Tuesday, May 5, 2015

A consideration of the RNAO meeting: an after the event article analysis.

ABSTRACT:
The following article is an analysis of Carol Goar's newspaper piece about her moderation of the RNAO annual general meeting I attended on April 18, 2015.  I have linked to the article and to my earlier piece so you may consider the context.  I ask a critical question at the end of the article.

THE BLOG:
The CDMS was kind enough to send me the text of the Record article, written by Carol Goar.  I will deconstruct the article below.  The text of the article is in courier.

You can find the text of the article by clicking right here.

You can find the first article I wrote about the RNAO by clicking right here.
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The following are some extracts from the Waterloo Record article written by Carol Goar.  I was at the meeting that she is writing about, and I have shared my thoughts on it in an earlier blog post.

Almost three months have passed since the Supreme Court handed down its historic decision to lift Canada's ban on assisted suicide.
The ruling was unequivocal. All nine justices concurred that denying competent adults with a "grievous and irremediable medical condition" the right to terminate their lives violated the Charter of Rights and the "principles of fundamental justice."

Denying competent adults leaves adolescents and children out of the equation.  The Quebec Association of Social Workers said at the hearings for Bill 52 that they would challenge any age cutoff on the basis of the Charter of Rights as discrimination.
  
The court gave Ottawa and the provinces one year to craft a new law that would balance the interests of patients seeking to end their lives, doctors unwilling to hasten death and individuals who need protection.

It is a vital task. Without clear rules, doctors will have no criteria to apply when a patient seeks help to die; people with disabilities will have no legal safeguard and Canadians will have no opportunity to shape the laws that determine how they end their lives.

Define clear, define rules, define clear rules, define criteria, define apply, define seeks, define patient…

It is true that people with disabilities will have no safeguard; they have few enough of those now.

Yet none of Canada's governments has taken up the Supreme Court's challenge.

At the federal level, the Conservative cabinet has made it clear it sees no urgency. Liberal Leader Justin Trudeau tried to initiate an all-party discussion, but his proposal that a special committee be struck to listen to Canadians, doctors and nurses, ethicists, lawyers, spiritual leaders and psychosocial specialists was defeated 146 to 132. No further deliberation is expected before October's election.

The provinces — with the exception of Quebec, which passed its own assisted suicide law last summer — are looking to Ottawa for leadership.

The Canadian Medical Association, likewise, is waiting for the federal government to act. It accepts that assisted suicide is a "therapeutic service" but wants explicit guidelines for its members.

What exactly, is the therapy involved in killing a patient?  Given that we know that there are instances where assisted suicide goes wrong, the ideal type is that the doctor provides the medicine, or leaves it on a table; the patient then ‘courageously’ takes the poison and expires with a happy sigh.

In reality, ‘The number of clinical complications…”  Complications are never mentioned.  The same source for the previous quote: “According to a study published in 1997 [before euthanasia was legal] the average time that elapsed between the administration of the drugs and death was 8 minutes (range 0-90 minutes).”  I assume that average here is the mean, but this is not specified. “…another study found that complications occurred in 5% of the cases studied.  The section of the source paragraph then concludes, “…the occurrence of complications probably is one of the reasons why the great majority of cases of assisted dying in the Netherlands involve euthanasia…”  [Quotes previous taken from Guenter Lewy Assisted Suicide: Four Regimes and their Lessons, pages 36-37]

How are doctors to react when this happens?  Why, they kill the patient.  That becomes active euthanasia and not assisted suicide.  We can expect the same to happen in Canada, unless our population is more biologically compliant in the face of poisons.

"It is of utmost importance that nurses lead the charge when it comes to driving conversations on end-of-life issues," said Dr. Vanessa Burkoski, president of the 33,000-member association. "Death, dying, universal access to comprehensive palliative care and assisted death — these topics all have tremendous ethical, legal and policy implications for nurses, health-care providers and the public.

"That's why it is vital to ensure everyone is able to share their thoughts and engage in open, respectful dialogue."

Define open, define respectful and define dialogue.  It seems to me that the arc of marginalization in the life of someone who is disabled will continue until they are dead, and they will be chased to death. How is that respectful?

The panel members spanned the ethical/moral spectrum. There was a champion of medically assisted suicide; a nurse who maintained that no one would choose death if proper palliative care were available; a doctor who wanted a "principled framework" for decision-making; a constitutional lawyer and a medical specialist from Belgium where euthanasia has been legal since 2002.

The audience — approximately 500 nurses, medical professionals and concerned citizens — represented an even wider range of beliefs than the panellists.

There were 500 nurses, but there were about 800 people in the audience.  So there is lost data in numbers.  The concerned citizens are not quoted, however.

Some participants argued that the Supreme Court was wrong. Others felt it didn't go far enough.

I would be one of those who felt the Supreme Court was wrong.  I think it was wrong because I have read the SCOC decision, and I know from experience that there are going to be problems with this situation.

Despite the sharp divisions and raw emotions in the room, the dialogue (which I had the privilege of moderating) was respectful. No view was dismissed, no perspective excluded.

Sharp divisions is one thing; whether those who are marginalized get heard and listened to and respected is another.   And Goar has written for the Toronto Star newspaper.

Two strong messages came through:

•Without better pain management, improved psychological support for the terminally ill, affordable drugs outside hospitals and a greater willingness to talk about death and dying, Canadians will choose assisted suicide because it is the least bad option.
•People are hungry for a national discussion. The session had to be extended because so many participants wanted to ask questions, share their concerns, tell their stories and be involved. Canadians know the issue is morally and emotionally fraught. They know there will be no consensus. But they want a fair, inclusive process.

Here are a few voices from Saturday's dialogue:

Maureen Taylor, wife of Dr. Donald Low who died of an inoperable brain tumour 19 months ago: "Don died at home with wonderful palliative care. But it was not the death he would have chosen."

Michelle O'Rourke, an emergency and critical care nurse: "We've medicalized dying. We treat it as a failure of acute care medicine. What does this say about who we are as a culture and a society?"

Lesley Hirst, an oncology and palliative care nurse: "The decision (to seek assisted suicide) is often driven by fear of what lies ahead and what a patient's family will go through. We have to try to do everything we can to support that person."

Vanessa Burkoski, Registered Nurses Association of Ontario president: "Today is the starting point. Now we have to get the ball rolling out there in the community."

Unfortunately, that ball would seem to be rolling down a slippery slope, bouncing off a few hard cases along the way to the bottom.

That’s one way of putting it.  We have already had those hard cases (Latimer, Wenglie, Rassouli) in the media, so the public has been prepped for the discussion and its boundaries.
Again, the social and economic context of assisted suicide is being missed in Canada: we are repeatedly told that our health care system is broke; and we are facing a tidal wave of elderly sick patients.

This was barely touched upon in the discussions.  It was also not mentioned that economics could become the main motivator for offering death before anything else.  There is nothing stopping the government or individual hospitals from making death on presentation the option, the question is – how will we know if this is the case?  Confidentiality and hospitals go hand in hand now.

One of the things not mentioned at the RNAO meeting on …. Was problems with the provision of death in Belgium.  The difficulty with this is that we do not now have a balanced viewpoint.  We did not hear of people extending the mission of death by asking for it when they were tired of life.  We did not hear in detail about how the mission of euthanasia was extended to children in 2014, and we did not hear about Tom Mortier’s case involving his mother.

We did not hear of the nurse at the meeting whose daughter was denied pain medication for Crohn’s on the basis of the woman ‘seeking drugs’.  We also did not hear from another nurse there who wanted better palliative care education for nurses generally; we did not hear of the nurses who applauded when it was said we needed better palliative care in Canada altogether.  We did not hear from the one attendee who talked about his mother being abused on her deathbed, and his being the recipient of overall bad care on numerous occasions, including being accused of being a drugs addict.

In addition, we did not hear about the slow-code blues; silent DNR orders; imposition of doctor orders despite written patient requests; the Rasouli case – all these things were passed over.  So how then can we say that we have a fair and open dialogue in this matter if we are missing data with which to make up our minds?

Simple.  The media will now treat this issue of problems as a dog bites man story: happens every day.  The conflicts now will no doubt be between .. pro lifers and the righteous euthanasia enthusiasts.  Don’t say you haven’t been warned.  This should be your wake up call, you who are worried about the quality of medical care in Ontario.

The discussions will be couched in the following terms: if you are against medically provided death, you are now cruel because you are denying that single choice.  If you are for it, you are on the side of right, justice, goodness, fairness and democracy.  And that is not hyperbole: this is the way the dialogue goes.  So now we have to work harder to cut through the static.

So much for a fair and open dialogue: in the instance of medically provided death, that does not and will not exist.  The euthanasia enthusiasts can’t afford to let discussions of errors get out.  It would weaken their arguments too much.

Human lives are at stake: yours and mine.  You can’t afford to disagree and be silent anymore.


Critical question: How balanced is this article, given that it was written by the person who moderated what is a fait accompli on medically provided death, and the author of said article asks no critical questions?

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