Physician-assisted dying

Joan (not her real name) was dying of amyotrophic lateral sclerosis. She was all but “locked in.” She could move her eyes—up meant yes; down, no. When she could still speak, we had often discussed advanced directives, and she was clear: If you can, hasten my death when I tell you I am ready. Now with her eyes she was asking me to help her die—the sooner the better. She was suffering from marked dyspnea, treated effectively with opioids and benzodiazepines, but refused bi-level positive airway pressure, as she believed it would delay her death. To live this way and not die of her own accord caused her extreme anxiety. Thinking about a world in the not-too-distant future where I might have the option (dilemma?) to provide physician-assisted death (PAD) causes me serious anxiety.

Inevitably, that world will arrive in Canada. This past June the BC Supreme Court rendered a decision that Gloria Taylor, a woman also suffering with amyotrophic lateral sclerosis, has the constitutional right to assisted suicide.¹ She was granted a yearlong exemption from the current ban, permitting her to receive PAD without the physician risking prosecution and potential imprisonment for up to 14 years.² The judge also suspended the ruling for a year to allow parliament to change the current law. An appeal to the BC Court of Appeals is pending, and the issue will likely make it all the way to the Supreme Court of Canada.

The trend to PAD (which encompasses physician-assisted suicide and euthanasia)³ is occurring worldwide.⁴ In 2007, 76% of Canadians agreed that people with incurable disease have the right to die,³ and in 2010, 67% supported the legalization of euthanasia.⁵ The Collège des médecins du Québec,⁶ the Royal Society of Canada Expert Panel,⁷ and the Quebec National Assembly⁸ have all proposed legislative reforms that would permit PAD. Other health care organizations have published papers examining the issue.⁹ It is now time for the CFPC to bring the specific perspective of Canada’s FPs to the table.

Most palliative and end-of-life care delivered in Canada today is provided by FPs working with other care providers. The number of patients requesting PAD might be small, but any FP offering end-of-life care, despite providing comprehensive, compassionate, and competent care, will still encounter patients who will consider PAD because of extreme physical, psychological, social, or spiritual suffering. Many FPs have the necessary knowledge, skills, and experience to offer considered and thoughtful opinions on this subject. Given this expertise, our patients, their families, and all Canadians should reasonably expect that we can inform the development of public policy in this area. And any change in public policy will have an important impact on FPs, who will be called on to implement the change. Will we have a choice? If we do not bring our voice to the national discussion now, then when a court ruling or legislation withdrawing the prohibition against PAD is ultimately passed, we might not get another chance.

The CFPC has not been sitting idly by. This year our Palliative Care Program Committee prepared a statement on end-of-life care.¹⁰ Our Committee on Ethics has been meeting to advise the Executive and Board on how to contribute to the public discussion. It is critical to clarify and define the varied terms in this debate; provide well-researched and evidence-supported educational material to facilitate understanding so that FPs can have informed discussions with patients and families; and support scholarly work by FPs that contributes to understanding the professional, legal, and ethical implications of legislative change. Using resources like Ethics in Family Medicine: Faculty Handbook,¹¹ we can help residents develop the competencies to incorporate the different ethical considerations into their decision making, as this most surely is an issue they will be forced to deal with in their careers. And we must work with our sister organizations to bring the overall perspective of physicians to the national conversation.

I also need the guidance of my colleagues and discipline to decide whether I can participate in PAD. Joan was not my first patient to request PAD and she will not be my last. Reflecting on my own anxiety, I am also asking what I would want in her situation. Therein too lies my answer.

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