The editorial on physician-assisted suicide follows a recent report by a Quebec government commission, which recommends that some dying patients should have the right, under strict conditions, to request medical help to die.
The Dying with Dignity commission — a multi-partisan group of nine members of Quebec's national assembly — issued its 180-page report a month ago after two years of research and public and expert consultation on the thorny issue.
Among its 24 recommendations is one suggesting that Quebec's attorney general suggest to Crown prosecutors in the province that a doctor who has helped a terminally ill patient to die not be charged with an offence. Euthanasia and assisted suicide are illegal in Canada under the Criminal Code.
Monday's editorial — entitled "Choosing when and how to die: Are we ready to perform therapeutic homicide?" — argues that the right-to-die issue should not be decided by the courts, such as the recent ruling rendered by a B.C. judge, but as part of a democratic process.
"Really what we wanted to say is that there are consequences of having a policy either way, but it's probably time that we do," said senior associate editor Dr. Ken Flegel, who co-authored the opinion piece with editor-in-chief Dr. John Fletcher.
"It's going to involve some sort of democratic process to arrive at a decision. And whatever the decision is, part of the country is not going to be very happy," Flegel said in an interview from Montreal.
"We'll just have to live with the fact that social choices and values will mature, change, move on, and we have to adapt to them. And it's time to have a very open public discussion and, we're hoping, a very democratic process for deciding how to change the law."
On June 15, a B.C. Supreme Court judge struck down the laws banning doctor-assisted suicide as unconstitutional, but suspended her ruling for one year to give Parliament time to draft new legislation. Judge Lynn Smith also ruled that one of the plaintiffs in the case, Gloria Taylor, would be allowed to seek assisted suicide within the year if she so chooses. Taylor, 64, of West Kelowna, B.C., has Lou Gehrig's disease.
Euthanasia and-or assisted suicide are legal in some European countries, among them the Netherlands, Belgium and Switzerland.
In Canada, repeated surveys have suggested that more than half of the population favour a dying patient having the right to end their suffering, and the proportion of doctors supporting medically assisted suicide tends to mirror the public's majority view, said Flegel.
"But there's a little extra issue inside this, and that's who is going to do this," he said, "because no one perceives themselves to have been trained to do it."
While the Hippocratic Oath charges physicians to "do no harm," Flegel said surgery, inserting needles to get blood samples and myriad other invasive procedures mean health providers do indeed do harm, but with the goal of healing. Under the Assault and Battery Act, doctors given patient consent are not subject to charge.
Flegel, an internal medicine specialist, acknowledged that terminally ill patients can have their deaths hastened as a result of being given heavy doses of morphine to control pain.
Under a bioethical principle called "second intention," doctors often relieve patients' suffering with drugs to the extent necessary, even if the secondary adverse effect means it shortens their lives, he said. "That's really not an issue anymore and that's a foundational principle of modern palliative care."
The Quebec report is important because it moves beyond the locked-in position that palliative-care physicians find themselves in by saying there are times when patients' suffering is so intolerable that they would rather stop that care and end their lives, Flegel said.
However, the commission stresses that euthanasia or doctor-assisted suicide would be allowed only under "very strict conditions."
"Then it goes on to say that we do not want this done by back-street operators, we do not want this done in non-transparent clinics in another country. We want it done where it can be monitored, where it can be adjudicated, where it's subject to controls and all the good things that happen when people make decisions openly and democratically and transparently."
Commenting on the editorial, health law expert Erin Nelson said Quebec doesn't have the ability to change federal law.
"All they can do is potentially seek to have some control over what happens in the province in terms of actually prosecuting people," Nelson, an associate professor of law at the University of Alberta, said Monday from Edmonton.
However, how Quebec deals with the issue could conceivably motivate change in the rest of Canada — or at least renewed discussion, she said.
"It's possible if people got very engaged about this issue and raised it and there was a sustained public discussion about it ... that the (federal) government would pay some attention to that.
"It's anyone's guess as to whether that would happen. These are very, very contentious issues where there tend to be very polarized views and not a whole lot of middle ground. And it's probably kind of a challenge from a political perspective to imagine how you're going to make everybody happy on a topic like this."
Still, the CMAJ editorial says it's time for Canadians to speak up with conviction, whether they are for or against the idea of a dying person's having the right to seek help to end their life.
"Personally, in an ideal world, I would like to see people calling their MPs," said Flegel. "And I think we need a free vote in the House of Commons on this. I don't think a referendum is appropriate here."
Flegel, who has accessed palliative care for many dying patients over his 33 years of practice, declined to disclose his own stance on assisted suicide, but said his position is deeply nuanced and took a lot of work and time to formulate.
Nelson said if informed public dialogue could lead to a middle ground on doctor-enabled suicide that most Canadians could feel comfortable with, "that would be fantastic. But I'm a little bit skeptical that that kind of informed discussion has a lot of potential.
"I think that's an area where there's a significant amount of public discomfort. And I think what will happen if that debate gets opened up is a lot of misunderstanding, misinformation and confusion — and some of it will be very deliberate — to lead to the result that we end up at an impasse.
"And that would be unfortunate because I don't think that would serve anybody well."