Carleton University Sponsors Two-Day Symposium on Physician Assisted Suicide
By Karen Young

I recently had the opportunity to attend a symposium on the “Ethical, Legal and Social Perspectives on Physician Assisted Suicide.”  What I thought would be two days of traumatizing discussions on why and how to get Physician Assisted Suicide legalized in Canada turned out to be a thought-provoking weekend of great decision and honest debate.
           
The symposium opened with Tom Beauchamp, a philosophy professor from Georgetown University with an interest in practical ethics and policies.  Beauchamp worked with the organization Compassionate Dying—now called Compassionate Choices—which promotes assisted suicide.  He began his discussion of Physician Assisted Suicide (PAS) by stating that there is no real consensus among physicians or ethicists on the issue, which he prefers to refer to as Physician Hastened Death. 

In attempting to justify PAS, Beauchamp identified two issues: whether physicians are morally justified to comply with patients who request PAS and whether it is morally justified to legalize PAS.  Regarding the moral justification for physicians, Beauchamp argued that helping a patient with a “valid” request could be morally justified, based on the claim that palliative care does not ade quately serve the suffering, loss of ability and unhappiness of terminally ill patients. Causing a death was not a wrong in itself, according to Beauchamp, especially if the cause of death was passive—the withdrawal of treatment—since this would not unjustly cause harm. Beauchamp also concluded, however, that legalization of PAS was not necessarily justified on the basis of morality. While he argued that physicians ought to be free to support PAS, he also stated that physicians could not be coerced into accepting requests for PAS or told what decision to make on the issue.
           
Beauchamp also questioned why the law permits patients to request the withdrawal of treatments in order to hasten their death, but patients who are terminally ill but not receiving life sustaining treatments are denied the option to hasten death and must rely on palliative care.  
           
Jerome Bickenbach is a professor at Queen’s University in Kingston with a background in the ethical, philosophical, and legal issues surrounding disability policies. He spoke on the issue of PAS using a disability critique--Bickenbach insisted that the discussion over PAS must account for issues of equality.  Questioning whether equality constituted autonomy, Bickenbach challenged the notion that autonomy is the corner stone to the justification of PAS, since a ‘quality of life’ clause is always inserted into PAS legislation.  If the right to autonomy is the foundational argument for legalized PAS, there should be no need for a ‘quality of life’ clause. Furthermore, if autonomy is a sufficient argument, anyone should have the right to request PAS regardless of any conditions, he argued—an able-bodied 17 would then be permitted to request PAS without any objections. 
           
Most reasonable people find this abhorrent, as does society at large, considering the time and resources spent on suicide prevention programs; thus, a ‘quality of life’ condition becomes necessary to make PAS legitimate. 
           
Once ‘quality of life’ becomes a necessary component of PAS, however, things get tricky.  Who assesses ‘quality of life?’ 
           
It is an established fact that persons with disabilities rate themselves as having a higher ‘quality of life’ than an able bodied person would rate the life quality of the disabled. Bickenbach also made the point that we are all terminal and in the process of dying, we just don’t know when. We all suffer, we all bear pain and we all bear pain differently—what is bearable to one, might be unbearable to another—and most people see life as having more value than death.   
           
Jocelyn Downie, the director of the Health Law Institute at Dalhousie University, focused on presenting PAS from the legal stand point. While assisted suicide is prohibited in the law books of Canada, Downie stated, the law on the street is somewhat more tolerant.  That tolerance is evidenced in the cases of assisted suicide over the past decade in which the persons involved have been either acquitted or convicted with a suspended sentence.  
           
John Griffiths, from the University of Groningen in the Netherlands, spoke about the situation in the Netherlands and the Dutch Euthanasia Law.  The premise of his discussion was the need to regulate the practice of euthanasia.  In defence of his argument he cited the ‘Nude Beach’ phenomenon.  For decades, nude beaches were taboo in the Netherlands.  During the ‘70’s nude beaches began to become less and less taboo and instead of legalizing nude beaches, regulations and guidelines were drawn up to ensure that people ‘dressed’ appropriately on beaches.  Similarly, as euthanasia became less taboo, regulations and guidelines were needed to ensure patient care—the Dutch Euthanasia Laws.  Griffiths claimed that patients are only euthanized if a review committee agrees that all the conditions of autonomy, equality and ‘quality of life’ have been satisfied.   He even stated that in the Netherlands discrimination and concern that vulnerable persons would be euthanized has proven to be a non-issue in practice. (Research and extensive self-reporting from Dutch doctors involved in the practice in fact have shown serious abuses of the guidelines, with the numbers of “involuntary” euthanasia victims, including children and infants, estimated to be at least 1000 annually.)
           
Carlos Gomez, a physician from Church Falls Virginia who works with terminally ill patients, began his presentation by saying that there will always be cases in which he would have a tough time arguing against PAS; however, he also stated that laws cannot be based on the most ‘difficult’ cases.  We are all mortal, Gomez said, and the only difference between us and terminal patients is that they must suddenly face their mortality.  Gomez spoke to the patient-physician relationship, explaining that as a physician he views his responsibility towards his patients as greater than a contractual agreement.  He made the argument that physicians are human, they make mistakes and they have their own altruisms. 
           
In his early years as a ‘house official,’ Gomez explained that the formula used to determine the quality of physician care was the number of women on hormone replacement therapy compared to the number of menopausal women in a given doctors practice.  Gomez openly admitted that based on the health benefits promoted and the fact that his ‘abilities’ as a doctor rested on the number of menopausal women he had placed on hormonal therapy, he badgered and coerced woman into taking hormone replacements. 
           
Despite all the data and experience of doctors working with the terminally ill, they consistently over-estimate the survival rate of their patients, often by months, Gomez said.  The only significant, factor determining the doctor’s estimation was the length of time the physician had known the patient—the longer the doctor had known the patient, the greater the likelihood he would over-estimate the patient’s survival time.  Gomez also expressed that one of his concerns with PAS a decade ago was that vulnerable persons might be coerced into PAS.  But, he pointed out that in fact it is white, middle class males who are educated, have medical insurance and are either widowed, divorced or alone that request PAS most frequently.  This is confirmed by the data from Oregon, the only state in North American to legalize PAS.

Language was an issue for Gomez, who stated the trend to refer to PAS as something other than ‘suicide’ is double-speak. He questioned why the practice should be called ‘physician hastened death’; “call it what it is.”  He also asked why we have turned mortality into a medical problem.  The PAS debate must be reframed into what we owe each other as human beings, Gomez concluded, and not what physicians owe their patients in end of life decisions. 
           
During question time, Tom Beauchamp questioned Gomez’s position on the need to use the term ‘suicide.’  Beauchamp asserted that it was unfair to use the term suicide in reference to a patient who requests to be removed from life support so that they can die.  Gomez responded that he had never encountered such a scenario is his entire career.  An incensed Beauchamp, snapped, “You’ve never had a patient request to be removed from life support.”  To which, Gomez replied, “Yes I have, but I have never had a patient declare ‘I want death, so take me off life support’.  Rather, patients nearing death simply request to be removed from the machine.  These patients recognize that death is inevitable, but death is not the goal, rather the goal is freedom from the machine.”
           
The final presenter, Daniel Weinstock, a philosophy professor from Montreal, rounded out the symposium with further decision on whether autonomy or ‘quality of life’ is the more salient issue for PAS.  
           
Gomez made reference to an experience he had treating a terminally ill Buddhist nun.  The nun’s faith dictated that she needed to be present to her own death.  This meant morphine was not permitted as it could alter the mental state.  This posed a problem since the nun was suffering from a lesion that needed daily redressing.  When the nurses would change the dressing the patient would moan incessantly due to the pain.  One of the attendees of the symposium found it ridiculous that this woman was allowed to suffer because suffering was of no value.  Gomez explained that the Buddhist nun found value in her suffering and pointed out that while some people might see no value in suffering, others find great meaning in suffering. 
           
The notion that terminally ill patients couldn’t possible have a good ‘quality of life’ and suffer senselessly seems to be the prevailing attitude of many PAS supporters.  It is almost as though the problem is not so much in the suffering of the patient but with those who have a lot of trouble witnessing others suffer.  Maybe this is because whenever we see someone suffering we are forced to recognize our own mortality.  Thus, in an effort to feel more comfortable, PAS supporters feel a need to rid themselves and the sufferer of their suffering at any cost.

The symposium was sponsored by the Centre on Values and Ethics at Carleton University and the Centre de Rechérche en Ethique de l’Université de Montréal, Université de Montréal.

Karen Young is the office manager for LifeCanada.