Dying With Dignity Canada raised the alarm earlier this month about the Canadian Medical Association's draft protocols for physician assisted dying. In particular, we are concerned by the CMA's insistence that doctors who oppose assisted dying for reasons of conscience should not be required to refer patients who request it to a willing provider or third-party referral body.
This policy, if implemented broadly, poses a significant barrier for patients — particularly those living in remote communities where healthcare services are scarce — looking to access their right to die with the help of a doctor. (CMA brass testified to a committee of federal MPs and senators this week that, no, foregoing a duty to refer won't threaten patient access. We're still not convinced.)
- Related: Old debates delay new laws for assisted dying
- Related: New CMA recommendations don't do enough to protect patients' rights
For his latest, most irreverent post to the DWDC blog, Dr. David Amies imagines a dialogue between a terminally ill man who wants to end his suffering and doctor who refuses to help and refuses to refer the patient to another physician. Yes, the piece is satirical and yes, the repartee is heavy-handed by design. However, as with any good morality play, the real-life ethical dilemmas it probes are ultimately what matters.
[Scene: a public general hospital in a medium sized town in the province British Saskaltoba, Canada. Poor Humble Patient (PHP) is lying on his bed, obviously distressed, breathless, sweating and anxious. Enter Dr. Righteous (Dr R)]
Dr R: Good morning, John. Are you feeling better today? It is now over a week since you finished your fifth round of chemo.
PHP: No, doctor. I feel lousy. I ache all over. I can’t sleep. I vomit after every meal. I am getting steadily weaker and I am not really sure how long I can go on like this. All the meds you are giving me are making me feel so drowsy and out of it.
Dr R: What are you saying, John?
PHP: I am telling you that I have come to know you and trust you during the last five years since my bloody cancer was discovered. I have had surgery which left me incontinent and impotent. It did not remove the cancer because a few months later, it was necessary for me to have x-ray treatment and that left me feeling exhausted. Then I started on chemo and that was a nightmare. My hair fell out, I felt sick all day long and very weak. It was no better after the second round or the third, fourth or fifth. I am pretty sure that this cancer is going to kill me if the treatment doesn’t get me first.
Dr R: Come on, John. This does not sound at all like you!
PHP: I’ve had it. I have talked to my wife and kids and told them that I don’t want any more. I have heard that it is now possible for a suffering person like me to ask his doctor for help in ending his life. After all, if my doggie was in such a mess, I would have long ago taken him to the vet. So, that’s what I am asking for. I want you to be the vet.
Dr R: John, I see you have not entirely lost you sense of humour but you are putting me on the spot. I am afraid that I cannot go along with your request. I am sorry but my religion just plain forbids me to take over God’s work. You see, don’t you, that only God can decide when a person’s life should end. For me to step in and give you drugs that I know will kill you would be blasphemous. I am sorry, but there it is.
PHP: So you are not prepared to help me?
Dr R: I feel your pain and I really want to give you hope and make you well again. I have heard of an experimental treatment that has had some success in Saudi…
PHP: Enough already! Stop right there! Haven’t you done enough?
Dr R: John, aside from my religious views, my job as a doctor is to preserve life not to take it…
PHP: OK, I understand that you can’t or won’t give me what I want the most but surely you can put me in the hands of someone who can.
Dr R: No John, I am sorry to have to tell you that I can’t. For you see, I am sure, for me to do so, would compromise my position. I would just be asking someone else to commit a grave sin. Not only my church agrees with this position but my medical association takes the same view.
PHP: So you are going to wash your hands of me. That’s the reward I get for subjecting myself to your ministrations for these past five years. You are cutting me loose when I most need help.
Dr R: That’s coming on a bit strong, but, in a word, yes.
Enter nurse, stage left, bearing marble bowl covered with purple cloth. She takes it to Dr R who removes the cover and ceremoniously washes his hands before leaving the stage. It is just possible to see a faint halo round his head and to hear solemn, sacred music.
I appreciate that I can be accused of over-egging the pudding here but sometimes it is necessary to do so, to make a point. There comes a time when honeyed words just do not cut it. The Canadian Medical Association (CMA) has spent the past two years sounding out its membership about physician assisted dying and has come up with several useful points. However, it has decreed that on the one hand, hospitals that oppose assisted dying should not be able to stop "their doctors" from providing the service at another location — good — but on the other, doctors who choose not to participate in assisted dying should not be required to refer patients to physicians willing to to do so — horrifying! They say that doctors must not abandon their patients but Dr. Righteous does not seem to have any other option if his (or her) conscientious objections to physician assisted dying are to be respected and the physician is to avoid the slightest compromise.
Dr. Righteous is more or less within his or her rights to cut loose the poor wretch, who is in extremis, and tell him to get on his bike and shift for himself. Imagine how much worse this situation would be if the institution in which this little play was set refused to allow assisted death to take place on its premises for religious reasons.
Surely this would be mean spirited to the nth degree. Patently, some way has to be found out of this dilemma. Dr. Righteous has the right to defer to his conscience. But, with rights come responsibilities. He is obligated to do no harm to his long-time patient. He cannot just shuck off his duty to PHP. Some way out of this dilemma has to be devised that is respectful to the patient, the doctor and the institution. I acknowledge that my scenario is a "what if" but the entire question of PAD is being framed and debated across the country in terms of "what ifs."
The CMA has more work to do!
Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.
- (Header photo credit: Steve Snodgrass/Flickr)