Wednesday, July 4, 2012

The Language of Ending Life


Art, like morality, consists of drawing the line somewhere.
(G.K. Chesterton)
Andre Picard of The Globe and Mail is one hell of a writer. In a piece considering a British Columbia court’s approval of medical assistance in dying, and the complexities of the language surrounding the issue, Picard wonders just what was decided.

This much seems clear: The court granted to Gloria Taylor, a woman who suffers from ALS, or Lou Gehrig’s disease, the unique, for now, right to end her life at the time of her choosing with the physical assistance of a physician. Meanwhile, the Canadian Supreme Court sometime soon will resolve the case in Ontario of Hassan Rasouli, a minimally conscious man on life support caught in a wrenching moral/ethical quandary in the space between hastening death and prolonging dying. The country to the north is engaging the end-of-life debate in ways that promise illumination.
So what, Picard asks, should the right earned by Gloria Taylor be called?
“Physician-assisted suicide? Physician-enabled death? Physician-hastened death? Euthanasia? Voluntary euthanasia? Rational suicide? Suicide? Mercy killing? State-sanctioned murder? Death with dignity? And there are many more variations, each loaded with legal and moral baggage. The language we choose tends to reflect where we stand on the underlying question of whether grievously and irremediably ill people should have the right to choose to end their lives rather than let an illness take its course.”
Picard’s attempt at divining a fair and accurate term mirrors in many ways the recent struggle by the Community Ethics Committeee in Boston. With the likelihood that Death With Dignity Initiative will be on the Massachusetts ballot in November, the CEC studied and debated the question for months (in the process delaying a report on “medical futility/intractable disputes,” yet another extreme test of language and understanding). In this dicey negotiation of the line between church and state, with respect for democratic process and the values of life and choice, language emerged as central, perhaps determinant, to deciding the appropriateness of the practice.
Among CEC members, there were proponents of the term“death with dignity”; there were proponents (including myself) of “physician-assisted suicide.” We achieved consensus on neither, but settled on “choosing medically induced death.” This, we found, focused attention on two important aspects: autonomous choice and the physician’s role in providing the prescription for the lethal dose. And though as a phrase it won’t roll off anyone’s tongue, or supplant strong attachments to the better-known competition, “choosing medically induced death” most clearly addressed the CEC’s task at hand.
Calling the act of killing oneself something other than suicide can seem euphemistic and unhelpful in understanding what is taking place. And yet Picard makes a strong point, in clear and simple language, when he says “calling medically assisted dying suicide is a lot like calling surgery a knife attack.” Killing the patient is never the purpose of legitimate surgery, but suicide is without question a loaded term.
The right language is literally vital, and so difficult to agree on.
In an earlier CEC study -- of the use of palliative sedation in treating dying patients in intractable pain -- we agreed to make no real distinction among physical, emotional or spiritual pain; pain is pain, we decided. We also became convinced that while deep sedation might in fact hasten death, it also with some frequency allowed organ function to resume and the patient to live longer than expected. The intent was to treat the pain, and causing death was uncertain. We made a distinction between palliative sedation for a terminal patient, and medically induced death.
Learning about Gloria Taylor’s medical and legal ordeal led me to another excellent piece of journalism, by Douglas Todd in the Vancouver Sun. Todd looks insightfully into Taylor’s story and the broader subject of assisted dying. I’ll post more about Todd’s story in a coming blog. (Watch Taylor speak about the decision here.)

The British Columbia ruling goes further than what is proposed for Massachusetts, where an affirmative majority vote of citizens in November 2012 would allow physicians to prescribe a lethal dose -- but not to administer it. The patient, with a prognosis of six months or less to live, would be required to administer the dose.
This with near certainty would leave out an ALS patient such as Gloria Taylor, who by the time she is in her last six months likely will be physically unable to self-administer the lethal dose. Under the British Columbia ruling, apparently, should Taylor take the option, her physician could fully participate.

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