Manipulating pain

Yet again, euthanasia is making headlines in Canada since the Quebec College of Physicians was reported as “tentatively proposing” legalized euthanasia. The college says that it could be seen “as part of appropriate care in certain particular circumstances.”

An Ottawa Citizen editorial (“Debating life’s end,” July 20) interprets this to say: “Terminally ill patients sometimes require increased dosages of painkillers to alleviate their pain although that can prove fatal. It certainly happens across the country that terminally ill patients are sometimes quietly given more painkillers despite the risk that they could die as a result. Many people would conclude that is the most humane course of action.”

We can all endorse the last sentence: People in pain have a right to fully adequate pain relief treatment. But that does not entail endorsing euthanasia, as pro-euthanasia advocates propose.

The pro-euthanasia lobby has deliberately confused pain relief treatment and euthanasia in order to promote their cause. Their argument is that necessary pain relief treatment that could shorten life is euthanasia; we are already giving such treatment and the vast majority of Canadians agree we should do so; therefore, we are practising euthanasia with the approval of Canadians so we should come out of the medical closet and legalize euthanasia. Indeed, they argue, doing so is just a small incremental step along a path we have already taken.

It’s true and to be welcomed that the vast majority of Canadians agree we should give fully adequate pain relief, but the pro-euthanasia lobby is wrong on all its other claims.

We need to distinguish treatment that is necessary to relieve pain, even if it could shorten life (which is a very rare occurrence if pain relief is competently prescribed), from the use of pain relief treatment as covert euthanasia. The former is not euthanasia, the latter is.

The distinction hinges on the physician’s primary intention in giving the treatment. Pain relief treatment given with a primary intention to relieve pain and reasonably necessary to achieve that outcome is not euthanasia, even if it does shorten the patient’s life. Any intervention, including the use of pain relief drugs, carried out with a primary intention of causing the patient’s death and resulting in that outcome, is euthanasia.

Acting with a primary intention to kill is a world apart from acting with a primary intention to relieve pain. And this is not a novel or exceptional approach. The law recognizes such distinctions daily. If we accidentally hit and kill a pedestrian with our car, it is not murder. If we deliberately run him down with our car intending to kill him, it is.

It is a tragedy for patients, especially those who are terminally ill and in pain, and a major disservice to physicians, nurses and humane and good medical care to confuse these situations as the college seems to do. Physicians and patients become frightened of giving and accepting adequate pain relief.

Physicians should not fear that giving adequate pain relief treatment is unethical or illegal; in fact, they should fear the ethical and legal consequences of not doing so. It is now generally accepted in the palliative care literature and practice that it is a breach of human rights to unreasonably leave a person in pain; doing so is medical negligence (malpractice); and, I believe, in extreme cases, it should be treated as criminal negligence — wanton or reckless disregard for human life or safety. It is torture by willful omission.

The proper goal of medicine and physicians is to kill the pain. It is explicitly not their role to kill the patient with the pain — to become society’s executioners — which is what euthanasia entails, no matter how merciful or compassionate our reasons.

Even most people who support legalizing euthanasia believe its use needs to be justified, usually as being necessary to relieve pain and suffering. Surveys of the general public that ask the question “Do you believe people in terrible pain should have access to euthanasia?” reflect that belief. But again this approach causes confusion between pain relief and euthanasia. It makes euthanasia the treatment for pain, and it makes it impossible for people to agree that all necessary pain relief must be provided, without also endorsing euthanasia. Respondents have either to agree to both pain relief and euthanasia or to reject both. Of course, to have the public endorse euthanasia might be the goal of some of these surveys.

Rights to pain relief treatment will, however, be nothing more than empty words unless that treatment is accessible. If, as I do, we believe legalizing euthanasia or physician-assisted suicide would be a terrible mistake for society, we have serious obligations to ensure fully adequate pain relief treatment is readily available to all Canadians who need it.

As to why legalizing euthanasia would be a terrible mistake, ask yourself the questions, “How would I not like my great-great-grandchildren to die?” and “What values do I want to pass on to the world of the future?” For answers, have a look at the 30-year history of legalized euthanasia in the Netherlands.

Margaret Somerville is director of the Centre for Medicine, Ethics and Law at McGill University, and author of Death Talk: The case against euthanasia and physician-assisted suicide. This article first appeared in The Ottawa Citizen, July 24.


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