THE COMING MURMURATION

April 12th, 2014

 

Suddenly, assisted suicide is everywhere. At least, talking about this once forbidden subject is everywhere.

 

The Federal Liberal Caucus and the Quebec Government have weighed in on it. The police and legal system have certainly acted on it. Last September, Dr. Donald Lowe, the man who guided Canada through the SARS crisis, made a video released days after he died asking why he couldn’t end his life rather than waste away from the brain tumor that killed him.

 

The Belgians, Dutch and Swiss have laid out the pathways that families need to follow in order to get to the end-path. It’s not easy or quick. Asking someone to end your life requires consultations with two and often three doctors. The Belgians instituted a legislated program in 2002 enabling individuals to control their exit from life. However, they claim there hasn’t been the dreaded escalation in requests beyond an annual base rate of just over 1,200 since it began.

 

Most of the Belgians in question are in their 70’s and most have terminal cancer.

 

Control and self-determination, those touchstones of who we are and what we hold most dear, are at the heart of this issue.

 

But there are two new provisions that have driven people of all ages and persuasions to the barricades: intractable mental illness or severe handicap in someone under the age of 18 who can understand the ramifications of their choice.

 

But there’s also a third new ‘allowance,’ one that’s even stickier for any country with an aging population: progressive Alzheimer’s disease.

 

There’s a Belgian documentary released last year called ‘End Credits’ about this very issue. To me, it asks the ultimate questions: at what point is life worth not living? And who has the right to make that decision?

 

The lawmakers there addressed this issue by requiring that the individual be able to engage in a dialogue with the physician required to process the request and do the deed. The film explores a different reality.

 

The cognitively impaired nursing home resident endlessly demands that his nurse put an end to his life. He’d stated many times in the past he wouldn’t want to be alive if he were to become demented, having witnessed it in his mother and sister. But when the doctor arrives to have the discussion, he rants at him about the doctor’s obvious sinister intent to kill him. Then he asks to be taken for a walk. His nurse, wryly nodding to life’s ironies, leads him away.

 

When I talk with patients in my office, their real fear is not death; mostly dying isn’t mentioned or is only hinted at. Even the spectre of uncontrollable pain has yielded its grip thanks to our ability to prescribe long-acting narcotics and ease the suffering from pain. Rather it is their loss of functionality – of being able to care for themselves that now propels the desire to control their end. The notion that they will need others to attend to the most basic functions – feeding, bathing, ‘cleaning them up’, overrides even the anticipation of severe or unremitting pain. And when that’s coupled with not even understanding who is doing this tending, the revulsion rises for many of us, and leads us to beg to have someone send us off.

 

Dr. Denise Larsen from the University of Alberta heads the Hope Foundation. She believes we are creatures of hope, even if it isn’t warranted by the facts. The facts show that even through endless rounds of cancer relapse and chemo, my patients choose to live. They cling, often ferociously, to whatever remains of their dwindling strength and life force. The facts show that they, too, are often as helpless and dependent as babies. Yet they endure because of hope that they will recover or at least endure in a mindful existence that doesn’t question their value.

 

But going forward, hope alone will not deal with all the issues around Alzheimer’s. For here, there are two other factors in play — value and cost.

 

First, the cost of care.

 

For some time now, when I’m counselling my younger patients as they finish high school and cast about for career paths, I have been applauding any suggestion that they may enter any field of health care provision. I especially enthuse about anything to do with servicing the needs of aging, be it housing, supply, support and care. Historically, it’s been daughters or wives who provided this. What’s been largely unspoken is the huge cost, aside from occasional estimates of potential lost income. But the cost of care is going to concentrate our focus in the next 30 years. That is the estimated time that policy and health care planners predict will see the doubling of Alzheimer’s sufferers to 60 million in North America.

 

One in six women over 65, one in 11 men.

 

So the film clip of that frail elderly Belgian haunts us. In a secular society, I know which of my patients still hold fast to a loving God and a deserved afterlife. But more and more, they feel the need to state their wishes to me categorically about the quality of life they want at the end of their life.

 

So it’s no surprise that not knowing anybody, not being continent, not being present, let alone being there but combative or weeping or begging to be taken home, all of these are abhorrent prospects. I certainly don’t want that for my family or myself.

One of the options being considered in Belgium is to include such instruction as a part of your Will. Then if you become mentally incompetent, you have left clear instructions in a legal document that can then be carried out.

 

But I also believe, as does Canada’s foremost ethicist, Margaret Somerville, that it’s a step that puts all of us on a slippery slope. You do not have to ask in a face-to-face justification of your right to decide if you want to live or die.

 

Somerville rails against euthanasia in any form. “A civil society does not kill its people,” is her declaration. She makes a clear distinction between withholding treatment and assisted dying. For her, one can be justified, the other not.

 

She goes so far as to say that people who request euthanasia are selfish: They ask a fellow human being to assume too much responsibility for what is an irretrievable act. If assisted dying becomes a committee decision of two or even five doctors for patients who are terminally ill and suffering, then why not allow the severely disabled, the addled, the depressed end their lives as well? She has been prescient in this warning and the slide seems very slick already.

 

What Somerville calls for is compassion and care — care to cushion and support those who are dying and compassion for those who are suffering. This isn’t because we rely on the tenets of a belief system that rewards us in an afterlife, but because we all share this one life, whatever it brings. Taking it should never be an option.

 

Which brings up the next consideration – the value of your life.

 

In a world where a thousand lives lost is a statistic, but one life lost is a moral dilemma, it seems that the dilemma is yours and for the most part, yours alone.  Reflecting on the value of life from cradle to grave, as I have done for many years first as a nurse and then a doctor, I’m only now starting to understand my own position. It is done while I’m still in good health, and with a clear mind.

 

So stay tuned for the next article.

 

Oh, and that poor, demented man in the Belgian nursing home who demanded his nurse end his life?

 

He died two days later of natural causes.

 

Dr. Jean

Marmoreo

 

Doctor. Writer. Athlete.

Advocate. Adventurer.