Distinguished Professor of Psychiatry at the University of Manitoba, expert advisor, EvidenceNetwork.ca
Dr. Chochinov is an advisor to EvidenceNetwork.ca, a Distinguished Professor of Psychiatry at the University of Manitoba, Canada Research Chair in Palliative Care and Director of the Manitoba Palliative Care Research.
One would hope that every patient whose angst expresses itself as a wish to die would have access to palliative care expertise, including a thorough and detailed evaluation of the physical, psychosocial, existential and spiritual drivers motivating their request for hastened death.
If physician-hastened death is part of the continuum of medicine, then we must treat it as such. Like any other new treatment or clinical innovation, it demands careful evaluation and methodological rigor, including fixed eligibility criteria, detailed data collection, objective monitoring of outcomes and tracking of adverse effects; the ability to analyze cumulative data, with incremental ramping up entirely based on preceding trial outcomes. We would insist on no less stringency for anything else.
In any assisted-dying regime, a competent patient is free to change their mind or express their ambivalence by withdrawing a request or postponing an assisted death. To permit an assisted death to proceed on the basis of an advance directive effectively denies this protection to persons who are no longer capable of making or expressing health-care decisions.
With the advent of physician-hastened death, there has never been a more pressing moment in history demanding we get our approach to human suffering and palliative care right. Fewer than two per cent of patients will likely choose to have their lives ended; most will want to live out the length of their days in care and comfort. That should not be asking too much. One thing is for certain: the dying are too ill to speak, and the dead will never complain.
The Parliament's Special Joint Committee on Physician-Assisted Death, nevertheless, urged the federal government not to exclude individuals with psychiatric conditions from being considered eligible. Their reasoning comes down to this: Mental suffering is no less profound than physical suffering, so denying individuals with mental illness access to physician hastened death would be discriminatory and a violation of their Charter rights. It's an excellent point, and one worth seriously discussing.
Human beings are not good at predicting how they will react in circumstances that have yet to unfold. Those of us working in healthcare understand that life-altering illness, trauma or anticipation of death can sometimes sap the will to live. In those instances, healthcare providers are called upon to commit time; time to manage distress, provide unwavering support and to assuage fear that patients might be abandoned to their hopelessness and despair. That is the essence of how medicine has traditionally responded to suffering. Stopping time by way of arranging the patient's death has never been part of that response.
For 70 to 80 per cent of Canadians, palliative care is not available and hence, not a real choice. A dear friend of mine recently died of brain cancer. She spent her final months in hospice, where she received exquisite end-of-life care. How might this kind of scenario play itself out in the many Canadian settings that do not have adequate palliative care?
This past week, the Supreme Court of Canada has been hearing an appeal by the BC Civil Liberties Association that could grant terminally ill Canadians the right to assisted suicide. The Court faces a daunting task. Palliative care cannot eliminate every facet of end-of life suffering. Preserving dignity for patients at the end of life requires a steadfast commitment to non-abandonment, meticulous management of suffering and a tone of care marked by kindness. In response to this dignity conserving approach, the former head of the Hemlock Society conceded that "if most individuals with a terminal illness were treated this way, the incentive to end their lives would be greatly reduced."
If all this sounds too daunting, here is some language you might want to consider. Imagine turning to the person you have in mind and begin by saying something like, "I love you." If that feels like a stretch, you can always start with: "Look, I care about you, most of the time" or "What matters to you matters to me."