Legalized MD-assisted suicide needed to improve care, physician tells right-to-die group
Anita Elash
CMAJ 1997;157:763-4
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Anita Elash is a freelance writer in Toronto.
© Anita Elash
In brief
Advocates of euthanasia say clear rules outlining procedures to follow when a terminally ill patient requests assisted suicide would help doctors provide better care without fear of legal or professional recrimination. The Canadian-born medical director of a US-based right-to die organization made the comments during the recent annual meeting of Dying With Dignity, a Canadian group.
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Les partisans de l'euthanasie affirment que des règles claires décrivant les procédures à suivre lorsqu'un patient en phase terminale demande de l'aide pour se suicider aideraient à prodiguer de meilleurs soins sans avoir à craindre des répercussions légales ou professionnelles. Canadien d'origine, le directeur médical d'une organisation américaine qui préconise le droit à la mort a formulé ces observations au cours de la récente assemblée annuelle de Mourir dans la Dignité, un groupe canadien.
Legalized physician-assisted suicide for patients with incurable illnesses should be part of an overall shift in the way these patients are treated, says the medical director of the Hemlock Society USA.
Dr. Richard MacDonald, a Canadian-trained physician who now lives in the US, said the new approach should include better education about the dying process, counselling to ensure the patient is not depressed and earlier and more frequent referral to hospice care to allow for better pain management and additional guidance for patients and their families.
"We need a new understanding of what the continuum of care should be," MacDonald told the recent annual meeting of Dying With Dignity, a Canadian right-to-die lobby group. "That should include giving the patient control over the manner and the time of dying, and in that should be included the choice to have physician aid in dying."
MacDonald also argued that allowing physician-assisted suicide can help to improve the care available to terminally ill patients. He said improvements are already noticeable in Oregon, where euthanasia was legalized in 1994. Although court challenges have rendered Oregon's Measure 16 ineffectual, MacDonald said the number of referrals to hospice care has increased dramatically since the law was passed.
Dying With Dignity, a Toronto-based group, was started in 1980 to promote the right of patients with an incurable illness to end their lives quickly, painlessly and with the help of a doctor. It has about 9500 members across Canada and an annual budget of approximately $140 000. There are at least 35 such organizations around the world, including 3 in Canada and 5 in the US. The Hemlock Society USA, which was also launched in 1980, is among the most prominent. Its founder, journalist Derek Humphrey, helped bring the issues of active euthanasia and physician-assisted death to the forefront in the early 1990s, when he published Final Exit. That bestseller instructed readers how to end their lives.
The Hemlock Society was instrumental in convincing state governments in Oregon, California and Washington to hold referendums on the issue of physician-assisted suicide. MacDonald, who graduated from the University of Alberta in 1952, practises family medicine near San Francisco. He became the Hemlock Society's medical director in 1993 and helped set up its medical advisory board in 1994.
Active euthanasia and physician-assisted suicide are illegal in most countries. The Netherlands does not sanction either option, although both have been practised there for 20 years. Active euthanasia was legal in the Northern Territory of Australia -- the only place in the world ever to allow it -- until March, when the law permitting it was struck down by the Australian Supreme Court. Physician-assisted suicide and euthanasia are illegal in Canada and are opposed by the CMA and many other groups.
MacDonald said clear rules outlining procedures to follow when a patient requests a hastened death would likely prevent criminal charges against physicians. Guidelines would allow doctors to consult colleagues, take their case to an ethics committee or ask for a psychiatric assessment to ensure the patient has made a sound decision.
According to MacDonald, opposition to such rules has come from religious groups and organizations such as the CMA and American Medical Association. However, he maintained that organized medicine often fails to reflect physicians' views. Until the early 1970s, said MacDonald, doctors routinely helped terminally ill patients end their lives and 75% to 85% of patients were sent home to die. "We would visit and we would make sure they had plenty of medication and we would let them know how much medication they could take to end their lives if life was no longer worth living."
He thinks this equation changed as technology became more sophisticated. Today most terminally ill patients die in hospital, where they are often kept alive even though their life has become meaningless. "Machines were not meant to treat when it is futile to do so, but that is what has happened."
MacDonald said the use of "overtreatment" is out of line with the beliefs of most physicians and patients. A 1996 Gallup poll concluded that 75% of people support euthanasia in cases where death is imminent. That corresponds closely with a 1995 survey of Oregon doctors, which revealed that 65% of respondents believed assisted death is ethical or should be legal. Another survey involving Colorado physicians indicated that 60% had treated patients for whom they felt active euthanasia was justified, but only 35% had given drugs that would shorten a patient's life.
MacDonald said doctors are reluctant to follow their patients' wishes and their own conscience because they are afraid they will be prosecuted. "They are afraid of losing their licence and of not being able to do what they are trained to do and what they love to do," he said.
He thinks legislation should set out criteria for "rational suicide." Assistance should only be allowed for patients who have an "unremitting, hopeless condition," who are mentally competent and who have gone through a "sound decision-making process" based on full disclosure from their physician. "To me suicide is an irrational act or an act of an irrational individual," MacDonald said. "This is for someone with a well mind but a very unwell body."
MacDonald agreed with several audience members who said religious morality is one of the biggest stumbling blocks facing the right-to-die movement.
Senator Joan Neiman, chair of the now-defunct Senate Committee on Euthanasia and Physician-Assisted Dying, said most politicians do not oppose physician-assisted suicide. However, they are reluctant to change the legislation because of pressure from constituents.
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