NewsCMAJ

Few health care topics stir debatelike euthanasia and assisted sui-cide, and some right-to-die

advocates believe that debate isslowly, but inexorably, shifting intheir favour.

Although assisted suicide recentlybecame legal in a second Americanstate and increasing numbers of peopleare seeking aid in dying at Europeanclinics, the issue has essentially laindormant in Canada since Liberal Sena-tor Sharon Carstairs’ unsuccessfulefforts of roughly a decade ago to intro-duce legislation shielding health careproviders from criminal liability if theyhonoured patients’ wishes to withholdor withdraw life-sustaining treatments.

Yet, that may be about to change asa Quebec College of Physicians taskforce on ethics weighs in this Novemberwith a discussion paper containing spe-cific recommendations on physician-assisted suicide. Meanwhile, Parliamentis expected to debate a private mem-ber’s euthanasia bill this fall (althoughthe bill will die on the order paper if afederal election is called).

Momentum for legislative changemay be gathering because populationsin most parts of the world are rapidlyaging, suggests Ruth von Fuchs, presi-dent and secretary of the Right to DieSociety of Canada.

“I think more people have seensomeone die badly, someone close tothem, and they think there has to be abetter way,” says von Fuchs, addingthat euthanasia should be part of “thecontinuum of care, the ultimate pallia-tion. Sometimes the most appropriateway to deal with suffering is to takeaway the substrata; life is what allowssuffering to occur.”

That’s been the case in Oregon since1997, when the state enacted its Deathwith Dignity Act, which “allows termi-nally-ill Oregonians to end their livesthrough the voluntary self-administrationof lethal medications, expressly pre-

scribed by a physician for that purpose.”In May, a woman suffering from pancre-atic cancer became the first person to dieunder the protection of similar legislationin Washington, which last year becamethe second state to legalize physician-assisted suicide.

In the Netherlands, physician-assisted suicide has been legal since1993 and enjoys widespread publicsupport. It is now also legal in Switzer-land, where more than 100 British peo-ple have journeyed to end their lives,including the conductor EdwardDownes, who, though not terminallyill, chose to die alongside his cancer-stricken wife in July at the Dignitasclinic in Zurich.

Canadian physicians have tradition-ally been hesitant to enter this publicand at times heated debate, but the Que-bec College of Physicians task force onethics, which has been privately debat-ing the issue for several years, proposedthat euthanasia be included “as part ofthe appropriate care in certain particularcircumstances.”

The task force, which does not sup-

port assisted-suicide clinics, is expectedto release its specific recommendationsin November in an effort to pressurethe federal government to change theCriminal Code to legalize euthanasia.This is necessary, according to the Col-lege, because terminally ill patientssometimes suffer from pain so intensethat the dose of painkillers required tocontrol it can be fatal; therefore, ineffect, euthanasia is already common-place and the law should be changed toreflect that.

That argument, however, is seen bysome opponents of euthanasia as notonly weak but nonsensical. Causingdeaths through efforts to reduce pain,they argue, is very different thanadministering overdoses with the intentto end lives.

“Pain relief treatment is not euthana-sia and giving increasing doses of nar-cotics can be incompetent medicalpractice — at a certain point differentpain relief modalities can be required.Unfortunately, some physicians’ med-ical knowledge is substandard in thisregard,” Margaret Somerville, director

CMAJ • OCTOBER 13, 2009 • 181(8)© 2009 Canadian Medical Association or its licensors

463

Euthanasia debate reignited

“The time has come for this Parliament to find a way to decriminalize medical assis-tance in dying, which is of such vital importance to those whose suffering can nolonger be relieved except by this ultimate compassion,” Francine Lalonde, Bloc Québé-cois Member of Parliament (La Pointe-de-l’Île) said while introducing Bill C-384.

Ch

ris

Wat

tie

/ Reu

ters

Previously published at www.cmaj.ca

News

Faced with staggering increases inopioid prescribing, rising rates ofaddiction and criminal activity,

as well as an apparent vacuum innational leadership, provincial collegesof physicians and surgeons are bandingtogether to craft opioid use guidelines.

Draft guidelines have been circu-lated to a national advisory group ofexperts in a bid to achieve consensusand are expected to be finalized inOctober as part of the provincial col-leges’ unprecedented move to createnational clinical practice guidelines.

Canadian doctors prescribe almosttwice as many of the powerful and addic-tive painkillers as they did a decade ago,making Canadians among the world’stop consumers of prescription opioids.

While that likely means better paincontrol for select groups — such as can-cer and palliative care patients — thecolleges are concerned that physiciansare inappropriately prescribing opioidsfor all manner of ailments. Others sug-gest that the colleges also hope to obviaterising concern about physician liability.

Janet Wright, assistant registrar ofthe Colleges of Physicians and Sur-geons of Alberta, says the regulatorycolleges decided to step in because no

one had created national guidelines. “Itis really unusual for regulatory bodiesto produce guidelines and we had lotsof discussion about whether we should.… But there was a void.”

Wright adds that the colleges alsofelt compelled to act because doctorshave identified opioid prescribing as a“tough practice area.” A survey con-

ducted by the College of Physicians andSurgeons of Ontario found that familyphysicians ranked chronic pain manage-ment second only to mental health as achallenging area of clinical practice.

In British Columbia, “we found outthat most doctors don’t really know therules of the road when prescribing forsomeone with chronic noncancer pain,”says Dr. Robert Vroom, deputy regis-trar for the College of Physicians andSurgeons of BC. “Why should we bepunishing our doctors for somethingthey don’t know? This is one of thosebig gaps in their education and wethought we should do something tohelp doctors rather than beat them up.”

The draft clinical practical guidelinesnow being circulated were created by anacademic group at the Institute for Workand Health in Toronto, Ontario, that hadearlier developed a chapter on opioidsfor the Ontario college’s guidelines onchronic noncancer pain, says Dr. AndreaFurlan, evidence-based practice coordi-nator for the Institute. It’s expected theguidelines will eventually be maintained,and regularly updated, by the newMichael G. DeGroote National PainCentre being established at McMasterUniversity in Hamilton, Ontario.

Wright says the colleges jointlyfunded the National Opioid Use Guide-

CMAJ • OCTOBER 13, 2009 • 181(8)© 2009 Canadian Medical Association or its licensors

464

Surveys indicate that one of the mostpuzzling challenges that doctors face isappropriate use of opioids for chronicpain management.

Previously published at www.cmaj.ca

Regulatory colleges to set painkiller guidelines

@20

09 J

up

iter

imag

es C

orp

.

of the Centre for Medicine, Ethics andLaw at McGill University and author ofDeath Talk: The case against euthana-sia and physician-assisted suicide,writes in an email to CMAJ.

Alex Schadenberg, executive direc-tor of the Euthanasia Prevention Coali-tion, likewise argues that the rationaleoffered to support the Quebec Collegeof Physicians’ proposal is lacking. Pro-viding comfort has nothing to do withintentionally ending a life, he says, andphysicians are not charged for improperuse of opioids if a patient dies as aresult of accepted pain-relief practices.

“If we were to go down the routethey are talking about, it would createmore confusion,” says Schadenberg,who believes, if the College’s proposal

became law, doctors would be undermore scrutiny when patients on painmedication die. “Why did they use thathigh amount? Did they use it to kill thepain or kill the patient?”

Also expected to drive the euthana-sia agenda this fall is Bill C-384, a pri-vate member’s bill introduced byFrancine Lalonde, that seeks amend-ments to the Criminal Code to permitthe “right to die with dignity.” The billsurvived first reading and is expected tobe debated in the House of Commonsunless Parliament is dissolved as aresult of a nonconfidence vote in theminority government.

The bill states that medical practi-tioners would not be considered to becommitting homicide when they assist

in the deaths of people who are at least18 years old, have severe “physical ormental pain without prospect of relief”and have “provided a medical practi-tioner, while appearing to be lucid, withtwo written requests more than 10 daysapart expressly stating the person’s freeand informed consent to opt to die.”

Schadenberg forecasts that, as withtwo previous attempts to legalizeeuthanasia, the bill will fail, in partbecause its language is too broad. Healso takes particular issue with thephrase “appearing to be lucid.” That isquite different, he says, from actuallybeing lucid, which in itself can be diffi-cult to assess. — Roger Collier, CMAJ

DOI:10.1503/cmaj.109-3034