Assisted Suicide: Canadian Perspectives

CROSSING THE LINE: A Reflection on Palliative Care and Assisted Suicide1

Robert Wesley Boston CROSSING THE LINE A Reflection on Palliative Care and Assisted Suicide1 Throughout most ofWestern history death has occurred at home. Only the indigent were taken to hospital to die, but in the second half of the 20th century things changed. Spurred by the exigenciesof the Second WorldWar and by the postwar surge of energy and affluence, the 1950's and 60's saw scientific medicine take a great leap forward. Among its accomplishments were the development of antibiotics, safer anesthetics and surgical techniques for treatment of heretofore inoperable disease. Instead of places of last resort, hospitals became places of hope, for cure and of promise for longer life. The center of scientific medicine moved from home and clinic to hospital, but with this shift death also moved from home to hospital. When curative treatment was no longer effective for patients in hospital, and when "nothing more could be done" for them, they were transferred either to the little side rooms of British wards or, in North America, to rooms furthest removed from the nursing station; and there they languished . Astute observers of what was happening wrote brilliantly about this shift of death from home to hospital— among them psychiatrists John Hinton in Britain2 and Elisabeth Kiibler-Ross in North America.3 A most memorable passage from Hinton's writings is this: "They (the nurses) emergewith far greater credit than we, who are capable of ignoring the conditions which make muted 15 ASSISTED SUICIDE: CANADIAN PERSPECTIVES people suffer. The dissatisfied dead cannot noise abroad the negligence they have experienced."4 One such British nurse, who had also trained as a social worker, was Cicely Saunders.5 Strongly motivated to improve the care of patients dying in hospital, she "swatted up medicine" so that she might confront , on its own turf, the medical establishment so neglectful of these patients. Her pioneering work in symptom control in terminal illness, and her foundingof St. Christopher's Hospice in Sydenham, England,6 set the stage for the development of modern palliative medicine. Dr. Saunders (later Dame Cicely Saunders) is now acknowledged as the founder of the modern hospice movement.7 Today, palliative medicine is a discipline with scientific standards as demanding as those for curative medicine, but with a philosophy of treatment that accepts the inevitability of death, and which aims "to add life to days rather than just days to life."8 This new medical specialty has gained formal recognition in several countries, and the movement has spread worldwide with one notable exception—the Netherlands. In that country voluntary euthanasia and/or assisted suicide has been championed as the alternative to the protracted suffering of a terminal illness. About the same time as Saunders was beginning to challenge the British medical establishment on how to care for dying patients isolated in the side rooms of their great wards, I was a junior intern on a Canadian Department ofVeterans'Affairs ward to which an elderly veteran, dying of stomach cancer , had been admitted. He was assigned the room furthest from the nursing station, very small and half underground. There, this wasted man with his large stomach tumor lived out his last days. On rounds, the august head of the teaching team would inquire ofthe dyingman and then turn the team around before it reached his room. Undoubtedlythat memory, after a quarter century as a neonatologist caring for sick and premature infants at the beginning of life, was one of the influences that nudged me toward a year of retraining in palliativemedicine and, in turn, led to a very rewarding nine years of palliative medicine practice in hospital and community. 16 CROSSING THE LINE As a clinician having struggled with ethical issues surrounding both the first breath and the last, I came to retirement with a wish to understand better the ethical principles that I believed had guided my practice. I took up philosophy. In this essay, drawing on myexperience as a palliative care clinician , I try to examine with the rigor of philosophy and the honesty of retirement, those principles that, in my mind, kept me from crossing the line that separates aggressive action to control symptoms in terminal illness from action designed to relieve suffering by hastening death. The March 9, 1998 issue of Maclean's magazine9 provides a graphic account of why the first-degree murder charge against Halifax respirologist Dr. Nancy Morrison was dismissed . Her patient was...