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Doctors, Death and Sue Rodriguez

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Doctors, Death and Sue Rodriguez VIEWPOINT * POINT DE VUE Doctors, death and Sue Rodriguez Eike-Henner Kluge, PhD T he debate about physician- However, section 241 of the not infringe on these rights; that is assisted suicide heated up Criminal Code states: "Everyone why it has been decriminalized recently because of Sue who ... (b) aids or abets a person since 1972. Rodriguez, a Victoria woman who to commit suicide, whether sui- Rodriguez could commit sui- has amyotrophic lateral sclerosis cide ensues or not, is guilty of an cide now - this would be consis- (ALS). She wants Canadian laws indictable offence and liable to tent with what is allowed under changed to allow physicians to imprisonment for a term not ex- the Criminal Code. However, she help patients commit suicide; ceeding fourteen years." As well, is not ready to do that yet. Others Some ALS patients live for the CMA has stated that this are willing to help her when she is years and continue to function at would be unethical medical prac- ready, but the code forbids this. a relatively high level. Stephen tice. To be able to do what she wants Hawking, the brilliant British physicist, is a celebrated example. However, Rodriguez has a partic- ularly acute form of ALS and a short life expectancy - perhaps only 3 to 15 months. In the later I believe that the Criminal Code is ethically stages of her disease, she will be flawed and section 241 should be struck unable to do anything for herself. She says that being in such a state down. would violate her sense of dignity and she would like to avoid this by committing suicide. Although she has not yet reached the stage of deterioration I believe that the Crimin- to do, she has to kill herself now. that would trigger this decision, al Code is ethically flawed and In other words, the current law she knows that when she does section 241 should be struck forces Rodriguez to buy her au- reach it she will be physically down. I also think that the tonomy at the price of an earlier unable to take her own life be- CMA should reconsider its own and as yet unwanted death. This cause she will be unable to control position. violates the principle of autonomy her limbs or even swallow an The Criminal Code injunc- and respect for persons. overdose of medication. She will tion violates three fundamental The principle of equality and need help and would prefer a ethical principles: autonomy and justice means that we should treat physician's assistance because she respect for persons; equality and others in a just and equitable feels doctors are the only ones justice; and beneficence. fashion. We should make due al- properly trained to help her. The principle of autonomy lowances for the differences and respect means that everyone among persons if these differences Eike-Henner Kluge is a professor with the has the right to self-determination would, or would likely, prevent Department ofPhilosophy at the University unless this infringes unjustly on these persons from taking equal of Victoria. the rights of others. Suicide does advantage of the opportunities MARCH 15, 1993 CAN MED ASSOCJ 1993; 148(6) 1015 that are open to other members of overcoming this handicap is to may be the most oppressive. It society. This principle underpins discriminate against her on the may be better to live under robber the social obligation to make al- basis of the handicap. The current barons than under omnipotent lowances for handicaps. Equity law does just that, and thus vio- moral busybodies. The robber employment policies are a non- lates the principle of equality and baron's cruelty may sometimes medical example of the principle justice. sleep, his cupidity may at some in practice. The principle of beneficence point he satiated; but those who Sue Rodriguez's inability to means that people have an obliga- torment us for our own good will commit suicide when life has be- tion to do good for others, and torment us without end for they come burdensome, undignified this notion of good is defined not do so with the approval of their and unbearable to her is related to by us but by those who are affect- conscience. They may be more the specific nature of her disease. ed by our acts. As C.S. Lewis,' one likely to go to Heaven, yet at the It is not a self-caused handicap of the foremost Christian writers same time likelier to make a Hell but arises out of circumstances of this century, stated: "Of all the of earth." beyond her control. Therefore, tyrannies a tyranny sincerely exer- Rodriguez has left no doubt failure to provide some means for cised for the good of its victims about what she considers to be "the good": it lies in the values Canapress that include her notion of dignity. Violation of this sense of dignity will cause her suffering, and this violates the principle of benefi- cence. Rodriguez's position is not unusual. Many people share her belief that suffering should not be protracted beyond the ability or the desire of individuals to bear it. Some say that Rodriguez could be palliated and that palliation would remove all elements of suf- fering. However, this argument betrays a radical misunderstand- ing of the notion of suffering it- self. Suffering is not something inherently physical. As psychia- trist and ethicist Erich Loewy2 notes, suffering has a central psy- chological component that is es- sentially different from physical pain. Palliation might mitigate Rodriguez's physical pain and dis- comfort but it will not deal with the violation of her sense of digni- ty. Therefore, it will do nothing for her suffering and neither will it deal with the reason for her suffering. It would merely make her insensitive to it. If that were ethically acceptable, we would never have to deal with the source of people's suffering. All we would have to do is drug them. The ethically appropriate way to deal with suffering is to remove the source in a way that respects the dignity of the person, as de- Rodriguez, accompanied by euthanasia advocate John Hofsess fined by that person. It is morally 1016 CAN MED ASSOC J 1993; 148 (6) LE 15 MARS 1993 perverse to suggest that Rodriguez to 51% of respondent physicians should allow herself to be palliat- were in favour of physician-assist- ed to the point that she would not ed suicide and/or euthanasia.3 experience her suffering. Is it ethi- Of course, ethics by poll is cal to violate a person's values as not ethics. However, it would be long as she is not aware of it? interesting to know whether Cana- SYMPTOMS AND TREATMENT What is the role of organized dian physicians agree with the rest OF OVERDOSAGE medicine in all this? Rodriguez of Canadian society. In a 1992 Patients have received single doses of PROSCARO (finasteride) up to 400 mg and multiple doses of has requested that physicians be Gallup poll, 77% of Canadians PROSCAR0 up to 80 mg/day for three months without adverse effects. exempt from section 241(b) of the were in favour of assisted suicide No specific treatment of overdosage with Criminal Code. Would physician and/or active euthanasia. PROSCAR® is known. involvement in her death contra- A CMA review would also be DOSAGE AND ADMINISTRATION vene the ethics and perspectives significant because the Report of The recommended dosage is one 5 mg tablet of the medical profession? The the British Columbia Royal Com- daily with or without food. Royal Dutch Medical Society has mission on Health Care and Although early improvement may be seen, at least 6-12 months of therapy with PROSCARs recently reached a formal agree- Costs, which devoted an entire may be necessary, in some patients, to assess ment with the Department of Jus- section to physician-assisted sui- whether a beneficial response has been achieved. If no clinical benefit is evident within this period, tice in the Netherlands that allows cide and euthanasia, recommend- patients should be re-evaluated and the decision for continuation or discontinuation of finasteride physicians to participate in assist- ed that the Criminal Code be therapy should be based upon assessment of in their disease status. ed suicide under certain carefully changed precisely the way Ro- Dosage in Renal InsffIciency defined and monitored condi- driguez is asking.4 Adjustments in dosage are not necessary in tions. This raises an important Finally, consider this. If Ro- patients with varying degrees of renal insufficiency (creatinine clearances as low as 9 question. Is medical ethics a mat- driguez was in intractable physical mL/min) as pharmacokinetic studies did not indicate any change in the disposition of ter of nationality, or does it follow pain and the amount of medica- finasteride. from the nature of the profession? tion needed to alleviate it would Dosage in the Elderly If the latter - and this is general- shorten her life or even kill her No adjustment in dosaqe is required although pharmacokinetic studies indicated the elimination ly accepted - then if it is ethical outright, she would have to be of finasteride is decreased in patients more than 70 years of age (See PHARMACOLOGY under for Dutch physicians to act this told this. Informed consent would Pharmacokinetics). way, why should it be unethical require it. If Rodriguez were then AVAILABILITY OF DOSAGE FORMS for Canadian physicians to do the to insist on the medication, it 3094 Ca - PROSCAR® (finasteride) 5 mg tablets same? It may be that Dutch physi- would be given.
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