4. The Problem in general
http://lawinquebec.wordpress.com/2014/07/23/controversial-dying-with-dignity-legislation-brings-discussion-around-euthanasia-to-the-forefront/
19. “If I cannot give consent to my own death, whose body is this? Who owns my life?”
– Sue Rodriguez**
Death as a part of life
All professions involved have a stake in serving,
preserving, enhancing life
Liberties and protection allotted to citizens,
including choice
International examples to lead the way, social
mindset reflected in current legislation
**(Einstat-Weinrib, 1994)
Sue Rodriguez, Gloria Taylor and many others have brought the issue of physician assisted death to the fore on many occasions, yet we have done nothing
(Play clip)
In favour of legalizing Physician Assisted Dying so as to incorporate it into our Palliative Care practices here in Canada I will give a brief background, the issue as it applies to the professions involved, the importance of the subject to us as individuals. I will share examples where Physician Assisted Dying has been legislated and successfully incorporated into palliative care practices.
Finally, I will share my recommendations on the road to adopting similar legislation and be open to questions. But first a little bit about myself……….
I became interested in this topic after stumbling across the documentary from which the clip was taken. As a private citizen, I am concerned about the options given to us in traditional medicine, in particular, palliative care. As a social work student I believe these need to be extended to include PAD in order to allow the individual control over their life and respect their dignity and preserve the integrity of the relationships formed with their caregivers.
My interest in pursuing a JD brought me to cover the issue as the current penalty for assisted suicide. Is quite severe. Though this is not the term preferred by proponents of such legislation, it carries with it loss of license and up to fourteen years in jail.
A few years ago, 2011 to be exact, the public’s support for Physician Assisted Dying was sitting well above the midway point, 67%, physicians were not so enthusiastic, less than half agreed to the practice. In light of the Supreme Court decision now pending, a Canada wide poll carried out by Ipsos Reid on behalf of Death with Dignity Canada states that both the general population as well as those working in the medical profession are in agreement when it comes to the issue.
The issue of physician assisted dying is one that effects several professions: social work, medicine and law. The focus of my argument is that there is a need for the practice, in order to carry out the mandates of all three professions, and more importantly to assure the individual that they will have choice and control at the end of life.
Collaboration is needed between the professions to ensure the individual is put first. This would include decriminalizing assisted dying in a medical context, extension of palliative care protocols to allow for these practices, thorough education of them to all health care professionals who deal with the affected groups and social activism to remove any lingering stigma on the subject.
In Social Work, we strive to meet the person where they are. In building rapport we aim to find ways for them to navigate through their difficulties, often imposed by society. For someone suffering from a terminal or degenerative disease, along with meeting their practical needs, we look to assess their spiritual, emotional and social needs as well. Their self-image and sense of autonomy and peace can be hampered by the restrictions of choice as they face the end of life. Even if they were to go through with an assisted death, the burden of the legal outcomes for the other party can weigh heavily on them and their family. With this barrier, we carry much responsibility in helping with what can be an irreconcilable situation.
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In debates, physician assisted death has been compared to Abortion, which before legalized, went underground. The same restrictions that hamper the efforts of social workers to help the individual, apply to many who wish to be able to offer their patient choice at the end of life. In both cases their hands are tied. And though some have carried through with the requests, they did so at great personal risk. These are consequences that send a strong message to other would be helpers as well as those who would seek their service.
Medicine is another arena where the basic values that guide and support decisions on patient care are the self-determination and autonomy of the individual. To this end, expanding options at end of life seems only logical and fair to both the health care provider and their charges. Limiting these choices due to fear of unwise decision making is both unnecessary if legislation were to be carefully codified as expected and paternalistic.
There are already measures in place for end of life care that grant some choice to the patient. An example of this would be the Do Not Resuscitate Order one can request. This allows for the withholding of life saving intervention in case of medical emergency for those terminally or critically ill.
Also, the practice of palliative sedation is used in the administration of pain relieving medicine. At a certain degree, this can hasten death, as one’s body may be too weak and the dose proves too strong. The argument that physician assisted death goes against the Hippocratic Oath of do no harm, neglects the practices already in place. The difference being that palliative sedations first objective is to manage and lessen pain, whereas active euthanasia, often carried out by the same means is meant to terminate life. It seems arbitrary that the fashion of assistance is what is under scrutiny, as the palliative sedation so often practiced could be likened to a Type 1 error, and following a DNR could be seen as a type 2 error, if we were to be fair. Following a DNR is, in practice, passive euthanasia, administered with consent. Consent should be key in any legislation allowing for PAD and a strong factor in its regulation and enactment. Indeed, the risks to the vulnerable are increased as long as these practices are banned and remain underground.
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Those opposed to Legalizing Physician Assisted Dying have been very vocal about the fear of a slippery slope. The abuses of such legislation that will no doubt impact the old, poor, disabled. The idea that this option will be pushed by doctors everywhere and unwilling patients will be subject to treatment when they do not consent. In many countries where this legislation has been debated a similar sentiment of cost savings of terminating a life versus accessing long term institutionalization has been used to oppose the implementation. This falls short when the countries which have successfully implemented PAD are reviewed. All are highly ranked in their economic health care commitments as well as other social service provisions.
“For all but our most recent history, dying was typically a brief process. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition….or the multiple debilities of very old age.” Mr. Gawande in his article discusses the issues faced when death remains imminent, but the timing not so.
Many individuals have been assisted by relatives, many as shown in the illustration have taken their own lives, in a secretive, violent manner. What we do with our lives brings meaning to them, one should have the choice as to what this meaning is and the same control when facing death.
Allowing for an expansion of palliative care to include PAD does not mean that it will be a consideration for everyone, but the option being available will make a difficult situation easier for those faced with the choice.
In a study of the individuals involved in palliative care, both professionally and personally many trends were shown. One was that the personality of those who opted for Physician Assisted Death were consistent with such choice, not out of character due to their circumstances. These traits included wilful, fiercely independent, as well as reflective. In Oregon, the passing of PAD legislation revealed a paradox: when allowed access to the medication to end their life sooner, led to a surge in wellbeing and peace of mind. This in turn renewed many patients desire to live longer. The theory behind this reaction relates back to the concept of dignity and self-determination, the individual shifts their self-perception from “helpless victim” to “willing survivor”.
It has been almost 25years since Dr. Kevorkian’s first publicized assisted suicide. In the time between, several states have enacted legislation allowing physician assisted dying. Oregon’s victory in passing the Death with Dignity Act came after similar legislation failed in California and the first attempt at the same in Washington State. One of the biggest challenges was the position stated by opponents that prescribing the required medication violated the Controlled Substances Act, and therefore both physician and pharmacist would be in breach of the law. This point was dismissed, the Rx given special status within the DWDA and the legislation enacted. Three years after its passing, loss of autonomy was given as a reason to access the DWDA, the number of patients who received the medication still outnumbers the patients who ultimately take it.
Upon a second attempt and shortly after Oregon’s victory, Washington State passed Initiative 1000, allowing similar practice.
Both the ODWDA and WDWDA carry very strict limitations as to what practices this term covers. Under Oregon’s individuals may acquire life ending medication by prescription from their doctor, but must administer the medication themselves. This poses an obstacle to those suffering from degenerative diseases such as ALS, MS and other illnesses that cause deterioration of mobility. If the quality of life is the concern and reason for the need for PAD, with the existing terms of the act legislated, what options are left for those who are able to follow through with the practice at a time in their lives they feel is still optimal and worth living?
Vermont’s Patient Choice at End of Life Act has allowed for a compromise between the needed legislation and regulation of Physician Assisted Death and the autonomy and freedom of the patient by still requiring a terminal diagnosis, but not enforcing the same 6month prognosis as the first two states.
Montana challenged RTD legislation in 2007. The idea that the individual protection of one’s personal freedoms as stated in the Constitution includes their EOL decisions, and therefore also offer protection to those whose help is requested and assist in DWD. This decision was brought up again in 2009, where the question of constitutional protection was not addressed. Instead, the state has allowed for a “consent defence” in which the physician will not be prosecuted if the process of due care was followed and informed, free and enduring consent was given by a competent, chronically ill patient. In its ruling, the court stated that “nothing in the Supreme Court or state statutes indicate that allowing PAD would go against public policy”. One has the right to determine one’s own fate as long as it does not impede on the rights of another.
Colombia has successfully defended PAD from legal prosecution permitting that certain conditions are met. The patient must be terminally ill yet competent to give consent. The issue is still largely divisive in a country that is moving forward but whose population is still largely, devoutly catholic. This has also been a barrier to legislating similar acts in Spain for the same reasons.
This religious homogeneity has been linked to some failures to implement PAD around the world. Though with the passing of PAD in several European countries, many are now in support of the change. In the shrinking global community we live in, many people of various spiritual and religious backgrounds still see the importance of self-determinism as a reason to support such law.
Belgium
Belgium legalized Euthanasia in 2002, there remain no regulations on Physician Assisted Death as described in the US models. In these cases, grounds for prosecution are considered on a case by case basis, and have o due with due care being shown to the individual. This has led to an underreporting depending on the methods of PAD used and reflects the difference between European countries and the importance of careful codification as this specifies what is legal, and what is recorded due to the practices status. In Belgium, within the eligibility criteria there is a distinction between those patients whose death is expected in the near future or not. If not expected soon, there are additional criteria to be met such as two additional medical doctors’ professional consult and opinion and at least one month between the request and its fulfillment.
Voluntary, active euthanasia has been practiced in the Netherlands, and in all practicality legal, since 1980. It was officially legalized in 2002 and carries with it many conditions to be met. The Netherlands model is the most comprehensive. The term PAD includes the practice used on Oregon, as well as active euthanasia. These practices are available, after due care guidelines are met, to both the terminally, critically ill and those who are otherwise facing unbearable, hopeless suffering. As such, the procedures can be carried out as stated by the patients verbal request, or, in case of advanced disease leading to inability to speak or comatose condition, an advanced directive may be followed.
The at-risk groups named by opponents of legalizing such practices, namely, women, elderly, uninsured, poor, racial/ethnic minorities, physically, chronically disabled, and minors were shown to be at no increased risk once the law was passed. This is in part due to the social acceptance of the practice before legislation came into place, but also due to the carefully considered means by which it could be used and the intent behind its enactment. The common knowledge of the PAD procedures available to the people of the Netherlands proves that the access to information and options is key in successfully implementing these practices to expand the ability of palliative and heath care in general.
The latest polls seem favourable, and the knowledge and results shown by other jurisdictions can be used to push for and support legislative change here in Canada.
