According to Health Canada’s recently released Third Interim Report on Medical Assistance in Dying in Canada, approximately 1,500 people died through active physician administered euthanasia in the six month period from July 1st to December 31st, 2017. This number, with reference to our common experience, is both small enough to be easily comprehensible, and large enough to command respect: a thousand dollars are a lot of dollars; a thousand kilometres are a lot of kilometres; and a thousand lives are a lot of lives.
There is a special solemnity we feel at the sight of any mortality statistics. We subconsciously feel the finality, the quiet and the weight, of the endless rows of burial plots where slumber those who have preceded us. But in this case, there is also a surreal dimension to our experience: because the defining characteristic of our acceptance lies in the inevitability of death. We are used to struggling, at great cost, with any sort of fatal contingency; we are used to denunciation and outrage at any sort of homicide; as doctors, especially, we are dedicated to combat the one and to refuse the other. We accept death, then, because we must. But only because we must.
And yet here are these thousands of discretionary deaths, provoked by doctors, in homes, clinics and hospitals, supported by administrative staff, reviewed with formal oversight, – justified with stamped certificates produced under the terms of published law – and appearing, at the end, compiled in the statistics of a government report. It is the very definition of surreal: that which is extraordinary, significant, and dangerous, portrayed in the light of boring normality.
Many of us will never feel at ease with these facts. There is a huge moral leap between suicide and assisted suicide; and there is an even greater leap between any sort of suicide and euthanasia. As doctors, we accept the refusal of a patient to continue active treatment, even if the refusal might lead to the patient’s death – but none of these things rises to the same level of moral hazard as the active taking of a patient’s life through the deliberate administration of lethal substances.
How then can we relate to this Brave New World? How can we function as doctors in this environment?
Thankfully, large, solemn, significant, and surreal as the numbers may appear, they also tell us that we are not alone. Only a small fraction of patients will ask for euthanasia. And only a small fraction of doctors will ever be willing to provide it.
Our main concern, then, is not to justify why we, personally, reject the medical practice of euthanasia, but rather to collaborate with the like-minded majority of our colleagues to refine our response to the needs and choices of the (non-suicidal) majority of our patients; and hopefully, also, to provide care of a quality which might shift the balance for some patients, even of the suicidal minority, from despair to hope, and from anguish to peace.
To do these things, shared information is of inestimable value. However, due to the parameters established for federal interim reporting (a more ambitious annual reporting framework is reputedly under development), the information contained in the current report is of very limited value.
The first priority, naturally, is the desire to avoid abuse of this law that allows doctors to deliberately cause death: to ensure that the law and the process are faithfully respected. As stated at the beginning of this report:
“… providing transparency and fostering public trust in the application of the law.”
To this end, all instances of euthanasia are declared to some public authority: in Quebec to a special End-of-Life Commission, in other provinces to the coroner. However, in all cases, this system suffers from a major flaw, in that the person submitting the report (after the fact) is the same person who evaluated the patient and performed the euthanasia to begin with. In other words, the doctor or nurse simply states what he or she did, and why. Thus the official truth of the matter becomes whatever it is claimed to be; the reviewing agency has access to no other information source; and the verification is reduced to a mere acknowledgement that the correct forms have been submitted by the correct people and signed in the correct places.
More promising, for our purposes, is the information purportedly gathered to provide the data for further policy development. This consists mainly of a statistical portrait of practice and patient type, compared across provincial jurisdictions. We learn, therefore, that the most likely euthanasia candidate is a cancer patient (65%), in BC (7.93 euthanasia deaths per 100,000 inhabitants; Quebec 5.35; Ontario 3.51; Atlantic Canada 2.97; Prairie Provinces 2.69) over fifty-five, living in a larger urban centre (57 %). And yet this outline, while interesting, is still of very little help, because what we really wish to know is why these particular people, among so many more who present the same superficial profile, would feel the need to ask for death, contrary to all natural instinct.
One interesting avenue in understanding the larger suicidal motivation concerns the people who asked for MAID, but whose requests were denied (Atlantic Canada 8 %; Alberta 8 %; Quebec 16 %; MB 18 % ; SK 23 %). But once again we are left unsatisfied, because the only reason given for rejection is the non-respect of admissibility criteria. From our point of view, the common threads connecting all those requests are much more important than their division according to some politically motivated criteria. And more disappointing yet: the first and third most populous provinces, Ontario and British Columbia, do not even keep such statistics.
Decidedly, we need and want more: We want to know if palliative care was available; we want to know if the person had – or lacked – family and social support; we want to know if adequate home care was available; we want to know about mental health conditions, and access to treatment if any were present; we want to know what influence the family exerted on decision making; we want to know what bias the attending doctor may have exhibited. In short, we want to know who this person was, why he chose to die, and what alternatives he or she was provided.
In the end, the type, volume and quality of data will reflect the use we wish to make of it. If the goal is to normalize and expand the practice of euthanasia, information gathering will be as simple as possible for the practitioner, and purely formal oversight (based on an uncritical honour system such as we observe now) will be the norm. Moreover, to the extent that patient profile information is recorded, the pro-euthanasia lobby’s goal will be to identify promising areas of expansion and identifiable groups of persons, presently excluded from qualifying criteria, to whom access might or “should” be extended.
Our goal, of course, is the exact opposite: we see every euthanasia death as a failure of some kind and we wish to know which of those failures might be prevented from a medical or societal point of view. In other words, every euthanasia death would ideally be subject to inquest, the breadth and depth of which would be limited only by the resources available. But while we will always press the authorities for a more systematic gathering of pertinent data, we should also be ready to show the way.
As time goes forward, with this radical social experiment of programmed demise, the force of anecdotal experience will play a critical role in the public imagination. In particular, we encourage doctors’ personal accounts of cases in which they believe patients to have chosen MAID because of the lack of feasible alternatives, or other constraints. The Physicians’ Alliance against Euthanasia proposes to publish these Doctors’ Voices (send them to info@collectifmedecins.org), through the full range from precise individual case history to the fictional generalization of larger experience. Inevitably, real and serious instances of abuse will eventually come to light, and be adjudicated in the courts of law. We believe the value and effect of such cases might be multiplied, a hundred times, by a proper preparation of the public mind.
Make euthanasia unimaginable.
Sincerely,
Catherine Ferrier
President