LETTERS * CORRESPONDANCE
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou dejia paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Assisting suicide O n June 4, 1990, Dr. Jack Kevorkian, a retired pathologist in the United States, inserted an intravenous tube into the arm of a 54-year-old woman with Alzheimer's disease so that she could kill herself using his "suicide machine". Before his retirement Kevorkian had worked primarily in the fields of microscopic diagnosis and autopsy. This would lead one to question his clinical ability to determine this woman's competence to consent to treatment. Many of us involved in clinical medicine know how confused patients can be about life-and-death decisions. Often they change their minds over time. Unfortunately, 168
CAN MED ASSOC J 1990; 143 (3)
this woman won't get the chance to do this. Physicians have no legitimate role in assisting suicide. They have a responsibility to their profession and to the public not to kill. Kevorkian's action demonstrates a callous disregard of all codes of medical ethics. For this action he should be reprimanded by state and national medical associations and should lose his licence to practise medicine. History reminds us that when physicians have compromised their ethics, disastrous consequences such as the mass murders in Nazi Germany have occurred. If society wants to permit people to be killed or people to kill themselves, physicians must not actively participate; otherwise all doctors and all patients will be losers. Gerry Craigen, MD, LLB, FRCPC Research fellow in biomedical ethics Department of Psychiatry Toronto General Hospital Associate Centre for Bioethics University of Toronto Neil Lazar, MD, FRCPC Assistant professor Department of Medicine Associate Centre for Bioethics University of Toronto Margaret Keatings, RN, MHSc Director of nursing Nephrology, renal and transplant services Toronto General Hospital Toronto, Ont.
Resuscitation of the terminally ill I have followed with interest the recent letters in CMAJ about this subject. The major moral problem is whether and how we should apprise seriously ill, possibly dying people of the
fact that there is a procedure that can be tried should they, for some reason, suddenly deteriorate before they are actually in the dying phase of their illness. Once patients are clearly dying, the dilemma of whether to advise an attempt at cardiopulmonary resuscitation (CPR) no longer exists, because trying to reverse the physiologic process of impending death would be not only unkind but also futile. Although they should not be offered useless therapy, these people still need gentle truth about what can and cannot be done for them. Thus, perhaps "Do not resuscitate" guidelines are focused on the wrong group of patients when they refer to the "imminently dying", because it is the seriously ill but not so imminently dying who present the dilemma. Although I am painfully aware of the difficulty in doing so, I believe that we should tell these people that CPR exists and allow them the opportunity to tell us what they think about it for themselves. Timing is everything, and this must be sensitively done when patient and physician are setting goals of care. The exact slant of the discussion will vary with each patient and clinical situation. It seems that physicians experience some difficulty in trusting that patients and families will make the right decision in this situation, and this may be why we are so reluctant to speak with them about CPR. Also, we think we know what the "right" decision is, when, in fact, we only know what our medical opinion and personal choice might be. However, we must realize that "right" may be quite different
from the patient's viewpoint. For better or worse, most people today are aware that machines "to keep people alive" exist, and they are not terribly surprised or distressed when the subject of the use or nonuse of these machines arises. This is particularly true for patients who have been encouraged to engage in open dialogue with their physician from the outset of the illness. In fact, some patients are relieved to have an opportunity for the reassurance that these machines will not be used in their care. Most of the discomfort with this issue is ours, and it arises because of our own knowledge of and ambivalence about the procedure and our fear that patients will want it when we don't feel they should. A further problem lies in how to describe CPR in accurate but gentle terms as the truly invasive event that it is, with an outcome, if successful, of artificial ventilation and likely prolonged suffering. And what if the patient chooses to have it? Do we feel that we have somehow let them or the system down? Do we feel that we haven't informed them sufficiently well? And what will our colleagues think of us? It has been my experience in 9 years of palliative care work in an acute care hospital that patients and families almost always make the decision that is right for them. Very few people persist in a request for CPR until the time they die, particularly when they have accurate information and a trusting, caring relationship with their physician. Those that do persist seem to be hoping for one last chance at staying alive. Surely we do not need to begrudge them this. There also seems to be a myth that we must offer CPR to patients, as though its use or nonuse were a clinically neutral issue for them to decide. This is far from so. Indeed, physicians must have an opinion as to whether resusci-
tice of tranquillizing deportees is "a matter between the physician and the person being treated". She also stated that it will continue. Despite the fact that a health care professional is invited by an immigration official to examine the deportee the ministry can produce no evidence that consent to treatment has been obtained. Neither is there any protocol for the procedure. Subject to several exceptions that are not relevant here, the administration of drugs to a competent person without his or her voluntary, informed consent violates not only the common law of Canada and the Canadian Charter of Rights and Freedoms but also the CMA's Code of Ethics. Moreover, it infringes several international conventions and declarations to which Canada is a signatory, such as the declarations of Tokyo and Hawaii and the 1951 Refugee Convention. The ministry's claim that such practices are justified under agreements drawn up by the International Air Transport Association has no substance. Nor can they be justified under any other such international agreements. There are serious issues arising from this practice, concerning principally the independence and integrity of the medical profesElizabeth J. Latimer, MD, CCFP sion, the policy of the government Director of palliative care and the autonomy of deportees. It Hamilton Civic Hospital incumbent on all parties inis Hamilton, Ont. volved, not least the medical profession, to render an honest acReference count of this highly questionable to resuscipractice. not E: The decision Latimer 1.
tation holds any advantage at all for a particular patient. If it does not, it might simply be acknowledged as a course of action that would be of no help and therefore will not be attempted and the reasons explained. Thus, the patient is not deprived of information about what is being "left out" of his or her care and has the opportunity to discuss with the physician how and why that particular decision was reached. I agree with Dr. Francoise E. Baylis (Can Med Assoc J 1990; 142: 530-531) that, whenever possible, patients need to know what decision-making processes are being applied to their care, so that they have an opportunity to respond and to make their ideas and wishes known. This is the basis of respect for them as autonomous individuals, and to act otherwise, without a compelling moral reason, is a dangerous precedent. The physician need not go along blindly with what the patient wishes, and I do not think that patients want this sort of relationship with us. However, they do want dialogue, information and respect. Such relationships are varied, interesting, challenging and sometimes difficult. They are never dull. Clinical aspects of these are described further in my paper.'
tate: talking with patients and families.
Can Med Assoc J 1989; 140: 133-135
Tranquillizing deportees of this year O Minister of Employment and Immigration Barbara McDougall stated in the House of Commons that the pracn May 8
Dermot K. Feenan, LLB Faculty of Law Queen's University Kingston, Ont.
[The ministry responds.] From time to time, people who have been ordered removed from Canada following due process of law require medical escort to the CAN MED ASSOC J 1990; 143 (3)
169
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou dejia paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Assisting suicide O n June 4, 1990, Dr. Jack Kevorkian, a retired pathologist in the United States, inserted an intravenous tube into the arm of a 54-year-old woman with Alzheimer's disease so that she could kill herself using his "suicide machine". Before his retirement Kevorkian had worked primarily in the fields of microscopic diagnosis and autopsy. This would lead one to question his clinical ability to determine this woman's competence to consent to treatment. Many of us involved in clinical medicine know how confused patients can be about life-and-death decisions. Often they change their minds over time. Unfortunately, 168
CAN MED ASSOC J 1990; 143 (3)
this woman won't get the chance to do this. Physicians have no legitimate role in assisting suicide. They have a responsibility to their profession and to the public not to kill. Kevorkian's action demonstrates a callous disregard of all codes of medical ethics. For this action he should be reprimanded by state and national medical associations and should lose his licence to practise medicine. History reminds us that when physicians have compromised their ethics, disastrous consequences such as the mass murders in Nazi Germany have occurred. If society wants to permit people to be killed or people to kill themselves, physicians must not actively participate; otherwise all doctors and all patients will be losers. Gerry Craigen, MD, LLB, FRCPC Research fellow in biomedical ethics Department of Psychiatry Toronto General Hospital Associate Centre for Bioethics University of Toronto Neil Lazar, MD, FRCPC Assistant professor Department of Medicine Associate Centre for Bioethics University of Toronto Margaret Keatings, RN, MHSc Director of nursing Nephrology, renal and transplant services Toronto General Hospital Toronto, Ont.
Resuscitation of the terminally ill I have followed with interest the recent letters in CMAJ about this subject. The major moral problem is whether and how we should apprise seriously ill, possibly dying people of the
fact that there is a procedure that can be tried should they, for some reason, suddenly deteriorate before they are actually in the dying phase of their illness. Once patients are clearly dying, the dilemma of whether to advise an attempt at cardiopulmonary resuscitation (CPR) no longer exists, because trying to reverse the physiologic process of impending death would be not only unkind but also futile. Although they should not be offered useless therapy, these people still need gentle truth about what can and cannot be done for them. Thus, perhaps "Do not resuscitate" guidelines are focused on the wrong group of patients when they refer to the "imminently dying", because it is the seriously ill but not so imminently dying who present the dilemma. Although I am painfully aware of the difficulty in doing so, I believe that we should tell these people that CPR exists and allow them the opportunity to tell us what they think about it for themselves. Timing is everything, and this must be sensitively done when patient and physician are setting goals of care. The exact slant of the discussion will vary with each patient and clinical situation. It seems that physicians experience some difficulty in trusting that patients and families will make the right decision in this situation, and this may be why we are so reluctant to speak with them about CPR. Also, we think we know what the "right" decision is, when, in fact, we only know what our medical opinion and personal choice might be. However, we must realize that "right" may be quite different
from the patient's viewpoint. For better or worse, most people today are aware that machines "to keep people alive" exist, and they are not terribly surprised or distressed when the subject of the use or nonuse of these machines arises. This is particularly true for patients who have been encouraged to engage in open dialogue with their physician from the outset of the illness. In fact, some patients are relieved to have an opportunity for the reassurance that these machines will not be used in their care. Most of the discomfort with this issue is ours, and it arises because of our own knowledge of and ambivalence about the procedure and our fear that patients will want it when we don't feel they should. A further problem lies in how to describe CPR in accurate but gentle terms as the truly invasive event that it is, with an outcome, if successful, of artificial ventilation and likely prolonged suffering. And what if the patient chooses to have it? Do we feel that we have somehow let them or the system down? Do we feel that we haven't informed them sufficiently well? And what will our colleagues think of us? It has been my experience in 9 years of palliative care work in an acute care hospital that patients and families almost always make the decision that is right for them. Very few people persist in a request for CPR until the time they die, particularly when they have accurate information and a trusting, caring relationship with their physician. Those that do persist seem to be hoping for one last chance at staying alive. Surely we do not need to begrudge them this. There also seems to be a myth that we must offer CPR to patients, as though its use or nonuse were a clinically neutral issue for them to decide. This is far from so. Indeed, physicians must have an opinion as to whether resusci-
tice of tranquillizing deportees is "a matter between the physician and the person being treated". She also stated that it will continue. Despite the fact that a health care professional is invited by an immigration official to examine the deportee the ministry can produce no evidence that consent to treatment has been obtained. Neither is there any protocol for the procedure. Subject to several exceptions that are not relevant here, the administration of drugs to a competent person without his or her voluntary, informed consent violates not only the common law of Canada and the Canadian Charter of Rights and Freedoms but also the CMA's Code of Ethics. Moreover, it infringes several international conventions and declarations to which Canada is a signatory, such as the declarations of Tokyo and Hawaii and the 1951 Refugee Convention. The ministry's claim that such practices are justified under agreements drawn up by the International Air Transport Association has no substance. Nor can they be justified under any other such international agreements. There are serious issues arising from this practice, concerning principally the independence and integrity of the medical profesElizabeth J. Latimer, MD, CCFP sion, the policy of the government Director of palliative care and the autonomy of deportees. It Hamilton Civic Hospital incumbent on all parties inis Hamilton, Ont. volved, not least the medical profession, to render an honest acReference count of this highly questionable to resuscipractice. not E: The decision Latimer 1.
tation holds any advantage at all for a particular patient. If it does not, it might simply be acknowledged as a course of action that would be of no help and therefore will not be attempted and the reasons explained. Thus, the patient is not deprived of information about what is being "left out" of his or her care and has the opportunity to discuss with the physician how and why that particular decision was reached. I agree with Dr. Francoise E. Baylis (Can Med Assoc J 1990; 142: 530-531) that, whenever possible, patients need to know what decision-making processes are being applied to their care, so that they have an opportunity to respond and to make their ideas and wishes known. This is the basis of respect for them as autonomous individuals, and to act otherwise, without a compelling moral reason, is a dangerous precedent. The physician need not go along blindly with what the patient wishes, and I do not think that patients want this sort of relationship with us. However, they do want dialogue, information and respect. Such relationships are varied, interesting, challenging and sometimes difficult. They are never dull. Clinical aspects of these are described further in my paper.'
tate: talking with patients and families.
Can Med Assoc J 1989; 140: 133-135
Tranquillizing deportees of this year O Minister of Employment and Immigration Barbara McDougall stated in the House of Commons that the pracn May 8
Dermot K. Feenan, LLB Faculty of Law Queen's University Kingston, Ont.
[The ministry responds.] From time to time, people who have been ordered removed from Canada following due process of law require medical escort to the CAN MED ASSOC J 1990; 143 (3)
169
