Choosing when and how to die: Are we ready to perform therapeutic homicide?

In a recent CMAJ editorial, Flegel and Fletcher called for a national dialogue on end-of-life care, arguing that policy change should not be the result of a single court decision(1). Different medical end-of-life practices are being debated in Canada, including treatment withdrawal, the use of medication justified by symptom management, and the use of lethal drugs by physicians (2-4). Concerns about the effects policies are central to the Canadian debate, and international evidence is quoted by proponents and opponents of legislative reforms.

We recently conducted a scoping review of international evidence on medical end-of-life practices, with a focus on the use of lethal drugs by physicians(5). Key findings from this review are of immediate relevance for the public debate:

1. We found no empirical study on the use of lethal drugs by physicians in Canada, which is surprizing given frequent claims that "assisted suicide", "euthanasia" or "medical aid in dying" are being practiced illegally in the country.

2. Studies on the medical use of lethal drugs can be conducted even in context of prohibition, as illustrated by large national studies from the United Kingdom, France, United States, Italy, Denmark, and Australia (6-10).

3. Official data sources on the use of lethal drugs (eg. jurisprudence and euthanasia review committees' reports) are insufficient to assess the potential effects of end-of-life policies, because only a fraction of cases are reported to public authorities, even where they are within the law (11, 12).

4. No systematic review of international evidence assessed the impact of end-of-life policies.

Policymakers should thus be careful in drawing conclusions about what is known (and not known) about the likely effects of policies. Our findings highlight the need for a systematic review to clarify the impact of different end-of-life policy options. Also, a pan-Canadian baseline study of medical end-of-life practices is urgently needed to assess current legislation, and to monitor the impact of any future legal change over time.

Scientific evidence alone cannot provide simple answers to complex end-of-life care dilemmas. However, having robust knowledge available publicly is a pre-condition for informed democratic deliberation on end-of -life care in Canada.

References

1. Flegel K, Fletcher J. Choosing when and how to die: Are we ready to perform therapeutic homicide? CMAJ. 2012;184(11):1227.

2. Carter v. Canada (Attorney General). BCSC 886; 2012.

3. Vogel L. Legal ambiguities surround authority to make end-of-life decisions. CMAJ. 2011;183(10):E617-8.

4. Loi concernant les soins de fin de vie (Projet de loi #52), Assemblée nationale du Québec (2013).

5. Boivin A, Marcoux I, Mays N, Pineault R, Premont M, van Leeuwen E, Lehoux P. What Evidence Is Available About The Medical Practice of Euthanasia In Contexts of Prohibition And Legalization? A Scoping Review. North American Primary Care Research Group Conference (Ottawa); November 12, 2013.

6. Seale C. End-of-life decisions in the UK involving medical practitioners. Palliat Med. 2009;23(3):198-204.

7. Emanuel EJ. Euthanasia and physician-assisted suicide: a review of the empirical data from the United States. Arch Intern Med. 2002;162(2):142-52.

8. van der Heide A, Deliens L, Faisst K, Nilstun T, Norup M, Paci E, et al. End-of-life decision-making in six European countries: descriptive study. Lancet. 2003;362(9381):345-50.

9. Lofmark R, Nilstun T, Cartwright C, Fischer S, van der Heide A, Mortier F, et al. Physicians' experiences with end-of-life decision- making: survey in 6 European countries and Australia. BMC Med. 2008;6:4.

10. Pennec S, Monnier A, Pontone S, Aubry R. End-of-life medical decisions in France: a death certificate follow-up survey 5 years after the 2005 act of parliament on patients' rights and end of life. BMC Palliat Care. 2012;11:25.

11. Smets T, Bilsen J, Cohen J, Rurup ML, Mortier F, Deliens L. Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ. 2010;341:c5174.

12. Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, de Jong-Krul GJ, van Delden JJ, van der Heide A. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet. 2012; 380: 908-15.

Conflict of Interest:

None declared

Having spent a good portion of my 2011-2012 sabbatical year investigating assisted death in Belgium and the Netherlands, I want to react to recent letters sent to the CMAJ on the subject, especially the November 6 th letter from Laval associate professor François Primeau. In the challenging debates on assisted death which will inevitably increase in the months and years to come, a first goal should be to set the basic facts straight, free from undue interpretation.

Assisted death policies in the three Benelux countries (Belgium, the Netherlands and Luxembourg) which offer this choice, under strict conditions and guidelines, are not out of control, very far from it. After several months of investigation and interviews, in the Netherlands and in Belgium, and also in Switzerland, I come to the conclusion that the policy situation there is well under control in the implementation phase, after these countries have decided to liberalize their practices after democratic processes that are in no need of lessons of other countries. I am sorry for not being very original, since I come to the very same conclusions as the two most serious Canadian reports on the end of life situations in the Benelux countries, the exhaustive study by the Royal Society of Canada published in 2011 and the study from the Special Committe of the National Assembly of Québec published in 2012. Both of those reports at least partly based their conclusions for a change in Canadian practices by taking into consideration on site interviews in the countries involved.

The fact that in Belgium "not a single case (of improper behavior) has been reported to the Justice department" by the Belgian Control Commission on assisted death is interpreted by Dr. Primeau as a sign, possibly even a proof, that the system of controls is not working there. Stange conclusion indeed, especially since the Commission was intentionally composed in part by specialists of palliative care, some of them sceptics about the new legal context, in order to assure its neutrality. Dr. Marc Englert, longtime member of the Commission, whom I interviewed at lenght, would be very surprised by Dr. Primeau's assertion that he and other memebes of the Commission are not attending to their tasks with anything other than the highest professional standards. Moreover, physicians are usually hesitant to implement assisted death, and when they do so, under strict guidelines, in the interest of their patient, and following his repeated requests, there is every reason to believe that they are mindful of the legal requirements.

True, there are still 20 % of assisted deaths that are not reported in the proper manner, in the propre forms.In most cases, if not all, these are not assisted deaths permitted by the law,but particual cases of terminal sedation, a common practice in most all developed countries. The discrepencies between reported cases and cases revealed by the anonymous epidemiological studies come partly from the fact that there are really three sets of data to draw inferences from. The first set, drawn from the anonymous epidemiological death certificates studies, is bases on the positive/negative answer the physician gives to the question of "drugs administered with the intention to hasten death", in the last death attended to. The second set of data, within the same epidemiologicla studies, is the physician's personal classification of the same case, and his answer here may be somewhat different from the one in the previous set. A case in point would be that of a comatose patient whom is given increased doses of sedatives to hasten death, a life ending situation reported in the first set of data, but not considered as such by the attending physician in an anwer to a slightly different, more technical question. And then, finally, there is a third set of data, drawn from the cases reported to the Control Commission. Such are the three sets of data used by any study dedicated to the question of reporting/underreporting of assisted deaths.

Consensus among the physicians I interviewed is that, when there is actual life termination, when the proper drugs are used, those specified by the legal definition of euthanasia (a life ending procedure requested by the patient), that is to say barbiturates to induce a coma, and then, when necesssary, a muscle relaxant, there is virtually a 100 % report rate, at least in both the Netherlands and Flanders, Belgium, the two jusrisdictions I have looked at more closely.

True, there presently debates, particularly in the Netherlands, on the appropriateness of extending assisted death to those seniors simply "tired of living". But let us not confuse a still illegal practice with a legitimate, democratic debate.

The opponents of assisted death should not become loose cannons, set to fire in all directions, in the hope that one flying bullet, against all odds, will find a mark. The opponents to assisted death have some valid arguments, but they are discrediting them in advance by their sometimes loose interpretations of what is happening in European jurisdictions which have their own choice on the subject, and who are implementing these choices with integrity and professionalism.

Conflict of Interest:

None declared

As an expert to the Quebec Commission on the special question of dying with dignity, I submitted a Memoir and was heard during the public consultations. I would like to share some facts which are not known by the majority of physicians and patients, even in Quebec.

There were a total of 427 oral presentations and written submissions to the Commission. Analysis of this data reveals that: 99% agreed that palliative care is the best choice to preserve dignity at the end of life for Quebecers; 60% of submissions opposed euthanasia; 34% either somewhat or strongly favoured euthanasia; 2% supported assisted suicide. Therefore, recommending euthanasia as "medical aid in dying" ignored arguments presented at the Commission. As Margaret Somerville stated in a piece published by The Gazette on March 26, 2012, the Commission's Report reads like "a pro-euthanasia manifesto". The recommendations on euthanasia from the Commission reflect an a priori ideological desire to impose "medical aid in dying" through some criteria, while neglecting worrisome facts which should dampen Quebec lawmakers'enthusiasm in this regard.

The Quebec Commission ignored results from the Remmelink Commission in the Netherlands that exposed abuse in the euthanasia process in 1990, 1995 and 2003. The Quebec Commission did not seem impressed that in the Netherlands, major depression is a valid condition for euthanasia, and has been so since 1993, and that 20% of euthanasia cases are regularly not reported, in clear violation of the law. In Belgium, where euthanasia has been legalized since 2002, the Institut europeen de bioethique recently published a 10-year report (2002-2012, at www.ieb-eib.org). It shows that the Control Commission to oversee euthanasia in Belgium confirmed in its first report for 2002-2003 that it could not effectively assess the validity of euthanasia requests; not a single case was reported to the Belgian Justice Department for review during those 10 years. In 2010, a process was started in Belgium to promote euthanasia for patients with dementia and minor of all ages; in the Netherlands, the pro-euthanasia lobby advocates currently the procedure for all those over 70 and "tired of living"!! TThese factcs alone should be a cause for further rreflection by Quebec lawmakers before instituting control commissions and criteria which have not been successful in controling or limiting euthanasia elsewhere. Furthermore, a recent report from the Netherlands published online in The Lancet on July 11, 2012, should not rejoice advocates of euthanasia: the alarming facts show a 73% increase in the number of euthanasia performed there since 2003, and a 50% increase in the number of deaths by terminal sedation, which has the same intent and result than euthanasia: death.

An in-depth reflection on how to die remains necessary. the notion of dignity at the end of life needs to be grounded in philosophy, not opinion polls. I suggest that physicians and other health care professionnals do not want to become agents of homicide at the end of life, even if it is llabeled "therapeutic".

Let's be clear: homicide is never therapeutic.

Conflict of Interest:

None declared

To the editor:

Drs. Flegel and Fletcher are to be praised for their use of the term "therapeutic homicide", which instils some clarity into the euthanasia debate, too often obscured by intentional use of euphemisms such as "physician-assisted death", "dying with dignity" and so on.

I am less impressed with their evaluation of the Quebec Select Committee on the Question of Dying with Dignity's report, which they qualify as "thoughtful". After spending hundreds of hours and much more than that in dollars, the Committee reached one conclusion that was already obvious to everyone, and another that flew in the face of what they heard from Quebec's citizens. No one needed all this work to know that palliative care is the state of the art for the care of dying people, and is sorely underprovided in Canada and especially in Quebec. On the other hand, the recommendation to legalize "medical aid in dying" was supported by only one-third of those who submitted briefs to the committee or presented at the hearings.

A journalist asked the committee president, Maryse Gaudreault, how she could justify their conclusions given these statistics.(1) She acknowledged them, but explained them away by saying that some anti- euthanasia groups made multiple submissions. "'In a certain city in Quebec, there was an organized group who presented the same position in about 40 different ways, but it's still the same position of one group,' Gaudreault said in a telephone interview, indicating that the committee had discounted some of what it felt were multiple submissions when determining its recommendations."(1) She did not name the group or give a source for this affirmation.

Indeed, it would be astonishing if she could. As far as I know there was no organized opposition to legalization of euthanasia in Quebec until Vivre dans la dignite (Living with Dignity) was formed about two months before the hearings opened.(2) In contrast, l'Association quebecoise pour le droit de mourir dans la dignite has been in existence since 2007 and had ample time to prepare its members to present at the hearings.

I presented a brief to the committee and listened to several other hearings, both in person and online. I saw people from all walks of life who went to express their concerns. I heard presentations by quite a number of physicians, of whom the great majority opposed euthanasia, contrary to the position of the Quebec College of Physicians, the instigator of the committee. There was little doubt that the committee had its mind made up on the euthanasia question before the hearings even began. One only had to observe the expression on the members' faces as they listened to the various presentations. One only had to see them trying to bully those opposed to the practice into admitting that there might be some extreme cases in which it could be necessary.

The commission members were told numerous times about the vulnerability and susceptibility to influence of the many elderly, chronically ill and dying patients we see every day in medical practice. They heard stories of such people being abused, neglected and coerced into asking for death. But they could not see past the tragic stories of the typical poster boys of the euthanasia movement: the articulate middle-aged person with a degenerative neurologic disease who sees controlling the manner and time of his death as the only solution to an otherwise hopeless situation. These stories are indeed very sad. But there are other solutions, and one cannot legislate for everyone based on a few extreme cases.

The Select Committee on the Question of Dying with Dignity made a show of listening to Quebec's citizens, but did not really do so. Their report deserves to collect dust on a shelf. It will no doubt do so, at least for a time, as the government and the opposition parties now have many other things on their minds.

Catherine Ferrier, MD, FCFP, Division of Geriatric Medicine, McGill University Health Centre

References:

1. Eric W. Mauser, "Medical aid in dying" problematic for many, Catholic Times, Spring 2012.

2. http://www.vivredignite.com/en/docs/29_day_hearings_results.pdf

Conflict of Interest:

None declared

With interest, and memories coming back, I read your editorial regarding "therapeutic homicide" 1. Transitioning from the country where I trained, The Netherlands, to Canada, has given me the opportunity to see the two sides of the debate around assisted suicide. I write this letter in the hope that it will support further the open discussion of one of the most difficult discussions in medical care.

Many years ago, during my second year of Internal Medicine residency, I was asked to do a consult for my staff regarding a patient in his mid fifties, who did not recover well after CABG. In the workup, an abdominal ultrasound and further CT-scans revealed widespread abnormalities suggesting a metastasized tumor. A biopsy of the most accessible lesion revealed a high-grade adenocarcinoma. The consulted oncology team rendered the changes of a response to therapy negligible.

The person was a very pleasant man, very well aware of his condition, continuously in pain and nauseated. Whatever palliative measures we tried as a team, the disease seemed to stay ahead of us. The patient during those weeks, started to consistently express the wish to be assisted to die. I was the 'doctor on the floor' and talked with him a lot, started to be deeply involved in his wish, and understood also from a medical perspective that there was no way to manage symptoms to the extent that it would be acceptable for him. I discussed his wish with my staff, we together went to discuss this with the Medicine Chair, who talked with the patient too. We agreed that the patient's right to choose his own destiny was key. Euthanasia was not legal at that time in The Netherlands, however, there was a protocol for reporting 2. My staff asked me explicitly whether I felt comfortable assisting the patient in the next steps, and assured me that he would be there to supervise and mentor at every step that we would take.

My patient was very consistent, and asked us to help him plan a date and to help him and his family to see his daughter's marriage happen, in the Hospital, before his death. With the help of everybody on the team, nurses, social work and the religious worker, all was arranged, and his daughter's marriage took place on our ward. I was there, standing in the corner, as you can imagine, quite moved.

In the background, we had arranged formal, legal and medical- organizational matters for his death, which was planned at 8 AM two days after the wedding of his daughter. We had gone through the steps of the 'euthanasia protocol', with, first of all, an assessment of another physician not related to the case about the hopelessness of the situation, and the expectation that the condition would become fatal within 6 weeks (a requisition at that time). It also included a psychiatric assessment of the patient, including competence and the consistency of the wish to die. We contacted the public prosecutor, and informed him of our plans, including the details of the case and the assessment. We also consulted the 'euthanasia team', consisting of an anesthesiologist and a pharmacist, and prescribed the required drugs following their guidance.

The night before 'the day' I could not get to sleep, my mind went back and forth between all the words and feelings I had exchanged with my patient, his deep wish, my profession, my role as a helper, my role as a 'savior', the oath. For all those years that night has stayed with as much of the day to follow, it was a night of reconciliation, for myself, for my patient. It felt so right, but also so difficult.

That morning, all went smooth, it was surrealistic: my patient thanked me, the nurses and my staff for all the support, said bye to his wife and children, we all hugged. The infusion was started by my staff, my dear patient smiled, fell asleep and stopped breathing shortly after. It was sad yet beautiful: we had not been able to cure him, we had been able to assist him in his wish.

The aftermath was confrontational: we reported the whole procedure to the public prosecutor the same day. The next day, the prosecutor came to the hospital, to 'investigate the case'. We had provided all the charts, forms, etc. so that all could be checked. We were called to the office of the chair about two hours later, and sat in front of the prosecutor, who said: "You both are accused of murder, and we have sufficient evidence to support that you are guilty". He asked us to leave the room, and was calling the judge. After minutes that seemed an hour, we were called back in. The prosecutor, talking very official, said: "Given the nature of the case and the circumstances, you will not be further prosecuted". The events left me emotionally drained for a few weeks; I kept thinking about the gratefulness of my patient moments before his self-chosen, assisted death. I have had few more cases in my life, many more cases of 'palliative sedation', but fortunately always with very transparent communication between all involved parties, following the wish of the patient.

It has been many years since that 'first time', and I now practice in Canada. Shortly after I arrived here, I had a discussion with a resident about a terminally ill patient, who had expressed the wish to stop all treatment. The resident, without any second thought, mentioned that the treatment should be continued, since there was still hope of recovery. When I carefully explained that it is the law that a patient can accept, but also refuse treatment, this resident was quick to answer that 'in the country where you come from, the doctors are even willing to kill their patients'. A recent remark of a potential American presidential candidate mentions that elderly people in The Netherlands avoid being admitted in their own country, since the chances of being killed by their physicians is 50%. Believe me, this kind of pre-judgment is really painful.

Yet, I agree very much with Flegel and Fletcher that palliative care is underused, and not well appreciated, here and in The Netherlands. I also would like to emphasize that we all should try to avoid stigmatizing. In that respect the title 'therapeutic homicide' seems, to me, a poor choice, as it is loaded with judgment.

My story is one of many stories, possibly also partly representing the untold in our country. It for sure does not address all the numerous aspects of assisted death. Let the discussion be open, for the sake of the autonomy of our patients, for the sake of avoidance of abuse, for the sake of sanity of our own hearts.

Branko Braam Edmonton, August 24, 2012

1. Flegel K, Fletcher J. Choosing when and how to die: Are we ready to perform therapeutic homicide? Cmaj. 2012;184:1227

2. van der Wal G, van der Maas PJ, Bosma JM, Onwuteaka-Philipsen BD, Willems DL, Haverkate I, Kostense PJ. Evaluation of the notification procedure for physician-assisted death in the netherlands. The New England journal of medicine. 1996;335:1706-1711

Conflict of Interest:

None declared

Drs. Flegel and Fletcher (CMAJ 7 August, p1227) invite "those who care...to speak up now, and with conviction." I find the phrase "therapeutic homicide" which they use in their editorial to be chilling and Orwellian.

One person's right can become another person's obligation. When patients have the right to choose euthanasia, this sends an implicit message that some lives aren't worth living. Frail elderly, handicapped, and cancer patients can easily perceive that society doesn't want them around, when they can instead choose to die "with dignity". It is a short step from believing that they CAN choose dying to believing that they SHOULD choose dying.

Sometimes individual rights are trumped by the common good. In the matter of physician-assisted suicide, this is one of those times.

Respectfully,

Howard Bright MD Chilliwack, BC

Conflict of Interest:

None declared

Dear Sir,

Sensible discussion of euthanasia is always hindered by a persistent error, continued in your editorial (CMAJ 7 August, p1227). It is always assumed that euthanasia should be administered by doctors!

You do not take your car to a wrecker's yard to be repaired. You would be equally reluctant to take your mother to a hospital that kills old women - despite reassurances. And a medical degree is not needed to kill people comfortably - any good pharmacist or physiologist can do it.

Once the debate is simplified to "Should we allow funeral parlours to kill people with their consent", it's much easier to think clearly. Let's keep health care and death separate!

But yes, doctors may be needed to assess competence.

Conflict of Interest:

None declared

Letter to the editor of CMAJ

On doctors and "therapeutic homicide"

Dear Editor: We would like to comment on the "tacit assumption that doctors do not kill people" as posed by Flegel and Fletcher in the CMAJ in June of this year.

Euthanasia is always a tough topic that should not be dealt with in a simplistic way.

The word "euthanasia" is, indeed, a loaded one - surrounded by many very dramatic personal stories. The key question here is "is euthanasia the best way to manage many of these situations?" Our thinking, as physicians, is that it is not.

In our rapid and stressful world, we need to reflect more deeply about the doctor's role and position in medical care and wider society. His/her work is not only one of a technician, even if much of the curriculum of medical sciences is technical in nature. They are not dealing only with machines or chemical reactions; but, with people with feelings, emotions, personalities, every one of which has their own story. This is why relationships in medicine are crucial. As we know, a good relationship is built on the reciprocal trust of both sides.

In this context of relationship it is important that doctors are always "for" the patient's life, even when it is at his or her final stage and there are no more curative treatments to offer. In these situations, doctors can and should continue to be at the bedside of the patient, helping to approach these last days in the best way. Today, we have much more to offer than our predecessors in terms of palliative care; but, it would be an error to think that the doctor's role is only to "give something" in these situations. It is also a question of "being there", of not breaking the personal relationship. In this context it becomes important that doctors are never "against" a patient's life. Otherwise, the relationship will suffer a profound change and will pass from one of personal help to a mere technical one. During the last decades, some prominent doctors have argued convincingly about it in the field of bioethics (Kass 1989, Pellegrino 1992).

One of the reasons why the Hippocratic body of teachings (including the famous Oath) became normative to the medical profession was actually that this "new" medicine distinguished the role of cure from the role of killing. We think it is important to continue with this distinction.

In the last meeting of the British Medical Association its outgoing Chairman of Council,Dr. Hamish Meldrum, explained that the medical profession should not take a neutral position about euthanasia; but, keep its opposition to it. He added that "I don't come to this from any strong religious view but I do come to these views from having worked as a doctor for 40 years - mostly in general practice." (http://www.bioedge.org/index.php/bioethics/bioethics _article/10129).

We would strongly agree - we feel that the medical profession must continue to take a strong stand against euthanasia in Canada and beyond.

Conflict of Interest:

None declared

Dear Editors, CMAJ

This is in response to the recent CMAJ editorial entitled "Choosing when and how to die: Are we ready to perform therapeutic homicide?"1 Although the 'we' is not clearly identified — it could be referring to physicians, all health care professionals or society at large — this editorial should serve as a wake-up call from a collective stupor. For this the authors are to be congratulated. At the same time, I am deeply concerned with one of their statements. It is argued that the euthanasia debate has in the past been largely theoretical because of the "tacit assumption that doctors do not kill people." I find this a less than forceful description of the mandate of medicine.

It is far from a tacit thing that doctors do not purposefully take lives. Quite the contrary, this constraint has been a rock-hard and invariant truth of medical practice for millennia. The Oxford English Dictionary defines 'tacit' as unspoken or silent.2 Those qualities are certainly not the case in the instance of medical euthanasia. The Hippocratic Oath includes the injunction: "I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect."3 A manuscript written in 1826 by German physician Carl Friedrich Marx states: "How can it be permitted that he who is by law required to preserve life be the originator of, or partner in, its destruction?"4 There are innumerable examples where the prohibition of homicide by doctors is expressed unambiguously. That doctors are admonished not to kill is more than gentle etiquette and far from a vague and mushy notion. To label it as an 'assumption' and to qualify it as 'tacit' is dangerous. This saps the intellectual rigour and ethical grounding of the injunction against medical homicide while suggesting that it is open to question and reversal. If Canada is to toss this long-standing ethical interdiction out the window let it do so with brutal honesty — let it be overturned not on the (faulty) basis that it was hardly explicit from the outset but rather on the basis of persuasive arguments mustered against it. I consider it unlikely that any such argument will prevail and I am remain extremely concerned about the damage that could be done to the profession if it were to accept assisted-suicide as a medical act.

I have suggested elsewhere that responsibility for implementing assisted-suicide could be mandated to a non-physician group: euthanatrics.5 Its practitioners — euthanologists — could ensure that society-sanctioned suicides are carried out expertly and with transparency and accountability. It would provide a mechanism to meet new legislative demands while protecting the medical profession so that it can continue unfettered to fulfill its ancient mandate of healing. Euthanizing and healing are simply not miscible, nor can they be two sides of one coin. I maintain that this is not a tacit assumption but rather the expression of a reverberating imperative.

References 1. Flegel K. Fletcher J. Choosing when and how to die: Are we ready to perform therapeutic homicide? CMAJ. 2012. 184:1227. 2. Oxford English Dictionary. Electronic format. Available at http://www.oed.com/. Accessed August 6, 2012. 3. Hippocratic Oath, reproduced and translated by Ludwig Edelstein. In: Ancient Medicine. Selected Papers of Ludwig Edelstein (1967). Owsei Temkin, C. Lilian Temkin (Eds). Johns Hopkins University Press. Baltimore. MD. 4. Cane W. Medical euthanasia. A paper, published in Latin in 1826, translated and reintroduced to the medical profession. J Hist Med. 1952. 7:401-416. 5. Boudreau JD. Physician-Assisted Suicide and Euthanasia: Can you even imagine teaching medical students how to end their patients' lives. Perm J. 2011. 15:79-84.

J. Donald Boudreau, M.D., F.R.C.P.C. Associate Professor, Department of Medicine, McGill University

Arnold P. Gold Foundation Associate Professor of Medicine

Conflict of Interest:

None declared

CMAJ authors Flegel and Fletcher in their editorial of June 25, 2012 recently asked: "Choosing when and how to die: Are we ready to perform therapeutic homicide?"

As the professional body representing more than 300 physicians practicing palliative medicine, the Canadian Society of Palliative Care Physicians answers with an emphatic "No!" Physician-assisted dying is NOT part of the continuum of end-of-life care, nor has it been part of 2,500 years of Hippocratic tradition.

We were encouraged the CMAJ authors made two important observations about palliative care: specifically that it "has come of age and is adequate to meet the needs of most dying people," and more importantly that "it is under-provided, particularly in remote and rural areas." The Canadian Hospice Palliative Care Association has determined only 30% of Canadians have access to palliative care.

Regarding the call to "speak up now, and with conviction," our 2011 member survey found 83.3% of respondents were against legalization or decriminalization of euthanasia, and 90.6% would not participate in it; 80.6% opposed physician-assisted suicide, and 83.6% would not aid in it. We also applaud the Conservative government's appeal of the B.C. decision allowing physician-assisted suicide.

We are concerned that liberalizing euthanasia laws in other countries has led to its being performed without appropriate consent , and not always for terminal illness. We oppose any suggestion that these acts become part of standard end-of-life care. As a nation with a proud tradition of caring for the vulnerable, let us instead choose to ensure that the dying have the choice of palliative care.

Conflict of Interest:

None declared

I am a cancer doctor in Oregon where physician-assisted suicide is legal. This letter responds to the editorial by Dr. Flegel and Dr.Fletcher, "Choosing when and how to die: Are we ready to perform therapeutic homicide?" (June 25 2012)

In Oregon, the combination of assisted-suicide legalization and prioritized medical care based on prognosis has created a danger for my patients on the government run Oregon Health Plan (Medicaid).

The Plan limits medical care and treatment for patients with a likelihood of a 5% or less 5-year survival. My patients in that category, who say, have a good chance of living another three years and who want to live, cannot receive surgery, chemotherapy or radiation therapy to obtain that goal. The Plan guidelines state that the Plan will not cover "chemotherapy or surgical interventions with the primary intent to prolong life or alter disease progression." The Plan WILL cover the cost of the patient's suicide.

Under our law, a patient is not supposed to be eligible for voluntary suicide until they are deemed to have six months or less to live. In the well publicized cases of Barbara Wagner and Randy Stroup, neither of them had such diagnoses, nor had they asked for suicide. The Plan, nonetheless, offered them suicide.

In Oregon, the mere presence of legal assisted-suicide steers patients to suicide even when there is not an issue of coverage. One of my patients was adamant she would use the law. I convinced her to be treated. Now twelve years later she is thrilled to be alive. I hope that you can avoid Oregon's mistake.

[Support for this letter regarding Barbara Wagner and Randy Stroup can be found in these articles: http://www.katu.com/news/26119539.html & http://abcnews.go.com/Health/story?id=5517492&page=1 My patient's letter in the Boston Globe describing her then being alive 11 years later can be read here: http://articles.boston.com/2011-10- 04/bostonglobe/30243525_1_suicide-doctor-ballot-initiative]

Conflict of Interest:

None declared

I believe that every minute of life is important. My daughter who deceased of Hodgkin's disease, called the ones who had seriously discussed euthanasia to end her life, criminals in spite of her 5 months intubation and ivs in ICU. She was able to smile until the last day without being masochist. The presence of loving friends and/or relatives can increase the level of endorphin tremendously. I personally will refuse to become a therapeutic killer.

Conflict of Interest:

None declared