The Supreme Court of Canada dropped a bit of a bomb on the medical community last week by striking down a complete prohibition against physician-assisted suicide and giving legislatures and physician colleges a year to respond. This reverses a previous decision over 20 years ago effectively upholding such a ban, but it was generally expected that such a reversal would happen.
What wasn't expected was how strongly the SCoC sent the message that such a ban was not justified by the current legal framework in this country. The previous decision was 5-4 in favour of a ban. This decision was a full 9-0 against a ban. More than that, all nine justices appear to have had a hand in writing the decision. That's rare and usually done to make a statement. Supreme Court justices are busy, so when they make a decision, usually one author writes the opinion of the Court and everyone who agrees with it signs their name and that's about it. For a 9-0 decision to occur, all nine justices had to agree strongly enough to each claim partial authorship of this decision. That's virtually unprecedented for such a controversial decision.
Yet, was this really a controversial decision? Opinion polls put support for physician assisted suicide somewhere in the 80% range. That's about as favourable an opinion as hockey gets, and this is Canada!
Alright, there is some opposition from some fairly important groups. There's a range of opinion, but I'll break the opposition into three main groups.
First, conservatives, particularly religious conservatives. Physician-assisted suicide is popular in all provinces except Alberta, where opinion is fairly split. Now, the federal Conservative government is taking a cautious approach to this ruling, so we'll see where they ultimately stand, and at least a few Conservative MPs are supportive of this decision, Steven Fletcher being the most outspoken one. Yet, conservative groups and individuals are among the more vocal ones in opposition to this ruling for a variety of reasons.
Second, some advocacy groups for the disabled or elderly. Again, this isn't a unanimous viewpoint, but the fear from some is that this decision, or decisions made down the road, will result in the disabled, elderly, or infirmed will be pushed into death against their will. Experience from other jurisdictions provides comfort that this can be protected against, but this is understandably a major concern for these groups and some of those they represent.
Lastly, physicians. I think this is why the Supreme Court's decision could be considered controversial - it has broad support from Canadians in general, but physicians are conflicted. Only very recently did the Canadian Medical Association change its official stance on the subject from being in opposition to a more neutral one. I've already seen some of that divide first-hand - some physicians are supportive, many are permissive, but more than a few are opposed. The reasons for this split from population opinion are many, but the two main ones I've heard concerns worries that the current system is too prone to allow mistakes which would be unacceptable when it comes to intentional deaths, and simple discomfort with the notion of physicians being part of intentionally contributing to the death of a patient.
The concerns of advocacy groups for the disabled and of physicians helped support the earlier, 1993 ruling upholding a ban on physician-assisted suicide. Part of the reason the Supreme Court decided otherwise in this case is due to the emergence of evidence from other jurisdictions that indicates these concerns can be addressed without a total ban on the practice.
My personal views on the matter are hesitantly supportive. We already do so much in medicine where our decisions result in death in accordance with a patient's wishes. We couch those instances in excuses - typically that we're respecting a patient's right to refuse care. Ultimately though, the patient has a choice between living in a state they would consider unacceptable or dying, and when they choose dying we act accordingly and the patient dies. We denied that choice to patients whose illness doesn't naturally progress to death as quickly as they'd like, but medicine is at its core about defying the natural course of disease.
I am somewhat uncomfortable about the prospect of enabling death rather than fighting for life, but I have misgivings about a number of elements to medicine that I'm less-than-comfortable with. That doesn't mean I won't participate in those elements. I took an oath to help my patients and that means, at times, doing things I'm uncomfortable with if it will help my patients. In some rare cases, that includes facilitating death. I'm not excited about it, but I'm willing.
Finally, I share the concerns advocacy groups and many of my colleagues have about the process. I want to see some very stringent restrictions on this practice to ensure it is not abused. I'm hopeful, given the Canadian Medical Association's tacit willingness to address this issue that physician will present a balanced viewpoint on this. I'm also hopeful that the Conservative government, ideologically opposed to physician-assisted suicide but responsive to public opinion, will put strong restrictions in place to appease their base without alienating the wider electorate.
More than anything, I'm happy this discussion is finally happening among those who hold the most power in this debate - namely physicians and politicians. For too long, this was a topic not to be discussed. Now, we have to talk about it.
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