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Discussion 10: On June 17, 2016, Bill C-14 “Medical Assistance in Dying” was passed by the Senate making physician-assisted dying now legal in Canada. Do you agree with this? Why or why not?

Lesson Ten: Assisted Dying
Tasks:
•
Review online lesson 10 notes and complete activities
•
Participate in group discussion
•
View the videos, listen to the audio clips, and complete questions as directed in
lesson notes
Assigned Readings:
1. Dembo, Justine (2010). “Catherine Frazee presentation to Members of
Parliament.” Journal of Ethics in Mental Health. 5(1). (available on ereserve).
Videos:
1. Low, Donald. (2013) “In memory of Dr. Donald Low.” Published on Sep.
24, 2013.
2. Frazee, Catherine (2014) “Catherine Frazee presentation to Members
of Parliament.” Published October 7, 2014.
Audio:
1. Goldman, Brian. (2012) “Nagui’s Choice Part 1.” White Coat, Black Art.
September 7, 2012.
2. Goldman, Brian. (2012) “Nagui’s Choice Part 2.” White Coat, Black Art.
September 14, 2012.
Learning Outcomes
By the end of this lesson you should be able to:
•
Distinguish between euthanasia and assisted dying
•
Summarize the law in Canada regarding euthanasia and assisted suicide
•
Discuss the range of positions on assisted dying among various religions
•
Discuss examples of people who wished they could have ended their life with the
help of a physician and their reasons for wanting this help
•
Discuss arguments in favour of assisted dying as well as concerns with assisted
dying
•
Summarize issues related to the matter of whether physician assisted dying should
be extended to people with severe mental illness
Introduction
This lesson looks at the issue of assisted dying. Many say there is a growing interest in
this topic in our country because as “baby boomers” (those born between 1946 and
1964) age, they want the same freedom to choose in matters regarding death as they
have enjoyed in matters related to sexuality and pregnancy.
In this lesson we look at the difference between assisted suicide (now called assisted
dying or medical assistance in dying) and euthanasia and the legal issues involved with
both. We then examine religious views on assisted dying. Next we look closely at
examples of individuals who wished they could have had the help of a physician to end
their lives, and spoke publicly about this wish. Finally we examine some arguments in
favour of assisted dying as well as concerns about it.
You might ask yourself as we go through this lesson: what’s the difference between
suicide, which we discussed in the last lesson, and assisted dying? Write your thoughts
about this in your notes.
Difference between Assisted Suicide and Euthanasia
But before we continue, let’s define assisted suicide and distinguish it from euthanasia.
While there is overlap in the two topics, this lesson will focus exclusively on assisted
suicide. The definitions for each can be found in a Parliament of Canada background
paper entitled “Euthanasia and Assisted Suicide in Canada.” Here’s a link to this paper
if you are interested to view it:
Euthanasia in this background paper is defined as:
the deliberate act undertaken by one person with the intention of ending the life of
another person in order to relieve that person’s suffering. Voluntary euthanasia occurs
when the act is done in accordance with the wishes of a competent individual or a valid
advance directive. Non-voluntary euthanasia occurs when the act is done without
knowledge of the wishes of a competent individual or with respect to an incompetent
individual. Involuntary euthanasia, which is indistinguishable from murder or
manslaughter, occurs when the act is done against the wishes of a competent individual
or a valid advance directive.
Assisted suicide is defined as:
the act of intentionally killing oneself with the assistance of another who provides the
knowledge, means or both.
Thus the main difference between assisted suicide and euthanasia is that in assisted
suicide the patient performs the act of suicide. The assistant merely provides the means
for the patient to do so.
Legal Issues
The background paper then discusses the legal issues related to each:
Euthanasia:
Several Criminal Code provisions relate to euthanasia, but Section 14 relates most
directly. Section 14 provides that:
No person is entitled to consent to have death inflicted on him, and such consent does
not affect the criminal responsibility of any person by whom death may be inflicted on
the person by whom consent is given.
The paper goes on to explain that cases of euthanasia in Canada would likely be
prosecuted as first-degree murder. And the most famous case of euthanasia in Canada
is the Robert Latimer case. In 1993, Latimer killed his 12 year-old daughter Tracy who
had a severe case of cerebral palsy. Mr. Latimer killed her by putting her in a truck and
directed the exhaust fumes into the truck. His purpose was to put her out of her pain.
Mr. Latimer was charged with first-degree murder, convicted of second-degree murder,
and sentenced to life imprisonment with no possibility of parole for 10 years.
Assisted Suicide:
On Friday, February 6, 2015, the Supreme Court of Canada ruled in favour of physicianassisted suicide and on June 17, 2016, Bill C-14 “Medical Assistance in Dying” was
passed by the Senate making physician assisted dying now legal in Canada. With this
bill the term ‘assisted suicide’ is now referred to as ‘assisted dying’ or ‘medical
assistance in dying’.
Prior to June 17, 2016, assisted dying was illegal. Section 241 of the Criminal Code
read:
Everyone who a) counsels a person to commit suicide, or b) aids or abets a person to
commit suicide, whether suicide ensues or not, is guilty of an indictable offence and
liable to imprisonment for a term not exceeding fourteen years.
If you are interested, you’ll find at the end of this background paper, a full chronology of
euthanasia and assisted suicide in Canada from 1983 to January 2013.
In this lesson we look at two cases of terminally ill people in Canada who went public
with their views on assisted suicide and challenged this law. We will also consider
arguments for and against assisted dying.
Religious Views on Assisted Dying
Since the issue of assisted dying has to do with matters of life and death, most religious
traditions have explicitly stated positions on this topic. A U.S. based organization called
“Death with Dignity National Center,” whose aim is both to provide an option for dying
individuals and to stimulate nationwide improvements in end-of-life care, notes on their
website that “some faith traditions have embraced Death with Dignity as an ultimate act
of compassion, and others reject it is as morally bankrupt practice.” For your interest,
take a look at this website and notice the range of positions these religions have on
assisted dying.
Case Examples
Imagine that you are diagnosed with a terminal illness for which there is no cure. You learn that
the particular illness you have will end in an exceedingly painful and undignified process of
dying and death. You are told that the only help your medical team can offer you is palliative
care, that is, relief, through powerful pain medication and counselling, of the pain you are
already starting to feel. Your medical team discusses palliative care with you and sends you
to this website of the Canadian Hospice and Palliative Care Association in case you have any
further questions about it.
Imagine what you would be going through. Write your thoughts about this in your notes.
This is exactly what the following two people went through. And they both felt that the palliative
care they were offered was not enough to address their dire situation. Let’s see how they each
responded to this situation.
1. Donald Low
VIEW: Dr. Low became well known in Canada back in 2003 as the
microbiologist in Toronto who was the voice of calm during the SARS
(severe acute respiratory syndrome) crisis of 2003. In February 2013 Dr.
Low was diagnosed with a brain tumour. On September 24, 2013, this
video was posted on YouTube. The video was filmed eight days before Dr.
Low died on September 18, 2013 and it reignited the assisted suicide
debate in this country. Watch now this brief video:
In memory of Dr. Donald Low
Dr. Low says it will be a long time before we mature to a level where we
can accept “dying with dignity” in Canada. He’s referring to assisted
suicide, that is, physicians helping the terminally ill who choose to end their
lives by giving them lethal narcotics that will bring about their death as
simply as possible. Let’s look at another case:
2. Nagui Morcos
In 1995, when he was 45 years old, Nagui Morcos was diagnosed with
Huntington’s disease, a rare brain disorder that causes people to lose
control of their movements and their emotions. It was the same disease
that took his father’s life. Having watched his father suffer terribly with
Huntington’s, Nagui decided he would end his life before he was no longer
able to, rather than go through the final stages of this brutal disease.
Nagui lived eight years after this diagnosis and during this time he was
determined to get his message out in hopes that it would help to bring
about changes to the current laws in Canada to allow medically assisted
end of life for the terminally ill with little remaining quality of life.
Nagui went to many members of the media with his message, but he said
his favourite experience was being interviewed by Dr. Brian Goldman on
the CBC radio show called “White Coat, Black Art” which shows the health
care system from the point of view of healthcare providers. He was
interviewed numerous times on this show. We will listen to two of these
interviews.
LISTEN to both Part 1 and Part 2 of Nagui’s choice. Each is about 27
minutes long. Click on the link, and then click on the “Listen” button on the
webpage:
Nagui’s Choice Part 1 is the 3rd item in the list here
Nagui’s Choice Part 2 is the 4th item in the list here
As you listen, reflect on the following points and write your reply in your
notes.
o
Why does Nagui want to end his life?
o
How would his death have been different if medically
assisted suicide was legal?
Notice how Dr. Goldman’s views on physician assisted
suicide change during these two interviews.
o The interview refers to the farewell letter Nagui wrote and
was read at his memorial. Here’s a link to the letter:
o You might also want to explore his website found here
Nagui refers to an organization called “Dying with Dignity.” Here is the
organization’s mission statement: “We are a national, member-based
charity committed to helping people achieve quality in dying. We help
people understand all end-of-life options and work for choice in dying for all
Canadians.” Here’s a link to their website in case you are interested.
o
3. A Hypothetical Case
What if you suffered your entire life from a debilitating mental illness such
as severe depression? You had tried every form of therapy available to
you, but nothing helped. You also tried every form of medication for
depression and not only did it not help at all, but it gave you unbearable
side effects. You lived each day of your life in utter agony. The only thing
you desired was for your life to end.
READ: In November 2010 a very short article appeared in the Journal of
Ethics and Mental Health entitled “Addressing Treatment Futility and
Assisted Suicide in Psychiatry” written by Justine Dembo, a resident in
psychiatry at the University of Toronto. You can find the article here.
Dembo states that the purpose of her article is not to argue an opinion, but
to open a critical discussion on whether the growing interest in our society
on assisted suicide should include patients with unbearable suffering due
to a mental illness.
In order to engage this discussion, she asks a series of difficult yet
important questions, some of which I have highlighted here. See if you
have thoughts regarding any of these questions she poses:
o
Why are we more comfortable with “refractoriness”
(‘refractory’ means unresponsive to treatment) and
“terminality” in physical illness than in mental illness?
o
What would “palliative psychiatry” look like?
o
When if ever might assisted suicide be a reasonable
course of action in mental health care?
o
At what level of probability of no improvement or no cure
can we deem treatment of a mental illness “futile?” And
whose role is it to determine what constitutes “futility”
for a specific patient?
o
How many treatments should be attempted, and what
should the duration of each treatment be?
o
How many side effects should we expect patients to
tolerate in the name of treatment?
o
At what point should patients with severe mental illness
be allowed to give up on treatment, and on life itself?
Arguments in Favour of Assisted Dying
There are many arguments for assisted dying. The organization Dying with Dignity summarizes
these. Here are some of these arguments. If you are interested, you can look at their full list here.
These are the sorts of arguments made by people who wanted assisted dying to become legal in
Canada.
•
Palliative care cannot cure all suffering. There is some suffering that only death can
end.
•
Offering medically assisted dying is compassionate. It can be very distressing for
the family and health care team when someone terminally ill and in extreme pain is
begging for relief when there is no relief to be provided.
•
It’s what Canadians want. A public opinion poll by Angus Reid, dated 26th July
2012, states that 80% of respondents in Canada support allowing a doctor to assist
a patient in ending their life.
•
In Canada we already have the right to be removed from life support. Legalizing
assisted dying would give us all the same choice as those who rely on machines for
their survival.
•
Banning medically assisted death does not stop Canadians from ending their life.
Some choose to travel at great cost to Switzerland where it is legal. Some do it
without medical assistance, but this can be more painful than it would be if there
was medical assistance. Some choose very violent methods to end their life, which
can be traumatic, for themselves, their family and emergency help.
Concerns with Assisted Dying
There are also numerous arguments against assisted dying. Here are a few of these:
•
•
The Slippery Slope Argument. The concern here is that if we allow the
terminally ill the choice to have a physician assisted suicide, what would
stop us from eventually including not just the terminally ill, but the
chronically ill, the disabled, and other vulnerable populations? And what
would stop us from including not only those who choose to end their life this
way, but involuntary euthanasia as well?
The Question of “Dignity.” This argument is not so much against assisted
suicide as it is taking issue with one of the reasons some people with a
terminal illness would wish to have a physician help them end their life. We
saw that Dr. Low wished he could have had a physician help him end his
life so that he could have a “death with dignity.” Catherine Frazee, a former
chief commissioner of the Ontario Human Rights Commission and a
professor emerita of Ryerson University’s School of Disability Studies,
expressed concern that after seeing his video, one could draw the
conclusion that the solution to the problem of the experience of indignity is
to offer an expedited death. If we accept that things like paralysis, and bed
pans, and feeding tubes, etc., rob us of our dignity, she says, what we’re
saying is that the lives of many people with disabilities, who live with these
sorts of things every day, are inherently undignified.
VIEW this brief presentation Catherine Frazee gave to Members of
Parliament in October, 2014. Notice what she has to say about the matter
of “dignity.”
• Ethical Concerns for Physicians. Dembo, whose article we looked at above,
both raises and questions this concern in her article. She reminds us that in
taking the Hippocratic Oath, doctors swear both 1) to do no harm or
injustice to their patients and 2) not to give a lethal drug to anyone. For
many physicians, assisting someone to end their life is out of the question
because for them it clearly violates the Hippocratic Oath. But, Dembo asks,
is there a point at which refusing to give a lethal drug is in fact doing “harm”
in the sense that the refusal prolongs intractable suffering?
Discussion 10: On June 17, 2016, Bill C-14 “Medical Assistance in Dying” was passed
by the Senate making physician assisted dying now legal in Canada. Do you agree with
this? Why or why not?
Conclusion
In this lesson we looked at the difference between assisted suicide and euthanasia and
the legal issues involved with both. We then examined religious views on assisted
dying. Next we looked closely at examples of individuals who wished they could have
had the help of a physician to end their lives, and spoke publicly about this wish. Finally
we examined some arguments in favour of assisted dying as well as concerns about it.
Self Test
To help gauge your own learning of the material presented in this lesson, take this nongraded self-test. You will obtain instant feedback. Please feel free to complete this test
as many times as needed.
Question 1 of 11
Both suicide and assisted suicide are illegal in Canada.
a. True
b. False
Question 2 of 11
The main difference between euthanasia and assisted suicide is that:
a. “euthanasia” refers to getting help to end your life in the Far East and “assisted
suicide” is the term used in Canada to mean the same thing.
b. “euthanasia” refers to one person ending the life of another in order to relieve their
suffering, and “assisted suicide” refers to getting assistance to kill oneself from
someone who provides the knowledge and/or means to do so.
c. “euthanasia” refers to getting assistance to kill oneself from someone who provides
the knowledge and/or means to do so, and “assisted suicide” refers to one person
ending the life of another in order to relieve their suffering.
d. none of the above
Question 3 of 11
Both euthanasia and assisted suicide are criminal offences in Canada.
a. True
b. False
Question 4 of 11
A famous case of euthanasia in Canada is the case of:
a. Dr. Donald Low
b. Nagui Morcos
c. Dr. Brian Goldman
d. Robert Latimer
Question 5 of 11
The relief of pain through medication and counselling is referred to as:
a. euthanasia
b. assisted suicide
c. palliative care
d. dying with dignity
Question 6 of 11
Which statement is true of the law in Canada?
a. It is an indictable offence to both counsel a person to commit suicide or to help them
do so.
b. It is an indictable offence to help someone commit suicide, but it is not an indictable
offence to counsel a person to commit suicide.
c. It is an indictable offence to counsel a person to commit suicide but it is not an
indictable offence to help someone commit suicide.
d. none of the above
Question 7 of 11
Assisted suicide is legal in Canada if the person getting assistance has a severe mental
illness but it is not legal in the case of a terminal physical illness.
a. True
b. False
Question 8 of 11
According to an Angus Reid poll, more Canadians are in favour of physician-assisted
suicide.
a. True
b. False
Question 9 of 11
The “slippery slope” argument
a. expresses the concern that if we allow physician assisted suicide for the terminally ill,
what’s to stop this from progressing to include the chronically ill, the disabled, and other
populations?
b. states that because the terminally ill are so weak anyway and could slip and die from
the fall, it would be much more compassionate to have a physician assist them in taking
their life before they do fall.
c. states that if physicians break the Hippocratic Oath and help a person take their life
they will likely slip and be unethical in other areas of medicine too.
d. states that there is some suffering that only can end in death.
Question 10 of 11
An argument in favour of assisted suicide is that dying is inherently undignified.
a. True
b. False
Question 11 of 11
All religions support assisted suicide on compassionate grounds.
a. True
b. False

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