I finished this post at about 11:30 Atlantic Daylight Time, saved the draft, and then found that WordPress had eaten up about a thousand words and changed them all into ampersands! So, once again …

As they say, “pardon my French”! But I have been reading the Rapport de la Commission Québecoise sur la question de Mourir dans la Dignité, and I am quite frankly astonished at its grasp of the entire scope of the problem of end-of-life concerns, and how these interact with, and must be allowed to modify, how the medical ethics of end-of-life care can be interpreted in the light of issues and facts about death and dying today, in the age of technological medicine, that are becoming more and more clear as time passes. The report itself is only available in French, so far as I can tell. Indeed, it took some time before I was able to find it online, which explains why I have not addressed it so far. Now I am reading it in conjunction with the report of the Royal Society of Canada’s expert panel on end-of-life decision making, and consequently I will be making occasional comments in the days ahead on both of these documents, as well as on the ruling by Madame Justice Lynn Smith of the British Columbia Supreme Court. Today I simply want to take note of a few things of interest in the Québec Commission report — which I have uploaded, and is accessible here. I will give the text in the original French, and then provide my translation. My French is by no means perfect and I expect to be called on my translations from time to time. That is how it should be.

First of all there is this:

Enfin, nous avons été très étonnés d’apprendre que les futurs vétérinaires reçoivent plus d’heures de formation sur le contrôle de la douleur que les futurs médecins de famille, alors qu’il s’agit d’une question centrale dans les soins à donner en fin de vie. [30]

Finally, we were very astonished to learn that future veterinarians receive more hours of training in pain management than future family physicians, even though this is a central concern of the provision of care at the end-of-life.

Which surprised me too. And it becomes even more astonishing when you consider the following from one of the expert witnesses before the Commission. According to Doctor Golda Tradounsky:

Il est incroyable que les vétérinaires reçoivent une meilleure formation en traitement de la douleur que nous [notre] futurs médecins. Les futurs vétérinaires reçoivent en moyenne 130 heures de cours uniquement sur le traitement de la douleur, alors que les étudiants de médecine, seulement une quinzaine d’heures. [30: sidebar]

It is unbelievable that vets receive better training in pain management than our future doctors. Future vets receive on average 130 course hours devoted solely to pain management, whereas medical students receive only around fifteen hours.

I have to say that I found this unbelievable as well, although this explains the many stories one hears of inadequate pain management at the end-of-life. Some doctors, incredibly, express concerns over habit forming drugs and addiction in end-of-life situations, as though such considerations are relevant to someone who is dying.

In a related sidebar we are told about one woman’s experience of seeking relief for her husband, who was dying from cancer. Here we are told of the difficulty of getting doctor’s orders included in the patient’s “dossier” or file.

Ce médecin fait venir une garde et lui dit devant mon mari et moi de lui donner des doses selon sa demande ou la mienne. [31]

This doctor summoned a nurse and told her, in front of my husband and me, that she give him doses [of pain medication] at his or my request.

But then a shift change took place and the prescription was not included in the patient’s file, so the new nurse would not give him pain medication on demand, because ”sur demande” wasn’t stated in his dossier. And in this frustrating shift-change game of tag the woman saw five doctors between Friday and Monday, without receiving any satisfaction. Given that so little attention is paid to training in pain management, this is perhaps not surprising, since associated with inadequate training is the unstated assumption that this is not an important issue. So it is not surprising either that this is one of the early recommendations (the third) of the Commission on Dying with Dignity:

La Commission recommande que le ministère de la Santé et des Services sociaux s’assure que tous les professionnels de la santé reçoivent une formation adéquate en soins palliatifs. [33]

The Commission recomends that the Minister of Health and Social Services receives assurance that all health-care professionals receive adequate training in palliative care.

Presumably, this means not only future health-care professionals, but those now practicing. But notice the important thing about this recommendation. The question of assisted dying has been before the Canadian public for many years. Polls are regularly conducted about the issue. And yet, during all this time, when people like Margaret Somerville have been throwing up as many public roadblocks as she can against the legalisation of assisted dying, it is a commission enquiring into assisted dying that makes the recommendation that health professionals receive adequate training in pain management and palliative care.

It is important that the impetus for the formation of the Commission came from health-care professionals themselves, and specifically from le Collège des médecins du Québec, because this indicates end-of-life issues are becoming pressing for physicians who see patients when they are dying. In 2009 the College published a document entitled: “Le médecin, les soins appropriés et le débat sur l’euthanasie.” (“The physician, appropriate care and the debate over euthanasia”) And, according to this report, the Commission tells us:

Le Collège des médecins a conclu qu’il « existe des situations exceptionnelles, des douleurs incoercibles ou une souffrance interminable, par exemple, où l’euthanasie pourrait être considérée comme l’étape ultime, nécessaire pour assurer jusqu’à la fin des soins de qualité » [60]

The College of physician concluded that there “exist exceptional situations of uncontrollable pain and interminable suffering, for example, where euthanasia could be considered as the ultimate stage [of care], necessary for insuring quality health-care up to the end.”

In other words, assistance in dying, as I prefer to call it, should be seen, not as a departure from the physician’s obligation to provide quality health-care, but rather as something that is integral to quality health-care itself.

This is further borne out on the very next page, where the report says:

D’après des témoins, la raison d’être de la médecine est incompatible avec l’euthanasie. Envisager celle-ci comme un soin constitue tout simplement une aberration, puisque abréger la vie ne peut être synonyme de soulager ou de soigner. Nous comprenons cette opinion, mais nous estimons que l’euthanasie est pratiquée dans un souci de compassion et comme moyen ultime pour soulager, à sa demande, un patient de ses souffrances insupportables et constantes, lorsque tous les autres moyens qu’il juge acceptables se sont avérés insuffisants. Ainsi, l’euthanasie pourrait bel et bien faire partie du continuum de soins de n de vie. De plus, rappelons que certaines pratiques qui peuvent avoir pour effet d’abréger la vie, comme l’utilisation de certains médicaments, le refus ou l’arrêt de traitement et la sédation palliative continue font déjà partie du continuum de soins de fin de vie.

According to some witnesses, the raison d’être of medicine is incompatible with euthanasia. To envisage this as an [aspect of] care quite simply constitutes an aberration, since shortening life cannot be equivalent to providing relief or cure. We understand this opinion, but we believe that euthanasia is practiced for the sake of compassion, and as a means of ultimate relief, on request, of a patient whose suffering is intolerable and constant, when all other means [of relief] judged by the patient to be acceptable have proved inadequate. Thus euthanasia could well be part of the continuum of care at the end-of-life. Moreover, recall that certain practices which can have, as an effect, the shortening of life, such as the use of certain drugs, the refusal or withdrawal of treatment, and palliative sedation, are already part of the continuum of end-of-life care. [61]

And the report had just said that:

Le Collège rappelle, par ailleurs, que l’autonomie du patient est devenue un principe fondamental de l’éthique médicale. [61]

The College [of physicians of Quebec] points out, further, that the autonomy of the patient has become a fundamental principle of medical ethics.

So the element of patient choice transforms what might have been an aberration, according to former ways of thinking about medicine and its obligations, into an act of care, because responding to the intensely experienced needs and emergent request of the individual patient.

According to religious ethicists like Margaret Somerville, this emphasis on patient autonomy is the outcome of the ”unbridled individualism” of contemporary society, where individuals count for more than “any real sense of community.” (see her Death Talk, 108) Euthanasia, according to Somerville, will only have the effect of tipping the balance away from community towards increasing emphasis on the individual. But this is spurious. A community which respects individuals and individual choice is not less a community for doing so. Indeed, it is through the recognition of individuals that communities become more effective communities. It was when communities disregarded individuals and individual rights, when individuals were easily fungible and even expungeable, that the bonds of community were weakest. It is clear, as I read through the Commission’s report on dying with dignity, that along with its recognition of patient autonomy there is also a very sensitive recognition of what a community of care might look like, where customary carelessness about the intensity of individual suffering is remediated through training and sensitivity.

This sense of individual and community is eloquently expressed by a 90 year old witness before the Commission, who said:

Lorsque vous arrivez à une croisée des chemins, lequel choisissez-vous? Vous pouvez vous tromper, vous pouvez faire le bon choix. Vous le faites, on le fait presque tous les jours de notre vie, lorsque nous devons choisir entre deux choses, et si on choisit l’une, nous n’obtenons pas l’autre. Il s’agit de l’essence même de la vie, je crois. […] Et je pense que c’est pourquoi il est tellement important que la personne prenne sa propre décision […] à cette croisée des chemins.

When you come to a crossroads, which do you choose? You may make a mistake, you may make a good choice. You do it — we do it almost every day of our lives, when we must choose between two things, and if we choose one, we can’t have the other. It’s a question of the essence of life, I believe. [...] And I think that this is why it is so important that the person makes their own decision [...] at this crossroads. [60: sidebar]

That is very moving – the testimony of an old woman who has seen so much of life: Sara Susan Raphals. This is not a concern for individualism at the expense of community, but an understanding that, even in community, we come to crossroads in our lives, and that, at that point, we must choose for ourselves. It is not something that someone else can do for us. We may even make a mistake — and this is true throughout our lives. But this says nothing at all, as Somerville supposes, about lack of community. Even in community, we must make choices. And who should get to make the choice but each of us, individually, as the persons we are? That is eloquent testimony, heavy with human understanding, so unlike those who want to make choices for us, to prescribe how we shall die, without the option. It’s high time that such people were not listened to so intently, but that we instead begin to hear, with undiluted force, the often gentle and despairing appeals — because so often ignored – of those who are suffering, to whom we can respond with a community’s care and devotion.