March 31, 2001 (Montreal Gazette, EDITORIAL / OP-ED, Pg. B5) —  In the closing months of the millennium, the parliaments of both Holland and Canada took steps to further their respective versions of compassionate care at the end of life. 

In June 2000, the Senate committee to examine Canadian end-of-life care tabled its final report, Quality End-of-Life Care: The Right of Every Canadian. The recommendations comprise a detailed call for action, including: that the federal and provincial governments develop a national strategy for improving end-of-life care with particular attention to home care, pharmacare and family-caregiver income security and job protection; that responsible agencies support increased research and teaching regarding the needs of the dying and their families. 

On Nov. 28, 2000 the lower house of the Dutch parliament passed a bill that will render physicians participating in euthanasia and physician-assisted suicide exempt from criminal liability, if two criteria have been met. First, the physician must have fulfilled the requirements of "due care" and second, the municipal coroner must be notified of the actions taken and the case then reviewed by a regional committee. 

Under the new Dutch law, due care is defined as follows. The physician must be convinced that the patient's request was voluntary and well-considered and the suffering unremitting and unbearable; have advised the patient concerning the latter's prospects; have reached the firm conclusion, together with the patient, that there is no reasonable alternative solution to the patient's situation; have consulted at least one other independent physician, who has examined the patient and has formed a judgment concerning adequacy of due care; carry out the termination of life in a medically appropriate manner. 

The new Dutch law might appear to offer adequate protection of public interests. Appearances are, I believe, deceiving. 

Request must be voluntary and well considered: Life-ending without the request of the patient already occurs in Holland.  Fifteen per cent of a random sample of Dutch doctors interviewed in a 1995-96 study admitted to such acts. They account for 0.7 per cent of all deaths in the Netherlands and 40 per cent of cases in which Dutch physicians intentionally act to shorten life. While Dutch investigators argue that many of these patients were incompetent, it is worrisome that 37 per cent of patients whose lives were ended without explicit request were competent in a 1990 Dutch study, 21 per cent in 1995. Furthermore, 50 per cent of Dutch physicians who were surveyed felt that it is appropriate to suggest euthanasia to patients, thus risking compromising the voluntary nature of the process. Finally, what of those who feel their dying is draining others of limited resources? Will a right to assisted suicide begin to feel like an obligation? 

Suffering must be unremitting and unbearable: Whether suffering is unremitting frequently depends on the level of palliative-care competence. The fact that suffering is termed "unremitting" in the absence of adequate palliative care would seem to argue for improving quality care, not euthanasia and physician-assisted suicide. 

Patients must be advised regarding their situation and prospects: The lack of palliative-care training for both attending physicians and for euthanasia and physician-assisted-suicide consultants suggests the advice given to Dutch patients is less than optimal. To address this, in 1998 Holland allocated substantial funding for the development of six academic palliative-care centres as well as programs in designated nursing homes. While this is encouraging, the need for ongoing improvement in palliative-care standards and availability is great even in countries where programs have long been in existence. 

Physician and patient together must reach the conclusion that there is no reasonable alternative to the patient's situation: What constitutes a reasonable alternative? While transient wishes to die occur in 45 per cent of palliative-care cancer patients, 8.5 per cent report the sustained wish to die that would be required for euthanasia and physician-assisted suicide under the new Dutch law. The latter group is more likely to be depressed and they have greater pain and less social support than do patients without a sustained wish to die. Depression, pain and low social support are all potentially treatable sources of suffering. Access to expert care of distressing symptoms must be addressed before we can begin to consider options for terminating life. 

After 25 years as a palliative-care physician and now as a person experiencing cancer as both patient and family member, I remain uncertain that there is ever a situation that is without a reasonable alternative, the potential for hope. When, however, one is overwhelmed by the physical or existential realities at hand, there is a need for palliative-care competence that includes wisdom in symptom control including terminal sedation as required. 

The consultant: Although consultation is required, it takes place in only 63 per cent of euthanasia and physician-assisted-suicide cases in the Netherlands and only 37 per cent of unreported cases. To be effective, consultants need to have palliative-care knowledge and training in the role of a euthanasia and physician-assisted-suicide consultant. Neither is likely in Holland. Furthermore, the Dutch experience documents that physicians tend to consult colleagues who are accessible and of their own specialty and bias. 

Minors: The new bill stipulates that 16- and 17-year-olds "can in principle decide independently, though their parents must be involved in the decision or assist with their suicide." In the case of children 12 to 16 years old, "the consent of the parent or guardian" is required. The capacity of children to undertake such critical decisions is assumed. There are no safeguards against coercion by a distraught parent who feels that the child is burdensome, no recommended psychiatric consultation or mandated role for public health-care programs or social-support institutions, and no diagnosis-based criteria. 

While initiatives to improve palliative care and consultation competence in Holland are encouraging, the cart continues to be before the horse, in that euthanasia and physician-assisted suicide have been adopted as a solution prior to ensuring optimal palliative care. 

Meanwhile, what is the situation in Canada? The June 2000 Senate committee report documents a number of troubling facts. 

- A 1995 Senate committee report on end-of-life suffering in Canada has largely been ignored. The principles, expertise and medical infrastructure are evolving too slowly, due in part to inadequate federal and provincial collaboration, deficient allocation of resources and low priority assignment to end-of-life care. 

- Only 5 per cent of dying Canadians receive optimal palliative care. More than 90 per cent of these are cancer patients.  Palliative-care access is uneven and funding is inadequate. 

- While the need is increasing, the number of institutional palliative-care beds in Canada has decreased in recent years
due to budget cuts. 

The recent decrease in beds is particularly worrisome. In the next 20 years, Canadians in the care-providing age group (20 to 64 years) will increase in number by 12 per cent while those most likely to require end-of-life care, (those over 65 years of age) will increase in number by 69 per cent. Our ability to fund and staff competent palliative-care programs will undoubtedly continue to challenge us. The appeal of euthanasia and physician-assisted suicide as alternatives to overcrowded clinical services, inadequate fiscal resources and increasing family-caregiver burden is unlikely to lessen. 

The report of the Senate committee concludes, "Excellent health care remains an entitlement of each Canadian. A core aspect of this entitlement must be the right to expert, compassionate and interdisciplinary care at the end of life. The committee believes that, as Canadians, we will afford what we value." 

What progress has been made in the months since the Senate committee tabled its report? 

- The full Senate voted unanimous support for the report in late June and requested annual notification of progress toward realization of its 14 recommendations. 

- A meeting of representatives from 23 stakeholder organizations was convened on Dec. 1 to discuss a national strategy. This resulted in the formation of a coalition for quality end-of-life care. 

- The minister of health for Manitoba agreed to play a leadership role in establishing end-of-life care as a high priority and agenda item at meetings of the provincial ministers of health. 

- The coalition sent a resolution to the prime minister demanding immediate adoption of the June 2000 Senate report. 

- The Jan. 30 Speech from the Throne included reference to support for parents caring for gravely ill children. 

The Dutch choice of implementing euthanasia prior to palliative care was pragmatic and perhaps born out of cultural and historic factors. They now are adding palliative care. Thus in the Netherlands, both options will be available. 

In Canada, we have effectively chosen neither. Our courts voted against euthanasia by the narrowest of margins, while our governments have failed to give adequate support to palliative care. Canada must no longer sit on the fence. Unnecessary suffering cannot be tolerated. Canadians must speak out for those who cannot speak for themselves. Our political leaders must no longer hide behind federal-provincial jurisdictional squabbling. 


Balfour M. Mount is Eric M. Flanders professor of palliative medicine at McGill University. 

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Last modified: July 21, 2001