Image Credit: MacKay Cartoons   (Image: MacKay Cartoons)

In February, the Supreme Court of Canada overturned a ruling that strictly kept physician-assisted suicide illegal nationwide. Being an election year, this decision opened the gates for this issue to be discussed in the race to Parliament Hill. But rather than running with the issue, May, Mulcair and (now) Trudeau tiptoe forward with caution.


Both parties face resistance from the palliative care establishment within the Canadian Medical Association, which released a statement that assisted suicide should be limited to “...rare occasions where patients have such a [high] degree of suffering...”. Recognizing this pushback, the motion for reform is modest: make physician-assisted suicide available only in the most extreme medical circumstances.


While this seems like a rather safe starting point, it's completely out of touch with the unique ethical topography of death. Sensitive to the pulse of public opinion, it ignores the medical realities at hand.


The ethical questions connected to doctor-assisted suicide are numerous, but to understand the shakiness of the “start with the extreme cases” stance, we need only focus on one:


What happens if you change your mind?

 

Take, for example, a woman diagnosed with early-stage Alzheimer's Disease. While she still has near-normal cognition, she writes a living will stipulating that, once she loses her ability to speak, she would like to be assisted in ending her life. Her wishes sound reasonable but are immediately discarded if, at the later stages of her disease, she wants to continue living. Further, even if the timeline is reversed and the patient only wants to die towards the later stages of her disease, these wishes cannot be granted since she is not cognitively capable of rational decision-making. Surely Alzheimer's isn’t the “extreme case” that we should start with if we want to be ethically cautious.


Perhaps these ethical complications are unique to cognitive diseases. Let’s instead consider a disease that degenerates physical mobility but preserves a person’s mental state. A patient capable of decisions at every point leading to his or her death introduces complications on a finer timeline. If a patient consents but reneges after the physician has administered the fatal injection, the physician is responsible for killing against the wishes of the patient. But physician-assisted suicide—the procedure cleared by the Supreme Court—circumvents this legal risk. Once the doctor sets up a mechanism to end the patient’s life, the patient must physically trigger it themselves. This fixes the problem of killing, but excludes patients with late-stage neurodegenerative diseases that rob them of the mobility to trigger a mechanism. If we are legislating patient-assisted suicide, change can't start on these cases, either.


But when we talk about the “extreme cases,” the most obvious is patients living in unbearable pain. Here the prospect of changing your mind is more hypothetical. While a patient may consent to death when in the throes of pain, there is a possibility that this answer could change if their pain is ever adequately relieved. The challenge is in determining how much their decision is being coerced by short-term panic in the face of pain. In this case, the more extreme the pain, the more ethically troublesome physician-assisted suicide becomes. The safest cases on which to proceed are ones in which the patient’s pain is not overwhelmingly extreme.


Back to politics: where are these extreme cases we were going to cautiously approach, again?


If any inroads are to be made on this issue, we need to suspend our political intuitions to make way for our ethical ones. While emotional appeals pick at low hanging fruit—cases of cognitive incapacity, physical immobility or intolerable pain—the ethical way forward will have to begin with middle-of-the-line cases, not extremes.


As this issue enters the electoral race, it’s important to start off on the right foot and introduce Canadians to an ethical reality, not an emotional shell game. This means putting aside our expectations of politics; the first reforms will not necessarily accommodate the most in need.


The emerging debate on physician-assisted suicide opens a complex area of discourse. Assurances that changes will begin with only extreme cases ignore the practical ethics of doctor-assisted suicide. If this is to be a serious issue of this election, the discourse must come to terms with that reality.


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