Medecine and society
BY MICHEL DONGOIS MARCH 1st 2013 for L'ACTUALITÉ MÉDICALE
Approximately 6000 critically ill patients requested and obtained euthanasia in Belgium since 2002.
Dr Catherine Dopchie* recently spoke in Montreal about the decriminalisation of euthanasia in her country over the past ten years. She spoke about what she calls the "derivatives and misuses" of the law. L'actualité Médicale met with her. She gave her own personal point of view.
The criteria for the decriminalisation of euthanasia are clear (see frame) However, there are misuses, according to you. Can you give some examples?
Dr Catherine Dopchie. Photo: Michel Dongois
Elderly patients have been euthanised for weariness of living, or early suffering bereavement. For example we have euthanised a woman with her end-of-life husband because after 60 years of life together she would have suffered too much to go on without him. Old age with its losses is the critical and incurable illness required by law. The doctor who practiced these euthanasias ratified that these subjective sufferings were intolerable and unappeasable.
Suffering from Alzheimers gives access to euthanasia if you are still conscious and capable. The suffering is in the anticipation and the incurability doesn't take into account the progress that is yet to come. A suicidal patient was considered as sufficiently capable, and yet at the same time sufficiently incurable to be euthanised. To these patients who are at a loss for zest for life, we propose that they become organ donors, without it being considered as an external pressure.
The Federal commission for the control and evaluation of euthanasia doesn't prevent these misuses ?
The Commission pushed to interpret the law with more flexibility, despite the diverging viewpoints in its midst, notably on the notion of " unbearable and unappeasable psychic suffering". It also says, in substance : " Sign more and more anticipated declarations of euthanasia, they make life easier for the healthcare givers if you are unconscious." And to doctors: " Interpret in a less restrictive way the notion of irreversible unconsciousness." This comes to be the promotion of euthanasia along these lines: "Above all, sign your declaration at the first signs of Alzheimers. Don't wait to have dementia, or you won't be able to be euthanised."
In what ways do the law and the Commission differ ?
The law would have liked to have the fact respected that euthanasia is an ethical transgression, but the Commission introduced another thought, that of the right to master one's own death. The misuses are written in the subversive reading of the law. There is no controlable limit to this position.
What was the impact of euthanasia on palliative care in Belgium ?
It contributed to make it seem futile. Asking that euthanasia not be accessible for those who are not relieved by palliative care, is agressive therapy ! What patient wants to follow the path of suffering that may become an end of life if he hasn't experimented for himself what palliative care brings? However, the fruits of humanity are really there for the relatives and the survivors.
The lack of confidence in the possibility that the human beeing has to integrate the reality of his suffering and find a sense for living has reduced man to his suffering, and the healthgiver to the effectiveness of his actions. Wanting at any price to abolish suffering, is to abolish the person suffering. We have to live from the inside, daily, to seize the infinite nuances of these difficult realities.
Have you ever had yourself, as a doctor, requests for euthanasia from your patients ?
I do not practice euthanasia and my patients know it. But since the decriminalisation of this act, the request has become less of an exception than before. If it is a persistant request, the patient will be refered to another doctor. It seems simple, but in practice, for fragile patients, it's very complicated; it generates a lot of suffering for me too because I'm torn between the desire to help the patient and my refusal to compromise.
Have you experienced specific cases ?
Yes, on two occasions. One where the patient, who was still very autonomous, wanted to impose a claim on me : he managed his choice efficiently, taking us hostage with his right. He obtained the right to be euthanised at his home on the day and at the hour of his choosing and demanded the presence of his son. The experience of his dehumanized side chilled me.
The patient is not just his suffering and the healthgiver is not just his function. We do not want to sustain the other so that he goes through with his suffering but to eliminate his suffering. That is what bothers me.The other, where the patient had stalled, pinned by filial pressure, when he was avidly searching for another proof of love. A home transfer for euthanasia was organised with the consent of the patient and the treating doctor. The son's pressure, under the threat of a lawyer, so that the patient be euthanised in my service was such that he finally ended up being so, by another doctor, in my absence, without taking into consideration the paramedics. This left me with great feelings of sadness, powerlessness and revolt as well.
These two stories are a confirmation for me that euthanasia is not another path towards more humanity, but a counter-measure that leads to the death of our society.
Why do you think, people come to want euthanasia?
There exists exceptional clinical situations, let us specify that. For the others, there is anguish due to the lack of faith in our capability to integrate our limits and to accept that they may bring each of us to become someone bigger and better, that we do not recognize.
The human being wants to eliminate his limited nature: I do not want the limits of my sexed body, I do not want any more of my infirmity, I don't want any more of my social nature, relational by essence, because I don't want to depend on anyone. Add to that the tyranny of the " I'm allowed " and the bow is tied.
Euthanasia is then the refusal of dependance…
Yes, but mostly the refusal of solidarity. Pretending to eliminate suffering at all costs by eliminating the suffering person, is also to eliminate a large part of the humanity that is in each of us. Euthanasia is not a story of medicine or of technique but of a loss of the sense of man.
The patient is not just his suffering and the healthgiver is not just his function. We do not want to sustain the other so that he goes through with suffering but to eliminate his suffering. That is what bothers me.
Even where the best care is dispensed, won't there always exist a certain number of patients who want to determine for themselves the exact moment of their death ? How do we respect that ?
Respecting the wishes of another does not suffice for me. It's the person in all of his reality that I must respect. And respecting the person who is suffering in his globality, is to believe in them, it is not to pose an act that confirms his so-called indignity. The regard that I have for this person may be what will allow him to maybe take up the challenge of his life.
If, unfortunately, I am unable to do this, the end does not justify the means. If I accept to kill a fellow human being because I am unable to relieve his suffering, I condemn myself to an ultra-powerful utopia, that on the contrary, leads me more and more towards an incapability to sympathise with and to weaken other vulnerable people.
What do you most fear, as a doctor ?
To be reduced to my sole function, used, objectified, to become the one who tells his greatly suffering patients : " Choose between these three options : 1) chemo and aggressive therapy; 2) palliative care; 3) euthanasia ", and executes upon request.
Hasn't society, mostly, come to accept well-controled euthanasia, done voluntarily by some doctors, etc. ?
That's what they'd like us to believe by trying to impose on us the idea that the human being, and therefore society, is not capable of integrating suffering nor of durably sustaining the person who is suffering. But even if it were true, what consists the customs or the norms of society are not forcibly moral. Darwin said it before : what differentiates us from the animal, is the attention we give to the vulnerable.
Euthanasia means "gentle death". Isn't that what most people wish for ?
That's typically the story behind the whole topic. The words are used in a such a way as to generate confusion. In Belgium, euthanasia is the act of killing a suffering person upon his request. Of course, the protagonists are not monsters, on the contrary. But the act remains monstruous and has nothing to do with gentleness.
Your personal review as a doctor ?
Euthanasia reaches me for the same reasons that called me to study medicine. It demolishes me from the inside because I feel a lot of suffering about the fact that I am now blocked in my patient-doctor relationships. Before, we could be tenacious, persevering, continuing to search with the patient for ways to live. If death is an easy option, how can we preserve the exchange, the therapeutic alliance?
And if you yourself were agonizing…
My dignity would still be there. I need to believe that others, starting with my own daughters, would look at me through those eyes. Dignity cannot be relative.
The Belgian law, in summary
The law relating to euthanasia (May 28th 2002) limits it to particular cases, for hopeless medical situations. It notably evokes:
- An incurable illness and that the patient's suffering be of an unappeasable nature;
- The patient's repeated and voluntary request to die, with his written confirmation;
- The opinion of a doctor who has been necessarily consulted.
The law wanted, among other objectives, to counter clandestine euthanasias.
It guarantees the conscience clause for doctors who are not forced to practice euthanasia.
Approximately 6000 uncurable patients have asked for and received euthanasia in Belgium since 2002.
* Cancerologist responsible for a palliative healthcare unit in Belgium.
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2013