A few days after the Supreme Court of Canada overturned the prohibition against doctor-assisted suicide, I received a note from a wonderful colleague of mine saying that her closest friend’s 53-year-old son had just died of spinal cancer. Two weeks before his death, he had visited his doctor, experiencing “terrible pain.” Despite his anguish, his physician refused to give him morphine, claiming that because he was a smoker he was “more likely to become addicted.”
While this seems unfathomable, even grotesque, ignorance and lack of skill in attending to the needs of dying patients are still tragically common in Canada.
Despite the impressive strides that palliative care has taken in areas such as pain and symptom management, and sensitivities to the psychosocial, existential and spiritual challenges facing dying patients and their families, at their time of licensure, physicians have been taught less about pain management than those graduating from veterinary medicine. Most MDs have knowledge deficiencies that can significantly impair their ability to manage cancer pain.
Doctors are also not generally well trained to engage in end-of-life conversations, meaning that goals of care often remain unclear. Patients may not receive the care they want, nor the opportunity to live out their final days in the place they would want to die.
In light of the court decision, these issues have never been more important, nor the need to resolve them more pressing. The court has given Parliament a year to sort out how it will move forward and rewrite the Criminal Code. Within these deliberations, it should be noted that the authority to provide a hastened death will be conferred on physicians, many of whom lack competencies to care for dying patients. To be clear, dying badly in Canada will rarely be the fallout of not having access to a lethal overdose or injection and, almost invariably, the result of inadequate or substandard end-of-life care. The time for physicians to learn how to look after their patients until the very end, is now.
The court felt that patients needed to be provided more choices. By adding doctor assisted suicide into the mix, what options will dying patients in Canada actually have?
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. In the future, how might this kind of scenario play itself out in the many Canadian settings that do not have adequate palliative care? The choices will be settling for sub-optimal care, dislocating from friends and family to seek out better care elsewhere or considering medically hastened death. We are about to become a country that extends patients the right to a hastened death but no legislative guarantees or assurances that they will be well cared for until they die.
Federal and provincial governments will need to make large investments in hospice and palliative care in order to offer patients and families choices that are equitable, compassionate and real.
While autonomy has driven the right-to-die agenda, fear has been its engine. Now policy-makers will need to grapple with how to draw a circle around autonomy, which means determining for whom and under what conditions medically hastened death will be permitted. Establishing those boundaries has implications for who will feel more or less afraid, who will feel more or less valued and who will anticipate death with more or less sense of calm.
Of this we can be sure: the width and stability of that circle will profoundly influence the culture of caring for dying Canadians and those among us who are most vulnerable for generations to come.
— Dr. Harvey Chochinov is a psychiatry professor at the University of Manitoba and an expert adviser with EvidenceNetwork.ca.