I hold dear my claim to fame that in my grade ten year at high school, I came second in a public speaking contest to Robert Hurst. Not a mean feat. After all, Robert Hurst went on to become a foreign correspondent, broadcaster and President of CTV (shown here from the ’66 Kennedy Year Book … same yearbook as my photo below).
I remember that day well. I began my speech with the prozaic, “The Topic I would like to address …” while Robert started his with a suspenseful description of a bomb blowing up a church in the Southern Bible Belt. It was 1965, the beginnings of the race riots and freedom movements in the United States. It was a year of Canada attempting to distance itself in profile from our neighbors to the south, in terms of morality, foreign policy, racial hatred; both Robert and I were moved to lash out verbally against the discrimination we saw below our border, perhaps neglecting the same, however much less, in our own country.
I think he and I were 15 and 16 years old respectively. His passionate speech was so much better than mine, even though I came second in the contest for the school … second to Robert Hurst, future foreign correspondent and broadcaster. Not bad. More importantly, I learned tremendously from the experience, and from Robert’s demonstration of how to capture an audience. The distance between our skills was so great, I was not even disappointed. I chose instead to learn.
I went on in life to do a lot more public speaking. Activities in medicine, inlcuding medical administration in leadership positions in hospitals, cancer organizations, our judicial organization for doctors in the province. Fund-raising for the building of a new cancer center in Kitchener Waterloo supporting a concept of total holistic care for our patients helped me hone my skills.
One of the challenges on that day of public speaking contests, so many years ago, was the extemporaneous component. We would be given a topic to speak on for three minutes. We were secluded in order to have ten minutes to prepare. I forget Robert’s, and indeed, may not have been present for it as we were sequestered in between talks. I do remember that a close friend, a fellow football player, who went on to become a lawyer, and then a Member of the Provincial Parliament, asked me to brain storm with him (here he is on the right, with me on the left).
“Tell me what your topic is,” he said. “We can bounce ideas back and forth.”
My topic was Euthansia. At the time, I had no idea I would become a physician, let alone a physician whose practice might come to be involved in such a treatment, an oncologist. I thought I was headed towards physics as a career.
The response from my friend, the future lawyer and politician, whom I later helped in his math classes when we were both at University of Toronto, was both politically incorrect and yet darkly humorous.
“It’s terrible. Those kids get no education,” he said.
Well, in fact, none of us knew anything about youth in Asia, and much of our subsequent experience would suggest the reverse is often true. Their education was exceptionally good, as was, to our detriment, the colloquial propaganda we were fed at the time.
But Euthanasia was to become something important for me once again, as I delved into the issue discussing the Sue Rodrigues case with small groups of first year medical students, years later. It was part of a course on Introduction to Medicine and Professionalism, dedicated to critical thinking and analysis of the more socially and ethically fuzzy issues than pneumonia or heart attacks. The Rodrigues case was always good for an afternoon of discussion with a new crop of med students.
Years later still, Carter vs. Canada became a case celebre. It turns out that Josh Paterson, a young lawyer, friend and classmate in high school of my middle daughter, herself a lawyer, helped lead the charge to the Supreme Court of Canada, which brings us to this point of legal limbo: assisted suicide is not illegal, but physicians better not do it yet. Processes need to be in place.
I think I remember Josh Paterson, but as a parent, how do I know; I certainly remembered the name. He would be some young teenager I saw cross a high school stage years ago, or perhaps in one of the groups of friends who happened by. They were school mates, that’s all I remember. Until my daughter mentioned his recent success to one of her siblings as I listened (who must also know him, I suppose). Executive Director of the BC Civil Liberties Association, and key to the ultimate presentation of euthanasia before the Supreme Court of Canada; Josh Paterson is still just a young kid in my memory, much as are my three children who went to school with him.
In parallel with all this, I did spend nine years serving on the College of Physicians and Surgeons of Ontario representing my constituency and attempting to protect the public and serve the profession. CPSO is a wonderful organization promulgating what is usually best about self-governance. This organization, largely funded by physicians, is responsible for regulating physicians, registering them, and rarely, de-registering them if they do bad things.
College influence has been desultory, but in my view, always generally headed in the right direction as long as physicians remember its true purpose: To protect the public. Not physicians. The Public. The OMA is there to protect the interests of physicians.
An informal tag line suggested by council colleagues years ago, if my memory serves, was “To protect the public and serve the profession,” but I believe that has been abandoned, and rightly so, as being too cozy with physicians.
Now the Website says things like: The profession, through and with the College, has a duty to serve and protect the public interest by regulating the practice of the profession and governing in accordance with the Regulated Health Professions Act.
The shorter, informal tag line– Our Vision Defined: Quality Professionals, Healthy System, Public Trust.
All this is far more appropriate, from my point of view. But my attitudes when I was on council were opposed by a few at the time.
The CPSO has been around a long time, and enjoys a Coat of Arms (by some royal decree) with a motto, proudly displayed in the main halls of the College in Toronto. In fact, you can find the motto on a banner surrounding the Coat of Arms on the upper left corner of the CPSO website. It is hard to read, but it says ‘Fidus in Arcanis.’
My father-in-law, a Medical Oncologist and former dean at Western, was proud of my efforts on the College Council, but did not wish me to get too over-confident, and he had the motto translated for me. Ruefully, he smiled as he gave it to me.
“Faith in the mystical.”
He confided, somewhat later, that it probably was more aptly interpreted as,
“Trustworthy in matters of confidence.”
A wonderful man, Harold Warwick, we had that competitive relationship since first we met, all his life and beyond. I have recently published his book, reviewed here on this blog, in fact, “East of the Merrimack.” I placed a price on his book that is slightly more expensive than mine, lest his outsell (the competition is never over, Harold).
Protecting self-governance is certainly in the interest of physicians, but we enjoy that same self-governance at the pleasure of the public; it was an admonition in an address I gave to Council as out-going College President in 1990, “The only way I know of protecting self-governance is to self-govern properly.”
THE COLLEGE OF PHYSICIANS AND SURGEON DRAFT PAPER
Thus we come to the College’s recent draft paper: CPSO Interim Guidance on Physician-Assisted Death. This is a public document on which the College has invited feedback. It stems directly from the Supreme Court decision above, which found that the absolute prohibition against physician-assisted death does violate the Charter rights, a Charter, by the way, introduced to Canada by the first Prime Minister Trudeau, the father.
The document outlines the issue in several sections. Guiding principles of professionalism, that we all have been taught and many have forgotten, include compassion, service, altruism and trustworthiness. The primary interest of the patient in front of us (their rights, dignity and autonomy specifically) is our guiding concern (family members, government, colleagues and our profession are all secondary to that one noble purpose). Included in our goals must be equitable access to care, sensitive effective communication, and professional competence.
The College has taken direction of the Supreme Court. The patient who requests this service must be a competent adult, clearly consent to life termination, have a condition that is bad and is irremediable, and is experiencing intolerable suffering.
They go on further to point out that the ‘request’ must not be ambivalent, that the meaning of ‘intolerable’ is assessed from the patient’s point of view, and that ‘irremediable’ does not mean the patient must undertake treatments which to them are unacceptable.
The College paper makes allowance for conscientious objection, but in a limited way: “physicians must not impede access to care, even if that care conflicts with their conscience or religious beliefs.” Perhaps more importantly “physicians must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of the patient.” It is sad indeed that this last statement is necessary, anywhere north of the 49th parallel anyway. “Physicians must not withhold information [because it] conflicts with their conscience or religious beliefs … must not abandon their patient … effective referral to another health care provider must be provided.”
This position here is clear, where perhaps it has not been in the past, about other complicated issues that stray into personal belief territory. Physicians have a duty to their patients which transcends their religious convictions: the supreme authority of an all-knowing god will not be a shield behind which any physician can hide.
PROCESS MAP for PHYSICIAN ASSISTED DEATH
The College has researched other jurisdictions for experience and guidance. They are suggesting a process which includes the attending physician determining compliance with the four criteria set out above (in the third paragraph of the section above), when a patient requests physician-assisted death.
A second request is required two weeks later (a cooling off period). In certain circumstances, a shorter time may be necessary and justified.
This second request must be dated, and then signed by the patient; there must be two witnesses, at least one of whom is NOT an attending/consulting physician, a relative of the patient, a beneficiary of any portion of the estate of the patient, or an owner/operator/employee of the health care facility caring for the patient.
Cognitive capacity and voluntary nature of the decision must be established again, and should the patient lose their ability to rescind their decision, the process must immediately stop: assisted death ceases to be an option at that point.
Interestingly, an option exists for the patient to self-administer their fatal dose at home, after appropriate instruction.
Finally, the college is suggesting ways of ongoing formal monitoring and data collection, recognizing once again that all aspects of medical profession involve life-long learning.
CRITICISMS OF THIS POLICY
This document is an excellent beginning. The freedom to exercise control over one’s own body, in my view, brings us all out of some kind of medieval mindset, and is long overdue. It reflects society’s attitude to allow community members to make their own decisions without being unduly encumbered by traditional values. Religious beliefs may have value for each individual, for that individual to decide, but modern society is recognizing that such beliefs are a choice to be made by consenting adults, not a directive to be used by one community member upon another.
There are members of my profession who are concerned; some of that stems from their own religious beliefs, some from more secular concerns. Some Palliative Care physicians worry about pressure being removed from government sources to properly fund palliative services. Some worry the process will be abused in a slippery slope fashion.
This paper has gone a long way toward providing appropriate safeguards for the patients, as well as for the medical profession. I shall be sending in my comments to the CPSO in due course.
Although legal advice is outside the scope of medical practice, I think physicians involved might be wise to remind their patients that legal and financial ramifications of their decision should be reviewed in the context of their personal circumstances. We certainly need to know what the legal profession and insurance industries will do with these events. A legal definition of ‘physician-assisted death’ to be defined as meaning a ‘natural death’ for example, might help subsequent disputes.
Personally, I would be happier if both witnesses to the second request documentation fit the exclusionary criteria listed above, rather than just one.
As a tangential issue, but possibly within the interest of the College, academics who write professional literature in peer-reviewed journals should be required to declare a conflict of interest, much as we are required to do regarding our financial activities, when personal and religious beliefs might sway their otherwise unbiased research into such issues.
SIX DEGREES OF SEPARATION
I look forward to running into Robert Hurst in Huntsville again this summer. I look forward to sitting on the rocks outside the Algonquin Theatre and asking him what he had to say during that extemporaneous phase of our contest that I was not allowed to hear, some fifty years ago. A brilliant and knowledgeable man in his own right, I remember being surprised that he didn’t know who I was last year, although I knew him well enough from sight. My wife pointed out that he, of course, was on TV all the time after we left school, while I was merely hidden in clinics, and we had not interacted in over fifty years.
If I ever find Sam again, I expect he will have useful comments, notwithstanding his gaff years ago.
After I gather together my comments on this policy from friends and colleagues in various professions, I shall be writing to older friends and acquaintances in the College of Physicians and Surgeons, where I served as its president so many years ago, twenty-seven I think.
I have already asked my daughter to extend my sincere thanks to her friend, Josh Paterson, who was so critical to getting us legally to this point.
And once this policy is set, the procedures established, I shall work hard to avoid its need with my patients; but where my ministrations fail, it will be with the quiet ambivalence induced by pain and sorrow that I will offer this solution to their suffering, reflecting all the while on the empathetic maturation it implies of the modern society in which we are fortunate enough to live.