EDITOR'S COLUMN

A Surgery Department Viewpoint on Physician Assisted Death

Martin McKneally

The issue of physician assisted death moved beyond the why stage to how and who when Justice McLachlin and the Supreme Court decreed that physician assisted death will no longer be prosecuted as a criminal act. Dean Trevor Young has asked each of the departments in the Faculty of Medicine to provide a viewpoint paper from their perspective on this challenging issue. Jim Rutka asked me to put a paper together for the Surgery Department. I don’t want to speak for my colleagues without their consultation, so I will open the conversation with this column as a first draft. Please e-mail me (martin.mckneally@utoronto.ca) your reflections on how you will respond when a surgical patient asks you to terminate their suffering. The question for us is how and implicitly who will provide expedited death to suffering surgical patients. I begin with a conceptual framework and close with anonymized quotes from surgical colleagues.

Surgeons follow the same general pathway of moral reasoning as other physicians, moving from the Intuitive through the Rational to the Reflective stage.

THE INTUITIVE LEVEL

Our Intuitive revulsion at the thought of killing human beings is intensified by their vulnerability when they are patients. Their suffering from disease or injury further intensifies our resolution to do all in our power to cure, to follow our instinctive responses as warriors against disease and death. This is further intensified if they are entrusted to us - on our surgical service or as our personal patients. The fiduciary obligation is deeply engrained by our training and culture. Deliberately terminating the life of a surgical patient is culturally and intuitively unacceptable at the first level of response.

THE RATIONAL LEVEL

The Rational level is the one we turn to in order to deepen our understanding and clarify our thinking by reference to policies, laws and precedents that may provide guidance by specifying boundaries, rules and exceptions that are well accepted. This is the level of deliberation engaging our professional societies. Physiatrist Jeff Blackmer has done excellent work in this area. He is a physician who cares for quadraplegic and other severely disabled patients. An MHSc graduate of the Joint Centre for Bioethics, Jeff serves as Vice President, Medical Professionalism, for the Canadian Medical Association. He is consulting members of the CMA in public forums and professional rounds throughout the country (http:// www.med.uottawa.ca/physiatry/eng/blackmer.html). Jeff will try to help the profession develop guidance documents to help us navigate this challenging but manageable issue.

Similarly, our legislators are tasked by the Supreme Court with developing the detailed legal language that will clarify the obligations of institutions and caregivers, the legal restrictions, requirements, qualifications for conscientious objection and the requirements for documentation and other details. They are asking for more time.

THE REFLECTIVE LEVEL

The Reflective level of moral reasoning is the most important for all of us to think through. Using this column and conversations with colleagues, I am trying to elicit the advice of our Department members based on their values, beliefs, concerns and ideals to provide a response to the Dean’s request for a statement of the viewpoint of the Department of Surgery. I will be grateful for the opportunity to communicate the wisdom of our members, including our staff, our nurses, our residents and fellows. We all share an ethic of surgery that is based on defining elements of competence and commitment. Competence is not an issue in this viewpoint paper.

Commitment is the central issue. Because of the immediacy and significant consequences of surgical operations, the surgeon and the surgical team are committed to the patient in a way that is uniquely binding. The patient is our personal responsibility in a way that is different from other specialties. The outcomes, including the complications, are owned by the surgical team. Will nurse practitioners, residents and other staff members be asked to euthanize patients? The reflective level of reasoning on this subject needs careful consideration. Agency, i.e. direct responsibility, will not be defined by policies, but it will be specified on the death certificate. Death caused by hypoxia leading to cardiac arrest, leading to the final cause of death will of necessity say “cessation of cardiac and respiratory function secondary to succinyl choline injected by the surgeon or physician”.

COMMENTS FROM SURGICAL COLLEAGUES

I expected my surgical colleagues to reject the role of executioner in physician assisted death. I have asked various surgeons during meetings in recent weeks for their reflections. I have been told that “few people, fewer than 0.5% actually go through with physician assisted death after it has been agreed upon, but having the option helps reduce patients’ fears and keeps up their hopes that they can resolve and manage their symptoms”. Surgeons said “I would agree for some few patients, but only for those few, and I would certainly involve others in the decision-making.” Others said: “Hospital patients are ours. We let one go last night - a 72 year old patient who had been working prior to surgery, but was never extubated, she never recovered from her operation. The family wanted her wishes honoured.” “There is a spectrum, not categorical irreversibility. It is important to make sure that the patient and the family knows. When I withdraw, I withdraw with the help of others. If the deterioration is due to my mistake, it is another question.” Some said: “The family doctor knows the patient best and should participate in the consensus, but the most responsible physician including the surgeon should take this responsibility”. Even in specialties where death is uncommon, such as plastic surgery, there are cases of necrotizing fasciitis and burns that will bring this new law into focus. One surgeon said: “This is not new. We do it every day with morphine when we are allegedly intending only to relieve pain. The double effect gives us some cover, but in cases of necrotizing cellulitis, even with no pain, I have used morphine.” “The frontline is our responsibility. Conscientious objection should be allowed and specified. There are three principles: informed consent, family consent and the doctor who is willing. If all are met, I could even harvest from a ‘brain live donor’. We tend to rationalize and hide behind the double effect.”

Another surgeon said: “Departmental guidance is needed. We will be the agents of expedited death, but like abortion, there should be willing providers and conscientious objectors. Family doctors, palliative care doctors and others may be better suited to this role.” Palliative care physicians tend to disambiguate this difficult issue. They do not want to be thought of as executioners in hospice. The service is needed, and a service, not individual doctors, should provide euthanasia as a treatment for irremediable suffering.