
9. Maltoni M, Pitturen C. Scarpi E, et al. Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol 2009 Jul;20(7):1163-9.
10. Kmietovicz Z. R.E.S.P.E.C.T.—Why doctors are still getting enough of it. BMJ 2002 Jan 5;324(7328):11.
11. Rietjens JA, van der Maas PJ, Onwuteaka-Philipsen BD, van Delden JJ, van der Heide A. Two decades of research on euthanasia from the Netherlands. What we learnt and what questions remain? J Bioeth Inq 2009 Sep;6(3):271-83
12. Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics 2007 Oct;33(10):591-7.
13. Van den Block L, Deschepper R, Bilsen J, Bossuyt N, Van Casteren V, Deliens L. Euthanasia and other end of life decisions and care provided in final three months of life: nationwide retrospective study in Belgium. BMJ 2009 Jul 30;339:b2772.
14. Lewis CS. God in the dock. Grand Rapids, MI: Wm B Eerdmans Publishing; 2002. p 292.
15. Damasio A. Looking for Spinoza: joy, sorrow, and the feeling brain. Boston, MA: Harcourt; 2003.
Response to Dr Boisvert:
By qualifying it as ”fiction” it seems to have escaped Dr Boisvert that my commentary was rhetorical—intended to persuade the reader towards a particular perspective. Although the word rhetoric has acquired a pejorative connotation it arises out of an honored tradition. The question, “Can you even imagine teaching medical students how to end their patient’s lives” is rhetorical affirmation. “Can you even imagine” is meant to be received as, “No, of course not—one should not contemplate such a scenario.” With this goal in mind it would have been inappropriate to consult pro-euthanasia lobbyists.
The emotional tone evoked in Dr Boisvert’s letter is surprising to me. We are urged to conceive of end-of-life talk and actions as a sublime, stylized, mutually enriching, and obligatory pas-de-deux between suffering patient and benevolent physician, choreographed under bonds of autonomy. This is problematic on several levels. First, I believe that autonomy is inadequate as an ethical framework to understand the fiduciary duties of physicians. The ethicist Alfred Tauber has outlined the limitations of our rights-based politicojudicial and commercial culture where an atomistic interpretation of autonomy obfuscates the moral identity of the physician. His essay entitled ”Sick Autonomy” is critical to the euthanasia debate.1
Second, the notion of a linked autonomy may very well be internally flawed and indefensible. If I, in my role as physician, am to enjoy inviolate personal autonomy and exercise interdependent autonomous acts along with my patient how could I be obliged to act against my convictions? This notion merits judicious reflection. Third, although the term obbligato tandem is a lovely one and it may capture the ideal relationship between physician and patient, in the context of end-of-life care I fear that it borders on unwarranted Panglossism.
It is at odds with my own clinical practice and that of most physicians called to the bedside of dying patients. I am convinced that Dr Boisvert would be in agreement with the depiction of death as invariably painful and alienating. It is often experienced, at least initially, as a disorienting catastrophe. It is uncommonly wished for, rarely unfolds at convenient times and is endowed with few redeeming features. As such, I have reservations with the dance metaphor; this does not negate the desirability of a tight interpersonal bond implied with the eloquent phrase obbligato tandem.
Dr Boisvert reports that physicians in the Netherlands are highly trustworthy and opines that this status may be tied to their willingness to look favorably upon requests to be euthanized. The article by Kmietovicz, cited to support his claim, is hardly compelling. The authors themselves offer this disclaimer: “Our straw poll would never receive awards for being scientifically robust … .” There is no empirical evidence to support the claim that physicians endorsing physician-assisted suicide are more meritorious than those who are opposed.
Dr Boisvert rejects the slippery slope argument stating that “there is no evidence that ‘vulnerable’ persons have suffered any abuse.” His belief that the acceptance of physician-assisted suicide has not harmed vulnerable members of society is ill informed. The slippery slope is an important, sophisticated, and multifaceted construct. There is evidence for it in numerous crosscultural and historical contexts.2 The trajectory from top (morally desirable) to bottom (pernicious) situation has many slopes.3,4
One of these is the potential impact on those unable to give informed consent, ie, the transition from voluntary to ”involuntary” euthanasia. The latter should be referred to as culpable homicide. The (2005) Dutch Euthanasia Report concludes that a significant number of physician-assisted deaths occurred without explicit requests or consent.5 Recent studies from Belgium reveal similar findings.6,7 The softening of limits or constraints (eg, euthanasia of those with unbearable suffering to those with lesser degrees of existentialist angst) represents yet another slope.8 I wish to shine the light on a third slope: pedagogy.
The Netherlands recently approved the launching of mobile euthanasia clinics.9 A stated reason was that patients’ goals in self-determination were being thwarted by physician resistance. It establishes, yet again, that not all physicians, including many Dutch colleagues, are on-side with having euthanasia become a medical act. The mobile clinics reveal the pedagogical slippery slope; it is one greased with a generous dollop of absurdity and impudence. This unfortunate development buttresses the arguments contained in my commentary.
The Royal Dutch Medical Association has expressed reservation with respect to roving professional teams available to deliver death-on-demand; it has suggested that end-of-life decisions should ideally occur in the context of close relationships between patient and caregiver: “We have serious doubts whether this [physician-assisted suicide] can be done by a doctor who is only focused on performing euthanasia.”9 (my emphasis) Although the neologisms ”euthanasist”or ”euthanologist” were not used by the association’s spokesperson they could well have been as they describe the practitioner of an emergent discipline—one with an eye to euthanizing. The consequences I envisioned were not so ludicrous after all.
The suffering of dying patients must not be ignored. No arguments there. I believe, however, that options available to the profession (and society) to respond need be constrained by moral limits. It must be acknowledged that supporters and opponents of euthanasia have different understandings of autonomy (atomistic versus relationship-based autonomy), rely on different scripts of logic for slippery slope arguments, hold different conceptions as to the scope of a life worth living and subscribe to differing priorities with regards to personal responsibilities. The clash of values is undeniable. But, the argument advanced by Dr Boisvert that ministering to patients with authentic compassion, within a mutually trusting relationship, is an example of medical arrogance must be repudiated. It is offensive to conclude that the refusal of a physician to assist in a patient’s suicide is tantamount to oppression and paternalism.
Dr Boisvert invokes William Osler as a role model for contemporary physicians. Although this is totally conjectural, I consider it highly unlikely that Osler would have allied himself with the pro-euthanasia lobby or would have signed up for duty on the mobile euthanasia clinics. He practiced whole person care (even though he did not use that phrase) and enjoined the profession to spirituality. In an article entitled ”The faith that heals,” he stated, “The angel of Bethesda is at the pool—it behooves us [the profession] to jump in.”10 A wissenschaft of this nature seems incongruent with a physician placing a lethal dose of medication in someone’s mouth, vein, or … hand.
It was pointed out in a recent report by the British House of Lords that the greater the experience with end-of-life care, the less sure professionals are about the prospect of a change in the law in favor of euthanasia.11 Dame Cicely Saunders, founder of the modern hospice movement, was opposed to euthanasia. Balfour Mount, who coined the term palliative care and founded the McGill Programs in Whole Person Care, is opposed to euthanasia. Opposition by physicians to euthanasia is generally strongest amongst palliative care experts.12 Notwithstanding the recent endorsement by the College of Physicians of Quebec for Belgian-style euthanasia there are other developments, such as the recent vote taken by the Massachusetts Medical Society, confirming that we have not all gone soft on our values.13 We should not accept anything that might dampen the reflex to comfort at all times and for all times. Vigilance is called for. “Euthanatrics” can beguile even the most well-intentioned and sensitive ”palliativist.”
J Donald Boudreau, MD
Arnold P Gold Foundation Associate Professor of Medicine; Associate Professor, Department of Medicine; Director of the Office of Physicianship Curriculum Development; and Core Member, Centre for Medical Education Faculty of Medicine at McGill University in Montreal, Canada
1. Tauber AI. Sick Autonomy. Perspect Biol Med 2003 Fall; 46(4):484-95.
2. Young KK. A cross-cultural historical case against planned self-willed death and assisted suicide. McGill Law Journal 1994; 39:657-707.
3. Jones DA. Is there a logical slippery slope from voluntary to non-voluntary euthanasia? Kennedy Inst Ethics J 2011 Dec; 21(4):379-404.
4. Amarasekara K, Bagaric M. The legalisation of euthanasia in the Netherlands: lessons to be learnt. Monash University Law Review 2001;27(2):179-96.
5. van der Heide A, Onwuteake-Philpsen BD, Rurup M, et al. End-of-life practices in the Netherlands under the Euthanasia Act. New Engl J Med 2007 May 10; 356(19):1957-65.
6. Chambaere K, Bilson J, Cohen J, Onwuteake-Philpsen BD, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ 2010 Jun 15;182(9):895-901.
7. Smets T, Bilsen J, Cohen J, Rurup ML, Mortier F, Deliens L. Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ 2010 Oct 5;341:c5174.
8. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008 Oct 7;337:a1682.
9. Dutch launch mobile euthanasia teams [monograph on the Internet]. Canberra, Australia: Australian Broadcasting Company; 2012 [cited 2012 May 10]. Available from: www.abc.net.au/news/2012-03-01/dutch-launch-mobile-euthanasia-teams/3861636.
10. Osler W. The faith that heals. BMJ 1910 Jun 18;1(2581):1470-2.
11. Select Committee on Assisted Dying for the Terminally Ill Bill: First Report: Chapter 6: Public opinion [monograph on the Internet]. Ottawa, Canada: Parliament; 2005 [cited 2012 May 10]. Available from: www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8609.htm#a47.
12. Seale C. Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes. Palliat Med 2009 Apr;23(3):205-12.
13. MMS physicians reaffirm opposition to physician-assisted suicide [monograph on the Internet]. Boston, MA: Massachusetts Medical Society; 2011 Dec 3 [cited 2012 May 10]. Available from: www.massmed.org/AM/Template.cfm?Section=Online_Newsroom&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=65342.