Edited by Ian Gentles

Stoddart Publishing, 1995. 131 pages, $18.95

Reviewed by Sue Careless

You are a high-profile, public advocate against euthanasia, but in your private life your own father, dying of bowel, stomach and liver cancer, begs you to assist him in suicide. What do you do?

Ian Gentles, the editor of Euthanasia and Assisted Suicide: The Current Debate recounts how, for him, euthanasia hit home. It is one of the most moving passages in a fine book.

We who take public stands on issues will find ourselves having to live out private dramas. Ian was faithful to his convictions and to his father. He told him that no one was trying to prolong his death, only make him comfortable.

Gentles’ father was a confirmed atheist. While healthy, he had joined Dying with Dignity and had signed a “living will” requesting a lethal injection should he contract a terminal illness. When terminally ill, he read Final Exit. Gentles Sr. has never brooked any argument with his children. His two sons, along with his best friend and his physician, told him they respected his decision to refuse all medical treatment and supported his decision to die at home, but they drew the line at assisting in his suicide.

Gentles concludes, “In his last weeks my father ran into the perplexing opposition of friends and family and physicians to his expressed desire for suicide. But to his surprise he found himself enriched by the love of people who cared deeply for him and were competent enough to suppress his pain, make him feel that he was the centre of attention and to ease his passage out of this life. He died in peace and with dignity.

“If this fierce atheist, who was bound and determined that no one was going to stop him from enjoying the benefits of active euthanasia, finally abandoned his insistence on pursing such a course, then I am convinced that the great majority of other individuals who think they would like to end their lives could be rescued by first-rate palliative care and the love of those close to them.”

All the contributors to Euthanasia and Assisted Suicide: The Current Debate, are legal and medical experts, highly respected in their own fields. The Current Debate makes their insights accessible to the thoughtful lay person.

Most Canadians would be shocked to learn that the professionals involved in the bedside care of the dying are strongly opposed to the legalization of euthanasia and assisted suicide.

The Current Debate reports on a large-scale study of 545 North American health-care professionals who attended a recent International Conference on Terminal Care in Montreal. The study concluded that almost three-quarters of health care professionals think direct killing is unethical, while two-thirds do not think that the ending of terminally ill patients’ lives at their request should be accepted practice in palliative-care units.

According to the survey, the religiously committed are 21% more likely to oppose active euthanasia than the non-religiously committed. More than two-thirds of palliative care professionals in their sample (68%) identify themselves as attending religious services. Three-quarters of the professional care-givers state, “Yes, direct killing is unethical.”

The Canadian Palliative Care Association, representing about 500 formal programs in the country and the World Health Organization’s Cancer Pain Relief and Palliative Care Program both believe that euthanasia is not the answer to pain. The Canadian Medical Association has pointed out that, where euthanasia is easily available palliative care and pain management suffer.

The Current Debate also examines a small pilot study of 66 elderly but not terminally ill Canadians in two homes for the aged. These residence drew a clear distinction between refusing active treatment and euthanasia. They also did not support their children or next of kin making a decision to end their lives were they to become terminally ill.

Lawyer Robert Nadeau charts the legal trends on euthanasia in Canada, the United States and the Netherlands. “Active euthanasia, despite recent opinion polls, is not likely to become an accepted practise in Canada in the foreseeable future.” He cites “the firm and unequivocal rejection of active euthanasia by professional medical bodies in Canada and the United States.”

Nadeau examines “substituted judgement” or “surrogate decision-making,” deciding on behalf of a patient whose comatose or otherwise unable to give consent, that further medical treatment is useless and ought to be withdrawn.

Nadeau notes the Canadian Law Reform Commission’s firm presumption in favour of life: “the patient should always be presumed to want to live, and that the patient would prefer life to death even when unable to express that preference.” Yet the presumption “would not oblige the physician to use extraordinary or unduly burdensome measures to save a patient.” The Commission correctly pointed out that the principle of self-determination does not imply the right of an individual to require others to put him to death.

Justice John Sopinka, of the Supreme Court of Canada, agreed in his majority ruling on the Rodriguez case, “The active participation of one individual in the death of another is intrinsically morally and legally wrong.”

Law professor Ian Hunter writes with the scope of a philosopher. “In most cultures, questions concerning death and its significance are openly acknowledged to be spiritual questions. Only in Canada could one find a chief justice promising to consider life and death ‘without regard to philosophical or theological consideration’ and another justice writing of ‘sacred…in the secular sense.’”

The Current Debate supports these legal and philosophical considerations with sound practical care. Directors of palliative care units have repeatedly stated that more than 95% of patients under their care do not suffer uncontrollable pain. Wrongly, pain relieving drugs are still referred to as “sedatives.” However, “In the vast majority of cases the pain and symptoms of advanced disease can be relieved without a major impact on the level of consciousness.”

Gentles writes that death due to narcotics in pain management is very rare. “Patients being treated for extreme pain build up a tolerance for the narcotic. A dosage that might kill a normal patient is not an overdose for a normal cancer patient. Even if a dose of narcotics does hasten a patient’s death, provided that the primary intention was to relieve pain and the patient was nearing death, the ethical [and legal] consensus is this is sound medical practise.”

Dr. John Scott, head of palliative care at the University of Ottawa writes, “A person approaching death has no appetite for food and typically desires only to keep his or her mouth moistened…most health care professionals agree that patients who are allowed to die without artificial hydration and nutrition may be as comfortable or more so than patients who receive conventional amounts of both.”

“Euthanasia advocates fail to appreciate the richness and depth of the psychology of dying” says Scott. “Yes, the cries, ‘Let me die’, ‘Help me die’ or ‘I wish I could die’ are real and deep, but they can be interpreted only in the context of lamentation…Lamentation is a call for support and relief, a search for meaning, and an invitation for relationship. It is a cry for life.”

“Most deaths occur gently and without agitation or distress,” says Scott. “The cry for euthanasia is not arising from the bedside of the dying but from powerful minority political groups.”