Response to Parliamentary Committee on Palliative and Compassionate Care

Posted by on Oct 9, 2011 in Letters to the Editor, Medical Discoveries and Medical Ethics


The usual discussions of euthanasia, concentrate on the object and seldom mention its
effect on the subject, namely the medical profession. You need to realize that euthanasia
will put the final nail in the coffin of what we have come to accept as a noble profession.
It is rapidly becoming ignoble and not trust-worthy.
Role-play. ( Pythagoras, played by Anastasia Pearse, a very bright UVic student.)
H Good morning, Pythagoras, How are you old man?
P. Good morning to you Doctor Hippocrates.(1) If you really want to know and I
suspect you don’t, I’m miserable. Can’t sleep, pained in body and troubled in
mind. Yes I’m old but you are not far behind me. Some day you’ll be feeble
too, Doc.
H. Your mind is quite good. I am impressed with your theorem on squares of
adjacent sides etc. Well, you can be thankful to modern medicine. Straight from
the Royal Apothecary in Alexandria, I have just what you need. Sit up and take
a good sip. Then repeat every 2hours.
P. Hang on; what is it?
H. A potent combination of ascorbic acid, and…….
P. And hemlock.
H. My goodness you are suspicious.
P. I don’t trust you doctors. You think it’s a kindness to kill as well as cure.
H. Well, I admit it is common practice among us Greek Doctors in compassion to send
people on their way when the gods have cursed them and they cannot get better.
P. I don’t think I want to die just yet. On the other hand, although my mind is alert,
my body is often giving me grief.
H. Well this will give you a boost.
P Yeah, a boost right into eternity. I saw you making eyes at my wife. You figure to
send me on then take her and my estate. With your attitude about dying with dignity
from hemlock, no patient will ever trust your or your ilk.
H. I promise this is to ease your pain and give you rest.
P The dead feel no pain.
H. Look you old curmudgeon. I’m not going to spend all day trying to persuade you
to take something that’s good for what ails you.
P. Give me time to make up my mind.
H. My patience has run out. Take it or leave it.
P. Your bullying me makes me all the more suspicious.
H. This is ridiculous. But I suppose you have reason to not trust us. I do find it hard
trying to persuade my patients to cooperate. There has got to be a better way
Okay, let’s see if this works.
(With arms raised to the sky and shouting.
By Jupiter, by Hermes, and Aesculapius, Apollo and Zeus. I swear I will not
poison you or any other patient. In fact, so all my patients will learn to trust me, I also
swear not to have sex with patients or abort a woman.
P. Good grief, I think you really mean it. Okay Doc. Let me have it. (Drinks noisily
and smiles) Not bad. But don’t think that because I trusted you this time, I will
always trust you. How do I know what you believe a year from now?
H. I will hang a statement of my ethics in my office so you will know what I will do
on the really big issues. Know this for sure; I will always try to make you better.
P. Even so, it will take a few centuries to build patient confidence in doctors and it
wouldn’t take much to set it all back. The main problem is that you doctors want
power over life and death, healing and terminating human existence, curing or killing.
That power is too much for any man or woman. It will always corrupt.
————————————————————————— ———————–
The Psychiatric Institute, Hadamar in 1941 celebrated.(2) All the staff were given
bottle of beer for the occasion. What was the occasion? Out of compassion they had
just liquidated 10,000 psychopedic patients.
By 1945, 300,000 German psychiatric and psychopeadic patients died at the
hands of compassionate staff.
But, you say, these were cruel German, not like us loving Anglo Saxons.
Or you may say that was the nasty Nazis. German euthanasia began with the
publication of the book by Hoch and Binding, a psychiatrist and a jurist, in 1928. It
was titled, The Release for Destruction of Lives Devoid of Value. This was well
before the Nazis came to power. The Nazis took over the rational and process, which
was well established and used it for their own nefarious purposes.
When will people learn from history?
Do you trust doctors? Do I trust doctors? Not entirely.
After 50years as a physician, teaching in 5 med schools in 3 countries, full
professor x 4, academic and clinical department head, plenty of scientific articles and
books, including one on palliative care, (3) I have learned that doctors are people like
all others. Some you cannot trust. Others you can only trust under regulated
conditions. A lot are well intentioned and well trained but there is historic evidence
that they can also become self serving and lethal.
I have treated approximately 3200 people who wanted to die. I learned that
although they ostensibly wanted to commit suicide and often wished there was
someone to help them do it, none wanted to be dead. What they wanted was better
living, not oblivion.
When trust of physicians goes down, cost of medical care escalates.

a) Time to persuade to take meds, properly. Compliance in taking medication,
long term, is about 50 to 60% and diminishing.
b) Patients want more tests and investigations
c) They request more 2nd opinions
d) People delay in seeing a doctor.
e) Decline in the therapeutic placebo effect.
f) Physicians must take longer time to obtain informed consent.
g) The general population has greater preoccupation with their health and
emphasize small complaints.
h) Doctors must spend more time in court defending themselves against growing
malpractice suits and the allegations of suspicious patients.(4)
It has taken 23 centuries to establish a modicum of trust in the medical
profession. The whole structure of modern medicine depends on trust. It is now
being rapidly dismantled. The physicians are the largest contributors.
Recognizing they could never practice without patient trust and confidence,
Hippocrates and his colleagues swore by their gods to never poison a patient, have
sex with patients or abort pregnancies. Doctors are doing all 3 with increasing
frequency. Nurses are not far behind them. It is small wonder patient trust is rapidly
diminishing and costs are spirally upward.
Requiring physicians to assist suicides so a few people could “die with dignity”
would be the final, fatal blow to modern medicine. Physicians providing doctor
assisted death (dad) voluntarily would be worse.
What is the physician’s best recourse for refusing to be involved in providing
lethal injections, terminating preborn babies lives or giving sperm for IVF? Simply to
say, “I refuse to practice poor medicine”. And he/she would be supported by medical
science. There is ample evidence that abortion, doctor assisted suicide and sex with
patients, (Yes some doctors have the very twisted notion that their having sex with
patients is therapeutic), is bad medicine.
Margaret Mead, commenting on Hipporates, wrote. This was an amazing break
with the universal dual role of physicians curing and killing. She insisted that the law
and public opinion, must never let physicians revert to the pre-Hippocratic times.
Modern physicians appear to substitute popularity for trust. They seem to think
that now she distrusts me, she may cooperate with this examination because she likes
me. To be popular, the physician must be agreeable, with a tendency to provide his
patients with treatment they chose. They will accommodate the patient’s chose of
pregnancy termination and agree with the patient’s reasons she so chooses. It isn’t
surprising that eventually this physician has a cupboard well stocked with samples
and allows the patient to chose what they would like to try next.
We must always ask of any proposal for palliative care, does it work? Does it
result in: better care, lower costs, and greater trust in the caring profession. None of
these ideas can be supported on ideals. Physicians and patients must be pragmatic. Is
this any better than what we have in place? What is the hard evidence euthanasia is a
good practice?
I asked the person gently putting forward the Dying With Dignity position, “Does
it work. Do you know if people when dying (from a lethal injection) feel dignified?”
(Silence). It appears that you don’t know if they die with more or less dignity. Then
how can you promote a process if you don’t know works? On the other hand, there is
biochemical evidence that at the point of death, people feel terrified or for some, great

Homo sapiens seems to be the only species that wants to self-destruct. Most of
society struggles to contain that tendency.
Helplessness evokes: disgust, avoidance and destruction or nurture and protection.
There is very delicate balance. Unbalanced the species will be destroyed.
A seagull, tied by one leg, flaps about helplessly. Just because it is helpless, it will
be attacked by other members of its flock. Like the wounded in war or patients in
hospital are bayoneted in a frenzy uncharacteristic of the soldiers under usual
circumstances. That tendency to mutilate and kill the disgusting helpless is countered
by the Species Specific Instinctual Restraint of Aggression. SSIRA keeps all species
from killing and devouring their own kind.
Almost any parent awakened at 2:30 am after a difficult day by a screaming child
in the room next door, feels an irritation bordering on destructive rage. It only
increases as she or he stumbles down the hall bumping into hard objects. Yet when
they switch on the light, look on their distressed baby, the anger quickly subsides and
is replace by a feeling of warm concern. This amazing transformation is mediated
mainly by their SSIRA.
SSIRA is strongest when other factors, religion, mores, laws are weakest. It is
most powerful in protecting the young, wounded, weak, feeble, handicapped and all
those whose reasons for existing seem to have no justification.
If anyone overcomes the instinctual restraint (SSIRA), even once in order to kill, it
is significantly easier for him or her to harm or to kill again. SSIRA is most damaged
when anyone kills in cold blood, especially if the victim is an infant, or enfeebled family
member. It does not need to be a violent act. It can be agreeing to have someone do the
It appears that the weakened or damaged SSIRA is not easily repaired. That person
is different and they tend to know it, for life.
A soldier who has killed another senses a change. It makes it hard to speak of his
war experiences with any pride. A mother who has seriously attacked her child, from
that point is very careful with her anger and tends to want others to care for her child in
daycare. A physician who has aborted babies feels a deep shame, not only for what
he/she has done but also because of who they have become. Doctors who assist in some
old person’s suicide intuitively do not trust themselves and intuitively are not as well
trusted by their patients, especially the elderly ones.
If in fact or fantasy, anyone contributes to the death of family or friend, especially
those handicapped or small or elderly, guilt inevitably ensues. This is a biologically
based guilt, which has nothing very much to do with morals or beliefs.
Grief mixed with guilt doesn’t often resolve. It results in pathological, or
prolonged grief. This grief is easily mistaken for depression. Antidepressants are
usually given. Because one must walk thru grief, feeling intensely the whole gamut of
emotions: loss, regret, anger, abandonment, despair, etc. antidepressants that mute
these feelings, prolong or prorogue mourning.
Grief is the almost inevitable experience of every human. It has now become a
treatment resistant depression. Sadly, most physicians, instead of aiding their patients
with the root cause, prescribe more antidepressant. They claim there is an underlying
chemical imbalance for which their patient must take the antidepressant for life.
Case illustration. Joe was referred to me by his family physician because he was
depressed and suicidal. It began after his beloved mother died. His family was very
poor but his mother always well fed him and his sister even if it meant going without
food herself. As she aged, Joe and his sister placed her in a comfortable care home
and visited almost every day.
The mother deteriorated and so had to be transferred to a facility with more
services. She sorely missed her friends in the previous place and began to withdraw.
Her physician places her on antidepressant, which made her regress more quickly.
Eventually Joe and his sister agreed to the kind physicians suggestion that it was time
to let their mother “pass on”. “She’s had a good life and you wouldn’t want to see her
suffer like this anymore would you?”
Joe kept visiting daily. He watched his mother suffer the agonies of death by
starvation and dehydration. “The nurse even refused to moisten her cracked lips. I
watched my mother starve to death. My loving mother who fed me when she
wouldn’t feed herself, slowly died before my eyes, and it was my fault. I know I’ll
never be the same. I don’t deserve to be happy again.”

Although there are a wide variety of near death experiences (NDE), no human
has returned from the death to describe the final experience. However examining the
body and its biochemistry can give some critical clues.
“The stress of agony (the death struggle) induces a rise in serum
catecholamines”(5) Another study found that at post mortem, there are significantly
elevated hormones regardless of palliative medication given. That study was seeking
to determine, which drugs or combination of drugs was most effective in easing pain
and discomfort when dying.
Adrenaline, noradrenaline and dopamine levels were related to the cause of
death. One cause of death that resulted in high levels was poisoning.(6) If this is
true, then one can infer that doctor assisted death is more of a struggle than those who
promote it believe it to be.
This high level of stress hormones seems to indicate that at the point of death
there is either terror or extreme excitement. That final experience may depend on
which way the dead one is headed.
A recent study of Oregon’s experience with doctor-assisted death found that the
reasons people chose DAD was not pain control but because they didn’t want to be a
burden, they wanted to avoid losing control of their mind and or body. It seemed that
to the last they wanted to control their own destiny, rather than have it plucked from
their hands.
A careless or naughty child breaks his mother’s precious ancient Chinese vase.
They know they are “really going to get it when dad gets home. The suspense is
awful. But mum hasn’t noticed and dad doesn’t punish them and they feel they
deserve. “Why don’t they just get it over with”, he mutters to himself. It must be
because they are thinking up some really awful punishment”.
Next day he decides that the anticipation of his fate is worse than the fate itself.
“I’m going to make dad punish me now”. So in full view of his parents, he
deliberately breaks something else.
Maybe these people, in an effort to control their destiny, demand to have this one
last, “psuedo-brave” choice and not be in the hands of someone who may, sooner or
later, will take them to task. Maybe they tend to be “control freaks”
Just maybe, there is some value in losing one’s dignity, which is usually part of
pride. Maybe when people are more humble, they will finally come to grips with
unresolved family and spiritual issues.

For anyone with an ounce of empathy, it is painful to watch another person die.
“I can’t bear to see him suffer like this” “It tears me apart to hear her choke and
groan” So the families choice to end his/ her suffering is primarily for their own
benefit. There are many other very selfish reason that those into whose surrogate
hands, the decision to pull the plug is given:
a) “I just don’t have the time to keep visiting.
b) “My struggling business needs my time but I feel so guilty when I don’t visit”
c)“ My children suffer watching granny dying at our home like she wanted”
d)“ If I were her, I know I wouldn’t want to suffer any more”
e)“We are desperately in debt right now.
f) What’s in the will would solve all our problems.
g) “She keeps pleading, ‘let me go’”
There are many more possible and plausible reasons thought, some expressed
but more privately felt. Traumatic situations like dying tend to bring out the most
intense ambivalence in everyone toward life and living. Anyone can be made to
despair, though it may be short lived.
What children fear more than anything is being abandoned? That fear recurs
throughout life and when it does, many people respond with, “Well now that he is
gone, I might as well kill myself”. But the loss can be the anticipated loss of oneself.
It should be remembered that suicide is murder. I was often able to illicit
helpful insights with the question, “If you weren’t going to murder yourself, who
would it be?”
The most useful method I found to keep people from wanting to kill themselves
was to: a) understand and empathize with the patient’s experience which is usually
feeling trapped. b) To offer realistic hope and when necessary bargain for what is
tolerable. This is not, “We’ll make you feel as good as new”, but “We can ease the
discomfort by at least 15%. Is that acceptable?” c) Make or renew a commitment to
stick with the patient to the end, be it wellness or death.

Most people fear becoming dependent on other’s for short periods like having a
fractured right arm. The thought of being dependent for the remainder of their lives is
most distressing. “I would rather kill myself, than have my son and daughter in-law
be responsible for me till I die.” If you then ask why, you will find a number of
contradictory responses.
i) Fear of rejection. “They will grow to resent me; even wish I
was dead”
ii) Pride. “I have looked after myself and everyone else almost
all my life. I would be ashamed to have anyone care for me
iii) Fear of own dependency. “I would love to be totally cared
for but I’m afraid to say so.
iv) False courage. “I have been through 2 wars and nothing
stopped me. I’m not going to back away from death now.
Go ahead, bring it on and see if I flinch”.
v) Fear of revenge. “I know I haven’t been good to my kids.
I even aborted some of them. Now is their chance to get
even. But I will beat them to the punch.”
On the other hand I have heard some people say. “I’m glad my mother had to
admit she could not look after herself anymore. She was always so proud; she
wouldn’t let me do anything. Now I can bath and dress her. She even lets me cuddle
close and lie still”
Being dependent can be a gift. After all, under normal conditions, caring for
those who can no longer care for themselves brings out the best in us. It teaches us to
be loving
If people were given assisted death before they became really dependent on their
family or if they were cared for only by those paid to do so, I believe that people
would develop little capacity to love. They would become even more narcisstic than
they are now.

The Canadian Federal Government is holding meetings across the country in order to
find ways to stop people wishing to have doctor assisted death. If they won’t
consider the spiritual parameter, they will find no satisfactory answer.
Stranger (S) “Hello chaps. What are you all doing?”
Government types. (GTs) “We are trying to find a way to make this thing fly.
S. What have you tried so far?
GTs. Well, we beefed up the engine”
“And we improved the landing gear”
“ It’s now got new tires”
“ The cabin is much more comfortable”
S. “I don’t want to sound arrogant but how about attaching wings.”
GTs “Who do you think you are?”
“Don’t be so ridiculous.”
“Get lost”.
The fear of dying is almost universal in people. Their Creator made them with a
built in aversion and abhorrence of dying. Why? Because He wanted them to
enjoy living and survive as long as possible, struggling to live even under the most
extreme conditions. He did not want them to embrace death. Death was His
enemy. It should be theirs also.
The fear of being dead depends on where you are convinced you are going
when you die.
So unless, the government is going to help people deal with their existential
questions of life after death, they may as well save taxpayer’s money.
Since death is the 3rd most important event in one’s life, there should be some
preparation and help in dying. There are at least 10 important tasks that need to be
completed before taking off. Those who do these may have some residual fear of
dying, but no fear of death. (7)

A few references:
1. Edelstein I. The genuine works of Hippocrates. Bull Hist Med, 1939:
2. Wertham F. A Sign of Cain: an exploration of human violence. New
York, Macmillan, 1966.
3. Ney,PG Ethical dilemmas in psychiatry. New Zealand Med.J. 1983, 98:
4. Murray WGD. Increasing litigation: the size of settlements in
professional negligence. Lancet 1982,1:1063-4.
5. Hausdorfer C, Pedal I, Zimmer G, Remppis A, Strobel G Arch
Kriminol. Catecholamine, myofibrillary degeneration of the heart muscle
and cardiac tropin T in various types of agony. Arch Kriminol. 1995; 196
6. Zhu BL, Ishikawa T, Michiue T, Li DR, et al. Postmortem serum
catecholamine levels in relation to the cause of death. Forensic Sci Int.
2007; 173(2-3):122-9
7. Ney PG, Christian Principles of Palliative Care. Victoria, Pioneer
Publishing, 2007.