Health Minister Allan Rock, at the conclusion of the Canadian Medical Association's (CMA) annual meeting in Victoria two weeks ago, declared that, despite its problems, Canada's healthcare system is "still the best in the world." In Victoria, the practitioners of the best healthcare system in the world found time to debate two-tier medicine (they were against) and increased federal funding (they were in favour). But they did not debate a question that has divided the medical profession in two, and has cut to the heart of the profession's purpose—should doctors be allowed to kill patients? Given the unwillingness of the medical profession to condemn physician-assisted killing in principle, and the reluctance of individual doctors to report others who have dispatched patients, some physicians believe Canada may be drifting into legalized euthanasia almost by default.

That doctors who practice assisted suicide are protected by a professional code of silence was brought home forcefully by the release of the report of an external review committee that examined the death of a cancer patient last November at Halifax's Queen Elizabeth II Health Sciences Centre (QE II).

In May, Halifax police charged Dr. Nancy Morrison, 41, with the first-degree murder—allegedly a "mercy killing"—of Moncton, N.B., cancer patient Paul Mills, 65. Last November, a confidential internal review of Mills' death stated that injecting potassium chloride—a deadly, fast-acting poison—into a patient is "unacceptable" and "outside the bounds of medical practice." Then, however, Dr. Morrison was given a mere three-month suspension from the intensive care unit; she has since resigned. Halifax police learned about the case only in April, informed by a visiting doctor disgusted with what was later admitted to be a hospital cover-up.

After Dr. Morrison's arrest, QE II struck an external review committee, headed by Vancouver epidemiologist Charles Wright. This committee's report was released three weeks ago. Commenting on the release of the report, Dr. Wright made the astonishing claim that "there are no villains in this tragedy, other than the cancer that caused the death of Mr. Paul Mills." He then blamed Dr. Morrison's first-degree charge on the hospital's cover-up, arguing the accused might not have been charged with such a serious crime if the hospital had been more forthcoming originally. He conceded that "errors of judgement" had been made, and stressed the need for a clear distinction between "the compassionate relief of suffering" with analgesics, and the use of "any substance intended to cause immediate death."

The Wright report makes 11 recommendations: five deal with the hospital's need for better public relations; five deal with its staff's need for better ethical training, clearer rules for end-of-life decisions and better palliative care. The other argues for legal reform: "The Criminal Code should not include the same punishment for compassion-motivated murder and murder motivated by personal gain or evil intent." This request was then seconded by Nova Scotia's justice minister. What Dr. Morrison's intent might have been remains obscure. She has yet to enter a plea—her preliminary hearing is not expected until next year—and has never publicly denied the charge against her. She has, however, stated she believes her case will reignite the euthanasia debate. Mr. Mills' wife has affirmed that her husband would have been opposed to euthanasia; and since he reportedly could communicate only by blinking his eyes, Dr. Morrison may have difficulty proving that she had his consent. This will not make any difference, predicts Haligonian Herman Wills, president of Campaign Life Coalition Nova Scotia. He says the doctor has the medical, political and media elite on her side.

"We're being subjected to a massive public relations campaign here," Mr. Wills reports. "We're told about Morrison's recent marriage and honeymoon cruise, how she's nothing like Paul Bernardo, how courageous she is, and how well-liked around the hospital. They'll never find a jury to convict her now."

If Nova Scotia juries are anything like Michigan's, Mr. Wills' prediction is a near-certainty. "Dr. Death," Jack Kevorkian, the retired pathologist who has admitted responsibility for almost 50 killings, has been tried for murder four times. He has been acquitted three times; the other case ended in a mistrial. Last month, after another killing had become known, the State of Michigan announced it would not try him. Fifteen of Kevorkian's "deliverances" were accomplished with the use of potassium chloride.

In Halifax, Dr. Morrison has been released on bail, and having served her suspension, now administers to patients who specially request her at a clinic affiliated to the QE II.

The Wright report's call for the Criminal Code to be amended to provide for greatly reduced sentences for physicians who kill their patients for "compassionate" reasons may be taken up by Parliament. Federal Justice Minister Anne McLellan's office is reportedly awaiting its copy. Liberal Senator Sharon Carstairs of Manitoba is also eager to reintroduce an "improved" version of her own "physician-assisted suicide" bill, which died in Parliament last spring only because of the federal election. Prime Minister Jean Chretien had earlier promised a free vote on euthanasia, but whether or not he will keep that promise is unknown.

The last campaign for the legalization of euthanasia centred on Sue Rodriguez of Victoria, who very much wanted to die. In 1993, the Supreme Court ruled, by a five-to-four majority, that Ms. Rodriguez had no constitutional right to an assisted suicide. The Lou Gehrig's disease sufferer succumbed to a "mercy killing" in 1994; at her deathbed was euthanasia advocate and NDP MP Svend Robinson. In 1995, a Senate committee voted four to three against a legalization proposal. When Sen. Carstairs' bill was introduced in the Senate last year, it received little attention. She complained subsequently that Canadians needed "another Sue Rodriguez." Ironically, a murder charge in Halifax may have provided Parliament with just such a lightning rod.

If Parliament acts, it will do so without the opinion of the CMA. "We didn't discuss physician-assisted suicide or euthanasia. We didn't have time," says Alberta Medical Association president Kabir Jivraj. "As a whole, the CMA would prefer to duck it," says conference attender Grant Hill, an Okotoks, Alta., physician and Reform MP. Some doctors are concerned that the CMA's reticence has backed them into the role of public executioner.

"Canadian doctors are just like the Canadian public," says University of Toronto neurologist Paul Ranalli, vice-president of the deVeber Institute of Bioethics. "There are those pushing euthanasia, and those opposed to it, and then there's the big, squishy middle." Dr. Ranalli argues that doctors who oppose euthanasia fear that if it is legalized, they will eventually be unable to avoid performing it themselves. "Yet they do not want to deny anybody else the legal right to do so," Dr. Ranalli points out. "Unfortunately, a lot of high-ranking CMA people [like the late Ontario Medical Association president Douglas Waugh] have been pushing the agenda from the top down," he warns. "We should be clinging to the Criminal Code by our fingernails, because we know there's a vast potential for abuse. But we're letting ourselves slide into it, out of professional courtesy."

Public support for some sort of liberalization of the prohibition against euthanasia has continued to run around 75%. When polled in 1995, 47% of doctors favoured liberalization (38% for those with experience treating the terminally ill), 39% were opposed and 11% were undecided. However, while only 20% of doctors said they would themselves kill a patient, 55% reported they would not report a colleague who did so.

For Canadian medical professionals who do euthanize their patients, their weapon of choice has been the same potassium chloride used by Kevorkian and described by the QE II as "outside the bounds of medical practice." Potassium chloride is a common salt, often used as a dietary substitute for sodium chloride, table salt. In November 1991, Timmins, Ont., cancer patient Mary Graham, 70, asked to be removed from a respirator. As her assembled family sat around her bed, Dr. Alberto de la Rocha acceded to her wish. Then, without their knowledge, he injected her with potassium chloride and killed her, for which he later received a suspended sentence for "administering a noxious substance."

Later that year, the wife of comatose Toronto patient Joseph Sauder requested that extraordinary measures not be used on her husband. She then left the room. In her absence, nurse Scott Mataya administered a fatal dose of potassium chloride. Mr. Mataya also received a suspended sentence. Most of the so-called "angel of death" cases in Canada, Britain, Germany and the U.S., involving the killing of institutionalized infants and old people, have seen the use of the almost undetectable salt.

Given the propensity of the medical profession to protect physicians who engage in euthanasia, there are probably other medical killings that have not been reported. And that, of course, gives ammunition to the liberals. Dr. Ranalli reports, "There are people running around the CMA saying everyone's doing it. But everybody's not doing it. It's simply a standard liberal ploy to get the law changed. It's exactly what happened with abortion."

The law should be changed, but not in the manner the Wright report advocates, contends Douglas Kinsella, medical bioethics officer at the University of Calgary and president-elect of Canadian Bioethics Society. "The issue in murder is the intentionality," Dr. Kinsella explains. "Was the administering of some drug intended to relieve suffering, or was it intended to kill?" He insists that the Criminal Code must make a clearer distinction between withdrawing futile medical treatment, on the one hand, and actively hastening death, on the other. "It's always been considered moral and legal for patients to refuse invasive treatments, to insist that doctors allow them natural deaths," he says. "But doctors who try to obey them—either through their stated wishes or an advanced directive—need more legal protection in doing so. [Euthanasia advocates] like Kevorkian try to confuse the distinction between allowing a natural death and killing," he insists. "But it's essential, and doctors need to understand the difference."

And not just doctors, adds Rita Marker, executive director of the International Anti-Euthanasia Task Force in Steubenville, Ohio. "Most of the vague, popular support for the legalization of euthanasia comes from an obsolete fear," she suggests. "Twenty years ago, people may have legitimately feared that they or their loved one could end up some sort of unconscious artifact, kept alive indefinitely by tubes and wires. But today, that's no longer a reasonable fear. What they needed to know then, was that they've always had the right to refuse intrusive medical intervention. And if they knew it now, most of the popular support for euthanasia would vanish."

Dr. Hill, once an emergency ward physician, agrees; and he warns of the consequences if doctors fail to learn the distinction. "There are times when withdrawing treatment is reasonable and compassionate," he muses. "When you've consulted with the family, when you've got a second opinion, when treatment is futile, sometimes all you can do is turn off the machine." But there is all the difference in the world between that and killing your patient, he says. "Whether you're talking carbon monoxide from an exhaust pipe, a plastic bag over the head, or a potassium chloride injection, it's not compassion. That's premeditated murder, and the dividing line must be clearly drawn. Once we cross that line, nothing will save us from the Dutch experience. They've proven that euthanasia can't be regulated."

The Netherlands' experience has proved a cautionary lesson. In 1981, the Dutch decided they would no longer prosecute physicians for assisted suicide, as long as consent was given. Nine years later, the government released an investigation into the results. The Remmelink Report revealed that Dutch doctors were killing many patients, and the safeguards instituted had been ignored. Physicians were performing 11,840 killings a year, 9.1% of total deaths. Some 8,100 of these involved deliberate overdoses of pain medications simply to hasten death (with or without consent), so they were not counted as either "assisted suicide" or "involuntary euthanasia." Of the other 3,740 killings, only 2,700 were "voluntary euthanasia" or "assisted suicide," performed with the patient's consent. Fully 1,040 patients were killed without consent or consultation; and 146 of those had been fully competent and capable of making their own decisions—had the doctors chosen to ask them.

A follow-up study, Remmelink II, was released in 1995. It was a thorough examination of 5% of the nation's 130,000 yearly deaths. Both the Dutch medical establishment and the New England Journal of Medicine claimed the report proved that "physicians in the Netherlands are not moving down a slippery slope." But the numbers do not agree. For example, the number of deaths from "voluntary euthanasia-assisted suicide" climb-ed from 2,700 to 3,600, a 30% in-crease. The only improvement was in the category of "involuntary euthanasia"—what Canadian law calls first-degree murder. That figure dropped from 1,040 per year to 950. Fully 55% of Dutch physicians said they had or would engage in "involuntary euthanasia." And 59% of doctors still report their patient-killings as "natural deaths."

The reason Dutch physicians give most often for "ending life without the explicit request of the patient" is "low quality of life" (see story, page 28). This, contends Dr. Hill, is the symptom of a society that has embraced the culture of death. "Doctors [who presume to judge] the 'quality of life' are failing to see anything sacred in life itself," he says. "Perhaps they think human life itself is an absurd accident of evolution; or perhaps they just feel the need to exercise control over life—and even death. Either way, it's the glorification of personal autonomy. In a drifting society, some doctors try to play God."

University of Ottawa pediatrician John Patrick agrees. "In cases like the Halifax killing, you really get a sense that barbarism has entered the medical profession," he says. "We all believe in compassion, don't we? Well, when my dog suffers, when he has a 'low quality of life,' compassion tells me to have him put down by the vet." But our willingness to alleviate even a dog's suffering—animals other than humans feel no such obligation—proves that human beings are more than just animals, he suggests. For that very reason, "the development of medicine itself has depended entirely upon an enduring sense of the sanctity of human life."

As Canada's population ages, economic considerations may be valued more highly than moral ones. Currently, Canadians 65 and over are about one-eighth of the population; 30 years from now, they will be one-quarter. The average yearly cost of medical care now averages $1,156 for children, $1,663 for young adults, $2,432 for the middle-aged, and $8,068 for the elderly. The medical sector consumes 9.5% of Canadian GDP (versus 14.2% in the U.S.); but that percentage could rise substantially in the next century. And not only will the aged likely consume more resources, there will be proportionately fewer workers providing for them.

But popular fears of the coming social burden of the aged may be exaggerated, says Madeleine Gaul, a principal with the William Mercer Ltd. consulting firm in Toronto. "We should always expect that older people will place a heavier burden on the health system, in terms of medications, chronic care and so on," she says. "But we are still a relatively young country, in comparison with western Europe, and yet most European countries provide comparable or better care at less cost. Their secret is improved home care, even to the extent of providing allowances to responsible family members." Ms. Gaul believes Canada would be wise to investigate the European model.

If the aging of Canada means a great increase in the number of patients suffering chronic pain, some fear euthanasia will become commonplace. The good news about palliative care should dispel this worry, says family physician Jim Lane, president-elect of the B.C. Medical Association. Advances in pain-killing technology now give the medical profession the ability to suppress the physical pain of over 95% of terminal patients, and reduce it significantly in the rest. "The Canadian, American, British and Australian medical associations have all rejected euthanasia in favour of palliative care," Dr. Lane says. "The Canadian and American courts have decided that there's no inherent right to assisted suicide. So, if it comes to a public debate, doctors have to convince the public that palliative care is really what they're seeking."

There is a strong faction in the medical profession that wants euthanasia, Dr. Lane concedes. Governments—like the Dutch—have been known to implement destructive policies. Legal recognition of "mercy killing" would be just such a policy. "But I can't see Canada adopting a triage mentality," he insists. "I can't see us telling our disabled and elderly, 'You've spent your allowance and your time's up.' I just can't see it."

—Joe Woodard

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