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Salon

Care, compassion, respect

James Downar
CMAJ November 18, 2014 186 (17) 1336; DOI: https://doi.org/10.1503/cmaj.141340
James Downar
Divisions of Critical Care and Palliative Care, Department of Medicine, University of Toronto. Toronto, Ont.
MDCM
Roles: MHSc (Bioethics)
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Physician-assisted death (PAD) is a controversial subject in Canada, but it shouldn’t be. Polls show that Canadians support PAD almost as much as they support sunlight and clean drinking water.1 PAD is now legal in many jurisdictions, and we have a large body of evidence to address fears about slippery slopes.

When PAD was legalized in Europe, it did not become the default option for dying patients; it generally remained stable while palliative care grew dramatically.2 According to the Economist, the five countries that have legalized PAD are world leaders in the “[b]asic end-of-life healthcare environment,”3 while Canada sits in the middle of the pack. According to the Center to Advance Palliative Care, all three US states that have legalized PAD by statute rank in the top eight for availability of palliative care services in hospitals.4

The vulnerable do not appear to be pressured into accepting PAD — in fact, most patients who receive PAD are wealthy, educated and supported by family members and health insurance.5,6 I would call them “privileged,” but then I remember their suffering.

I don’t support death. I enjoy my life, and I work very hard as a critical care physician to keep patients alive — when I can. But I accept that there are times when I can’t. And there are times when I can keep people alive, but not in a state that they would value. I respect their right to know when they’ve had enough, and I don’t see why they should have this right only when they are dependent on life support.

Therefore, my support for PAD is based on an ethic of care, and the desire to help people achieve the death that they want. I’m not advocating for universal PAD, but universal choice. This debate calls for humility and a willingness to listen to our patients.

Editor’s note: Both articles were originally posted, unabridged, on CMAJ Blogs (http://cmajblogs.com/pad)

References

  1. ↵
    Most (84%) Canadians believe a doctor should be able to assist someone who is terminally ill and suffering unbearably to end their life. Toronto: Ipsos Reid; 2014. Available: www.ipsos-na.com/news-polls/pressrelease.aspx?id=6626 (accessed 2014 Oct. 14).
  2. ↵
    1. Onwuteaka-Philipsen BD,
    2. Brinkman-Stoppelenburg A,
    3. Penning C,
    4. et al
    . 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.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Praill D,
    2. Radbruch L,
    3. Rajagopal MR,
    4. et al
    . The quality of death: ranking end-of-life care across the world. Washington: The Economist Intelligence Unit; 2010.
  4. ↵
    A state-by-state report card on access to palliative care in our nation’s hospitals. New York: Center to Advance Palliative Care; 2011. Available: www.capc.org/reportcard/topten (accessed 2014 Oct. 14).
  5. ↵
    1. Loggers ET,
    2. Starks H,
    3. Shannon-Dudley M,
    4. et al
    . Implementing a death with dignity program at a comprehensive cancer center. N Engl J Med 2013;368:1417–24.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Steck N,
    2. Junker C,
    3. Maessen M,
    4. et al
    . Suicide assisted by right-to-die associations: a population based cohort study. Int J Epidemiol 2014;43:614–22.
    OpenUrlAbstract/FREE Full Text
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Canadian Medical Association Journal: 186 (17)
CMAJ
Vol. 186, Issue 17
18 Nov 2014
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James Downar
CMAJ Nov 2014, 186 (17) 1336; DOI: 10.1503/cmaj.141340

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