Discussion Group on Dying well (part 1 of 2)

Harry van Bommel
The Next City
March 21, 1998

“WE NEED TO SCHEDULE A TIME FOR OUR NEXT MEETING,” says the chair of the department. “How is May 11th at ten o’clock?”

“Oh, I’m sorry Johan,” says Peter. “That’s the day my father is scheduled to die. Can we do it later in the week?”

This kind of conversation does not occur in Canada today. But it does occur regularly in the Netherlands, where euthanasia and assisted suicide have become the stuff of everyday life. Dutch criminal law does not prosecute physicians for taking a life, let alone making it possible for someone else to take his. In the process, Dutch attitudes to life have been transformed. A close friend can, in good conscience, encourage someone he cares for to end it all. A beleaguered mother, unable to juggle her responsibilities to her children and tend to her ailing father, can without guilt sit him down and explain the logic in ending life sooner rather than later. Once seen as spiritual and sacred, a life more resembles a commodity to be cold-bloodedly analyzed, valued, and, if found wanting, discarded. Euthanasia and assisted suicide now account for more than one Dutch death in 40.

The transformation did not occur overnight. The members of the Royal Dutch Medical Association came to permit euthanasia only after much agonizing and only with strict guidelines to prevent abuse. At first, only competent people facing imminent death from a terminal illness and voluntarily asking for euthanasia were eligible. But the Dutch soon found themselves on a very slippery moral slope. Once euthanasia became thinkable in principle, its practice accelerated. Soon, the death didn’t need to be imminent; then, the illness didn’t need to be terminal. Over the past two decades, euthanasia has become an answer for people who are chronically ill, clinically depressed, anorexic, and who have not requested death at all. Chillingly, death has become a doctor-prescribed cure for any number of afflictions.

To breach the next Dutch frontier — euthanizing healthy elders — early this decade the Dutch Euthanasia Society produced “Through with Life,” a television docudrama about Mrs. van den Berg, a lonely woman in her 70s living in a seniors building. Her husband, daughter, and friends had died before her, and her only consolation, apart from Moniek, a young nursing aide who had befriended her, was biweekly visits from her son. She felt unproductive, her life bereft of meaning. She felt her body slowly deteriorating. She had no interest in the future other than to end it.

At first, Moniek and the son both opposed euthanasia for her, partly from guilt that their companionship was not enough to give her a will to live. But a counsellor at the seniors home convinced them that Mrs. van den Berg’s request was reasonable given her age and loneliness. In the documentary’s moving finale, she receives the lethal dose amid soft visuals and inspiring music that heighten sympathy for her and her right to die.

The docudrama and subsequent attempts to sway public opinion were not quite moving enough: For now, healthy people may not be legally euthanized. But as euthanasia proponents continue to bombard the aging Dutch population with images of rational suicides, public rejection of euthanasia for lonely or unhappy people is likely to fade. The Dutch combine a utilitarian view of human worth with a libertarian belief that individuals have the right to death upon request. But though this combination is most potent in the Netherlands, other western countries don’t lag far behind. The logic of euthanasia becomes especially compelling when our institutions create living hells for vulnerable people. In our compassion, we offer them death as a way out.

Canada, with the world’s highest rate of institutionalized seniors, is ripe for euthanasia arguments. Many seniors rightfully fear the neglect, abuse, and — worst of all — the stamp of worthlessness that brands residents of nursing homes and other long-term care facilities. At a home for the aged in Hamilton, Ontario, 74 per cent of women signed an advance directive refusing life-saving surgery or other major interventions should they become curably ill.

At the other end of life, Western society and, as our agents, physicians routinely define the worth of our children. When parents want children and when society values them, we spare little money, effort, and community spirit to care for them, regardless of the odds, as the septuplets born in the United States last year attest. If, however, the children are unwanted and are seen as burdensome to society, we often allow them to die “for their own good.” As of September, Britain’s Royal College of Pediatrics and Child Health began issuing guidelines advising doctors to pull the plug on children who would survive treatment but with severe mental or physical handicaps. Parents who want treatment for their children are now refused care. Yet the definition of severe is arbitrary; a reliable prognosis of a severe infant disability usually cannot be made. Many parents of people living, working, and raising families today were told to institutionalize their babies decades ago. Medical practitioners have not become any more qualified to predict an infant’s capabilities in later life.

The young and the old are not the only at-risk groups. Because Canada is less homogeneous than the Netherlands, where 96 per cent of citizens come from Dutch stock, we have greater degrees of disparity and more vulnerable people relative to our most valued citizens: People who are poor, speak English poorly or not at all, and people of color as well as people with disabilities receive a poorer quality of medical care and die younger. Peggy McDonough of the department of sociology at Toronto’s York University reviewed studies on income and mortality and concluded that consistently lower income levels predicted increased odds of dying by as much as 30 per cent. If Canada legalizes euthanasia, our many vulnerable people would become even more vulnerable, raising the prospect of euthanasia rates higher than in the Netherlands.

Real and imagined financial pressures may also exacerbate demand for euthanasia. As we’ve become the Me Generation, increasingly committed to instant gratification and individual freedoms, we’ve lost our commitment to family and community, often seeing them as impediments to personal fulfilment. With cutbacks in health care and public acceptance of rationing medical services, our elders, those with few family supports, the poor, and the unassertive will be expected to do the “right” thing and request death rather than costly care. Daniel Callahan, executive director of the Hastings Centre, one of the continent’s leading centres for bioethical research, promotes this very ethic: He calls for age-based rationing of scarce health care resources to reduce health care costs. After a “natural lifespan” of 70 to 80 years — “one in which life’s possibilities have on the whole been achieved and after which death may be understood as a sad, but nonetheless, relatively acceptable event,” he argues against interventions to prolong life.

Managed care organizations would also jump aboard this efficiency bandwagon. In Oregon, which recently legalized assisted suicide, managed care organizations have offered to pay for death rather than long-term care since “the least costly treatment for any illness is lethal medication,” explained Walter Dellinger, acting solicitor general of the United States, in oral presentations opposing euthanasia and assisted suicide to the Supreme Court last year. Efficiency arguments may also dictate dying to save the life of another. To obtain organs, physicians have often surreptitiously shortened the lives of patients with life-threatening conditions to benefit patients with better prognoses. Capitalizing on this kind of calculus, Dr. Jack Kevorkian, who has helped over a dozen people (not all terminally ill) to commit suicide, encourages his patients to donate their organs to any clinic willing to accept them.

ONE STRAIN OF EUTHANASIA SPRINGS FROM the eugenics movement and shares many of its motivations and impulses. Started in western academic-medical circles at the turn of the century, eugenics encouraged the breeding of a purer race to represent the middle-to-upper class educated best of the majority white population. At country fairs in North America, eugenics booths idealized the healthy, blonde, blue-eyed population. Poor, uneducated children, regardless of skin and eye color, were targeted as feebleminded and, therefore, a risk to the rest of the white race. Alberta’s Eugenics Board — formed to protect society from the vices of the feebleminded — approved 4,728 sterilizations of people labelled mentally defective, between 1929 and 1972, among the unknowing boys and girls confined to the Red Deer Provincial Training School.

Eugenics soon expanded to include euthanasia. In Europe and especially Germany, which took euthanasia the furthest, euthanasia thrived in the 1920s “within the culture of medicine, modern intellectualism, academicism, and scientism. The program began not because it was German, or even Nazi, but because it was a phenomenon of western science in general,” explained Wolf Wolfensberger, professor of special education at Syracuse University. “The explicit basis for euthanasia in Germany was described [in 1920], 13 years before Hitler came to power and 20 years before the Nazi euthanasia programs actually began.”

First, German institutions euthanized patients who had severe physical or mental handicaps, including developmental disabilities, mental disorders, tuberculosis, chronic illness, cerebral palsy, and epilepsy. Then, with the quick and easy success of the early phase of the program and with the presence of a death-making apparatus, authorities prescribed euthanasia for people who had lost bladder control and other less severely afflicted people; for dwarfs and others who were physically atypical but not necessarily impaired; for those suspected of genetic and racial taints; and for gypsies and others devalued entirely for their social identities. In time, authorities categorized people with behavior problems, odd-shaped ears, very dark eyes, hair, or complexion into these groups. The killing of the Jews evolved out of the desensitization, legitimization, personnel preparation, and equipment development associated with the killing of handicapped people.

The eugenics movement survived the Second World War — below the radar screen — and remains a hot debate, as shown by controversy over recent books like The Bell Curve and studies from the likes of Philippe Rushton, professor of psychology at the University of Western Ontario, which argue that human intelligence stems partly from race. In 1972, Episcopal theologian and bioethicist, Joseph Fletcher, whose work is a staple in university ethics courses, argued that only people with all 15 of his “indicators of personhood” — among them minimal intelligence, self-awareness, self-control, sense of time, curiosity, and willingness to accept change — should be allowed to live.

Today, eugenics takes a backseat in the euthanasia movement. Euthanasia champions — many of whom oppose eugenics — promote euthanasia as a basic human right. Derek Humphry, co-founder of the Hemlock Society in the U.S. and a world leader in the quest to legalize euthanasia, presents the movement’s goal in Dying with Dignity: “The essays in this book trace the steps toward the ultimate personal liberty: the right to die in the manner, at the time, and by the means that a competent adult wishes.” The movement’s strategy is to begin with legislation allowing living wills and advance directives; then, to modify or adopt regulations that, bit by bit, use the legislation to allow assisted suicide or euthanasia on the voluntary request of competent adults with a terminal illness.

In Canada, Humphry’s views have been winning important adherents: In 1994, the Supreme Court voted by the slimmest of margins, 5 to 4, against Sue Rodriguez, the 42-year-old B.C. woman with ALS, or Lou Gehrig’s disease, who had requested physician-assisted suicide, with Chief Justice Lamer among the dissenters. A person should be able to ask the courts for euthanasia, he argued, thereby minimizing abuse to vulnerable people — a basis for the criminal code law against assisted suicide.

At presentations made during senate committee hearings on euthanasia and assisted suicide in 1994 and 1995, many authorities endorsed euthanasia, and various experts argued for a third category of murder; namely, third degree murder, where “the killing was not exploitive or malicious, but . . . with the perception of the best interests, and on the request, of the person killed.” In the killing of Tracy Latimer, a child with cerebral palsy, the Canadian public and the Saskatchewan judge decided that a mercy killer need not have the consent of the person killed, and shifted their collective compassion from Tracy to the father who killed her.

The public has swung behind these experts: Polls show that about three-quarters of Canadians support the concept of people having the right to doctor-assisted suicide if they suffer unbearable pain.

EVERYONE WHO BELIEVES IN LEGALIZING EUTHANASIA — bioethicists, politicians, the Royal Dutch Medical Association, even Derek Humphry — wants safeguards to protect vulnerable people. Yet workable safeguards are delusions. Take the chief safeguard, informed consent: the requirement that people request euthanasia voluntarily and repeatedly.

Physicians have told me that simply by wearing their white lab coats and presenting information in a favorable light, patients will voluntarily consent to what amounts to tortuous treatments with little hope of success. Patients in desperate straits are emotionally vulnerable and without their normal defences. Physicians taught to practise euthanasia in medical school will have a professional bias to use their skills. How would they answer the common question: “If you were in my shoes, Doctor, what would you do?” No law can safeguard how physicians present information in their confidential conversations with patients.

Informed consent also implies that physicians and other care-givers have the time and training to counsel and help patients understand end-of-life decisions. One only has to examine the health care systems across Canada today to understand that such time is rarely available and rarely paid for by the government.

The safeguards are designed to let people change their minds on a dime, as if this can be effortlessly done in the real world. For example, an Ottawa professor in her late 50s dying of a blood disorder decided to forgo more blood transfusions and end her life within weeks. Soon after her decision, her husband had a stroke. Not wanting to leave him without care, she asked for her blood transfusions to resume. Her physicians turned her down, saying she couldn’t keep changing her mind. Thanks to her position in the community and friendship with the university hospital administrator, she successfully fought the decision, letting her help her husband over the initial period of his convalescence before her death. What would have happened had this person been a cleaning lady at the university?

Another real-world situation: Imagine a woman scheduled to die next week, with relatives flying in from Manitoba and Newfoundland to be by her side. Suddenly she feels better, and though knowing the improvement can’t last long, she begins to think in terms of hanging on long enough to attend her grandson’s graduation in three months. What do you expect will be her choice? How often might a family “allow” a loved one to change a scheduled death?

Those who’d have the courts decide euthanasia to minimize abuse forget that the courts are chronically backlogged. Inevitably, a court-based euthanasia process will be streamlined and bureaucratized into a rubber stamp, just as the courts have resorted to plea bargaining and other administrative shortcuts. In the Netherlands — the only western country to permit euthanasia — doctors do not report a majority — 59 per cent — of euthanasia and assisted suicide cases to Crown attorneys, as required by the Royal Dutch Medical Association and the courts. Dutch doctors, according to a major survey, justified flagrant disregard of reporting procedures due to the “burden” of paperwork. Another Dutch study found that in almost one-quarter of euthanasia and assisted suicide cases, the physicians ended life without the patient’s explicit, concurrent request. If Canada had Dutch death rates, we would have about 6,000 deaths per year by euthanasia, 1,800 people dying without their consent, and 1,000 assisted suicides. That’s five Tracy Latimers a day, and almost three Sue Rodriguezes a day.

The Dutch studies nevertheless endorse euthanasia because neither voluntary euthanasia, assisted suicide, nor unrequested euthanasia increased dramatically from 1990 to 1995, the time period they analyzed. They downplay the significance of so many unreported cases and aren’t disturbed by the death toll of people who did not explicitly request euthanasia. They rationalize the disregard for informed consent by suggesting that doctors had previously killed people surreptitiously without their requests, and that the Dutch euthanasia laws have only brought the practice to light. The studies pooh-pooh the inappropriate deaths as an inevitable cost that must be borne in reaping the greater benefits in legalizing euthanasia. In the Netherlands, physicians brought to court on charges of murder stemming from euthanasia cases are chastised for not following the guidelines but not imprisoned or prevented from practising medicine. The legal and health care systems — despite the official, elaborate safeguards in place — are entirely indifferent to unreported cases of euthanasia.

Canadians have no reason to believe that our crowded courts or beleaguered health care bureaucracy would be any more virtuous or diligent than the Netherlands’. Even before the recent countrywide health care cutbacks, Canadians’ trust of our physicians had been steadily declining. As put by Dr. Katherine Foley, an international pain management authority from the Sloan Kettering Cancer Center, at the 1994 International Congress on Care of the Terminally Ill in Montreal: “If you do not trust your doctors to care for you when you are dying, why would you trust them to kill you?” Foley described how the euthanasia movement rose to counter the failure of modern health care in meeting the needs of the dying. Rather than relieve suffering, extreme medical efforts often caused unnecessary pain. Foley also described another, simultaneous reaction to extreme medicine: the hospice movement, with its interest in alleviating pain through palliative care.

MY INTEREST IN PALLIATIVE CARE — and from it, my opposition to euthanasia — stems from caring first for my mother in Canada and then for my grandfather in the Netherlands and lastly for my father back in Canada, at home, until they died. I learned many things that help make me a better friend, husband, and father. That said, I would not have chosen to care for my mother had professionals offered to provide her with hospice care at home. I was 24 years old, a recent York University graduate studying French at Laval University in Quebec City. I had no experience in caring for any sick person and certainly none for someone who was dying. Preparing for the death of loved ones and for life without them was enough of an emotional roller coaster without having to know about pain and symptom control. However, I didn’t have that choice, and I learned to provide care for my parents and grandfather. I also learned that such experiences provide much laughter, joy, love, and intimacy. That part of the experience I wish everyone could experience. Those moments are life-defining and life-fulfilling.

In caring for my loved ones, a key issue came up over and over again — the need in the dying for a sense of control in the uncontrollable events leading up to a death. A sense of control is all-important. It is about maintaining our roles as parents, grandparents, workers, church members, neighbors. It is about continuing the decision-making process in our lives.

My grandfather had his cancerous stomach removed when he was 91. The surgery was a success but not his recovery. On death’s door on Christmas Eve 1980, he rallied into the following summer until his body couldn’t continue. No longer hungry or even thirsty, he asked us not to prepare his liquid diet any more; he just wanted water with some sugar added. Near the end of his life, he felt eating had become a charade; yet control remained important. Just one day after switching to sugared water, to our bewilderment, he asked for a ham sandwich. Once he got his sandwich he took one bite, smiled broadly, and said, “I just wanted to see if you would give it to me. I don’t want any more, thank you.” He continued to drink his sugared water and died a few weeks later.

A sense of control is important throughout a person’s illness. When my father first experienced seizures and breathing difficulties, he knew that he wasn’t well, but he didn’t know the extent of his illness. After the doctors concluded their tests and diagnoses, I told them I wanted to be the one to tell him he was dying. In going to him, I said: “The test results are in, and I have done some research on your condition. Would you like me to tell you what I found out?”

My father was now in charge. He could hear what I had to say, not hear the news, or wait. He chose to wait, to give himself time to prepare. Over the next few days he asked simple questions that I was able to answer. He took his time, eventually getting all the information I had. Once he had control over the medical information, he was better able emotionally to deal with his emphysema and the tumors in his brain.

Being in charge also requires carrying on with your family responsibilities; it requires refusing to succumb to a self-centred disregard for the needs of those close to you. I once asked my father what was most difficult about dying. “I’m most sad that I cannot be at your wedding in June,” he answered. Yet although his energy was low, although it would have been easier to dwell on dying than on our wedding, he helped us plan the service. We had offered to advance the wedding date and move it east from British Columbia to let him participate, but he wouldn’t hear of it since most of my fiancée’s family lived in the west. As a wedding gift, he gave my fiancée a necklace my mother only wore on important occasions — he felt it was important that her prospective father-in-law provide something very personal and precious, and he beamed with love in doing so. He also arranged for me to receive a wedding card — containing all his hopes and dreams for his only son — the night before my wedding. It must have been very difficult to write knowing that he would not be at the wedding. His effort, however, let me sob part of my grief away on my wedding eve, making the actual wedding day glorious, filled with love, beauty, and the promise of a wonderful family life ahead. An invaluable gift of love that only a parent can bestow.

A sense of control is about self-affirmation, self-respect. It is about being a person. Understandably, many people would rather die than lose their personhood, hence the attraction of euthanasia. We can all identify with the need for self-respect, and we all harbor fears that we might not rise to the challenge when our own time, or that of our family members, arrives. Hence our enormous sympathy for Sue Rodriguez. The thought that she would die a horrible death in front of her family by choking or failing to breathe terrified others with ALS, their family, and friends. More than a few people in the media, in politics, and in the public started conversations with “I’d rather be dead than have ALS.”

Dr. Peter Hargreaves is a family physician who has cared for hospice patients in Liverpool for about 12 years and at Lion’s Hospice near London since it opened five years ago. He has been involved in over 2,500 patient deaths, including many patients with ALS. “You can count on one hand the number of patients who have requested euthanasia,” says Hargreaves. “They usually request euthanasia because of uncontrolled symptoms, pain, nausea, vomiting, and they request it on admission because they ‘have had enough — put me out of my misery.’ If you gain their confidence by rapidly controlling those symptoms, they usually do not request euthanasia any more. If someone has wildly out-of-control pain and symptoms, I will actually get them pain-free, through helping them to sleep straight away — give them four to six hours of pain-free sleep. They come around and say, ‘I feel better. Thank you very much. What are we going to do now?’ Then we plan how to control their pain and symptoms. Once you have done that, the request for euthanasia stops. I have never had a sustained request for euthanasia apart from one patient who was psychotically depressed and needed treatment for the psychosis.”

What about the media reports of choking? According to Hargreaves and nurse Sue Watts, day programme manager at Lion’s Hospice, many family members give ALS patients liquids, thinking liquids are easier to swallow. However, because liquids do not trigger a swallowing reflex, they may actually cause a choking episode, leading the carers and the patients alike to believe that they cannot eat or drink anything anymore. “People stop giving themselves nourishment if they do not know better and that is a real pity,” says Watts. “Thickening fluids while making sure there are no solid lumps is most effective. Pureeing solids or softening food is also very effective.”

Concerns over patients who have trouble breathing are also misunderstood, explains Hargreaves. “The breathing — this thing about respiratory arrest — sounds very dramatic, but it is not a dramatic end. You tend to find that the breathing becomes gradually more shallow. Quite often the patient does not realize that the breathing has changed. When you look at them, you think, ‘they’re not breathing very much or very deeply.’ They get used to a smaller respiratory reserve. If they become aware of distressing breathing or they feel they cannot take a deep enough breath, then there are plenty of drugs that we can use to take the edge off that, to remove the fear about not being able to take a deep enough breath. You can deliver those drugs in a variety of means — at home, in the community, or in an inpatient setting. The important thing is, if you are at home, we need a range of drugs available for carers to give or for general practitioners, district nurses, or whomever. We encourage carers to be very much involved in this.”

The British ALS association has produced a box it calls the Breathing Space Kit. It has two little drawers, one marked for the visiting home doctors and nurses and one for the family carer. It encourages the family physician to put medication into each drawer, and trains the nurse and carer in how to handle them. Doing so gives everyone a sense of control and helps prevent crisis situations. Families are able, with telephone assistance, to give their loved ones whatever drugs they need.

Dying in unbearable pain, the greatest fear of people with a life-threatening or terminal illness, is a leading cause of demand for euthanasia. This fear would subside enormously if medical training simply kept up with medical knowledge. In knowledgeable hands, medicine can help most people be relatively pain-free and alert until they die. For example, only in five per cent of people experiencing pain with advanced cancer will the pain be difficult to manage. This five per cent represents people whose emotional or spiritual difficulties heighten their pain and make it untreatable solely with drugs. Their best medicine would be support from family, spiritual leaders, social workers, counsellors, or nurses. When all else fails, pain relief could come through short periods of drug-induced sleep.

Once pain is managed, other symptoms like nausea, vomiting, bed sores, and dry mouths are more easily controlled. Palliative care physicians provide such pain and symptom control successfully every day across Canada. Dr. Cicely Saunders, the modern founder of hospice care, has been teaching for decades that “nobody need die suffering.”

WHEN MY MOTHER WAS DYING, she received too little pain medication, and she received it too infrequently because her physicians, her pharmacists, and her family all thought that if we gave her too much, too soon, the drug’s power would soon wear off, leaving nothing to give her later on in the illness. We couldn’t have been more wrong.

Dr. Dorothy Ley, a palliative care pioneer in Canada and the first woman to win the Canadian Medical Association Medal of Service, explained that the “myth that too much pain medication will lead to addiction is just that — myth. When medication is used to combat pain, there is no high associated with its use and, therefore, no addiction.” The myths about addiction and drug tolerance were disproved by these and many other palliative care doctors in the 1960s and 1970s, yet they persist simply because the message has not hit home. Most physicians, untrained in pain control, remain hesitant to use modern methods, even though these methods are proven effective.

To help people live life fully until they die, their pain must be relieved immediately — “saving” larger doses for possible future pain is pointless when proper pain and symptom control can add months or years to a person’s life. Patients who are alert, comfortable, and able to meaningfully participate in their lives have more energy and hope for the immediate future.

Colleen McArthur was diagnosed with non-Hodgkin’s lymphoma in December 1988. On Boxing Day, her massive spleen was removed, revealing a cancer that had spread into surrounding lymph nodes and to the liver. Chemotherapy began right away, to her distress. “I was shocked to learn about the side effects. They told me my hair would fall out and that I would experience numbness in my fingers and feet. I was a piano teacher, the numbness made me feel very sad,” recalls McArthur.

Her chemotherapy began at St. Boniface Hospital in Winnipeg, but rather than drive the 120 miles into Winnipeg every three weeks, she switched to Morden District General Hospital, near her home, which fortunately had an outreach centre and a palliative care coordinator, Thelma Alexander. “Somehow she [Alexander] must have known about my first visit because there she was offering me a pencil and paper to write questions for my doctor. She was so kind and really made me feel comfortable on a very apprehensive day. This atmosphere of genuine concern and kindness continued right through my months of treatment.”

Alexander and her colleagues use various non-medical skills to help their clients deal with their physical and emotional pain and suffering. For McArthur, the care began with their willingness to simply listen and attend medical appointments with her; later, they helped her set up a cancer support group in her own community. Later still, it included gentle stretching exercises as well as deep breathing, Tai Chi, and long walks (out of the sun because chemotherapy and direct sunlight are not a healthy combination for skin).

McArthur has been relatively pain-free and alert because of excellent medical attention over the past nine years that let her remain in her community and share in the lives of people she loves most. But McArthur’s experience is rare. Most dying people do not receive such physical, emotional, spiritual, and informational supports. Until they do, some lonely, isolated, and suffering people — estimated at three per cent of the population — will continue to request death.

With a concerted effort, Canada could be substantially pain-free in five years — “Pain-Free by 2003” is the refrain of a nascent pain and symptom control campaign that aims to educate the public and the medical establishment that pain and discomforting symptoms need not be the norm for people who are dying. We must all learn to expect the opposite, and to view the existence of patients in pain as a national disgrace. Once we’ve learned to tend to our patients mercifully, once the public recognizes that they and their loved ones need not fear a painful death, the public debate over euthanasia will diminish and perhaps even disappear.

Our world includes unconscious trends that defy logic. On the one hand, we have physicians in Canada, Australia, and Europe developing a suicide pill for terminally ill patients upon request. On the other we have the knowledge and skills to make Canada a pain-free zone and the resources to treat vulnerable people (including most people with a terminal illness) with the dignity they require. We have the wherewithal to work together to dramatically improve the situations of people who are dying, chronically ill, or vulnerable. Will we?

Click here to continue on to read part 2: Letters

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