Maintaining humanity at the heart of pediatric care…

Euthanasia (MAID) was originally sold to the public, and to our profession, as an extraordinary response to a request made by a competent adult whose death was at hand, and whose unbearable suffering could be relieved (so it was said) by no other means. But the intention to rapidly extend the practice of euthanasia well beyond those limits was evident from the beginning. Along with currently contested access for psychiatric conditions, by advance request and when natural death is not reasonably foreseeable, we now find a proposal for extension of euthanasia to children (“mature minors”).

The question of euthanasia for capable pediatric patients was referred to the Canadian Council of Academies (CCA) after Bill C-14 was adopted, with a report expected in late 2018. A good indication of what the likely CCA findings will be, can be found in a paper originating from a working group at the Hospital for Sick Children in Toronto.

It should come as no surprise, given our experience of the euthanasia debate in Canada, that the authors of this essay conclude that voluntary euthanasia should be available to capable minors (which has no age criterion, being assessed on a purely individual basis) even to the extent that such patients might be euthanized without the notification of their parents, should that be their desire.

Before proceeding with the academic arguments, we might usefully pause to consider the full weight of such a blow to parents and families, not only at that moment, but throughout their lives. And to what end? In one case with which we are familiar, a young man spent two weeks in Intensive Care before identifying his parents, because, as he later stated, he “did not want them to be worried”. In his youth-distorted notion of responsibility to family, the idea that he might die without their having had the chance to say goodbye took second place to his fear of upsetting them. Can we doubt that certain pediatric MAID candidates will behave in just this manner?

The reasoning behind the authors’ position is simply stated: capable minors already have the right to refuse life sustaining treatment, or to have it withdrawn, with or without parental notification. Dead is dead. Death causing is death causing. Why should MAID be different from refusal of care? The critical proposition, then, is that euthanasia, — the active ending of life — is ethically equivalent to the withdrawal of burdensome care, to allowing a terminal illness to run its course while continuing to provide excellent symptom control.

Let us consider again the real world consequences: imagine a parent arriving at the hospital to find that today is different. Today she is confronted with a dying child, whose inevitable death is expected shortly (withdrawal of care); or imagine, rather, that she is presented with a cadaver (euthanasia). Is that not a significant difference?

As the authors state, on one side of this controversy (and opposed to euthanasia below age 18), we find the Canadian Paediatric Society, and on the other we find “scholars and advisory groups”. The central proposition (that euthanasia is ethically different from refusal of care) is admitted by the authors to be “standard in the literature on MAID and is foundational to nearly all assisted dying policies and guides we have encountered”. However, that preponderance of precedent will not prevent them from rejecting it.

The reason given is that the traditional interpretation has been derived from the perspective of the physician (for whom the two acts are clearly not ethically equivalent), while precedence should, in their view, be accorded to the perspective of the suicidal patient (for whom the motivation of escaping suffering is behind both refusal of care and the request for euthanasia). But wait a moment. We are discussing ethical medical practice. Obviously we must begin from the position of the physician!

There are huge ethical ramifications to the act of euthanasia. This also is admitted by the authors, for we are talking about nothing less than the age-old proscription against the taking of human life. The principle as presently laid down is perfectly clear and reasonable: the doctor has no right to continue treatment against the wishes of the patient even if she knows that stopping treatment will hasten death. The patient, on the other hand, has no right to dictate the ethical behaviour of the doctor, or of society at large, by demanding that someone else assume the moral responsibility for killing him.

With great generosity issued from an evident desire for fairness, the authors of this position paper express their conclusion thus: “Our drafted policy seeks a middle ground between these competing theorisations—treating MAID in a manner that is consistent with other medical interventions that result in the end of life, while still acknowledging that MAID may be experienced as distinct by some patients and clinicians.”

In other words, in the rarified scholarly view of the authors (against all precedent and mainstream ethical opinion) MAID really is ethically the same as other less controversial life-limiting actions, but, they graciously concede, some well-meaning (but objectively misguided) people may think differently! Obviously, they are setting the table for some sort of policy that will normalize their desired practice while according a limited “right of conscience” to the clear majority who are unwilling to participate.

Worse still, the effects of accepting such a standard do not end with mature minors, just as the potential evil of euthanasia is not limited to the voluntary application of MAID. For if we once admit the principle that performing euthanasia really is ethically equivalent to withholding or withdrawing care, the logical consequences are obvious, for expansion of euthanasia to the very young, to the very old, to those with cognitive disorders or severe disabilities, in short, to all those incapable of consent. Imagine the systematic telescoping of mortality from the eventual demise of “refusal of care” to the immediate fatality of euthanasia; the affront to the humanity of these persons; the systematic loss of those significant last months, days and hours which Palliative Care has invested such energy into maximizing.

Moreover, it is not possible to honestly discuss these issues without also mentioning the enormous financial interests of the State. Every hour of life lost to costly patients is many dollars gained by the administrators of our State funded system. This alone creates a huge institutional bias toward the expansion of euthanasia policy.

It is only with deliberate, constant effort and determination, therefore, that humanity, not crass utilitarian economics, can be maintained at the heart of our medical mission.

Make euthanasia unimaginable.


Catherine Ferrier


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