How Do You Judge Competency?

"We suggest the burden of proof lies with the Supreme Court [of Canada] to demonstrate the legitimacy of the nomination of physicians as the exclusive purveyors of a non-medical practise. ...Particularly when the ethos of medicine has historically forbidden participation in this very act."
"We need to consider this matter carefully, use sound medical judgement and seriously think through the highly contestable nature of what the courts [and perhaps our government] are asking us to undertake."
"We could actually have patients incurring harm that they may not have anticipated."
"The other concern is, how do you establish a standard of care for assisted death? How do you judge competency? What would that look like for assisted death?"
Dr. Cheryl Mack and Dr. Brendan Leier, Canadian Journal of Anesthesia

"A timeline set by the Supreme Court for legislation is one thing, but for us to actually get to the point we can safely provide it [doctor-assisted death/euthanasia] is another. It just seems like it's coming awfully fast."
"[We do not object to a] rational [suicide] But that's assuming, of course, we can distinguish between what is a rational suicide, and what is an irrational one."
Dr. Cheryl Mack, assistant professor of anesthesiology and pediatric palliative care medicine, University of Alberta

BRENDAN SMIALOWSKI/AFP/GettyImages

As chair of the clinical ethics committee for the University of Alberta hospitals, Dr. Mack and her co-author have set out to warn both those in their profession and the government, along with the Supreme Court that they have well founded and grave  apprehensions about tasking doctors and in particular those in her line of work with the dreadful business of hastening death, when their very professional code has always pledged otherwise.

Their fear of some instances where things go dreadfully wrong reflects the possibility of patients experiencing convulsions, a longer-than anticipated "time to death", or "awakenings" while waiting for the fatal drugs to take their effect. The medical profession in its entirety is none too pleased with being tasked by society through the Supreme Court of Canada ordering the government to issue guidelines for the decriminalization of assisted dying. They might prefer that "euthanists" be authorized to take the initiative in providing the service.

The concerns of anesthesiologists are several, and Dr. Mack and her co-author enumerated them in the article she co-authored for publication directed at the audience in her profession. Will her profession be tasked with developing "recipes" for euthanasia? Will it be up to the anesthesiologist to make a determination based on how they perceive the patient's state of mind? Pointing out that informed consent is represented by giving due warning to patients of the potential risks involved in the procedure.

And those potential risks are those which her profession must balance on a regular basis, but rarely in the process of hastening death rather than keeping the Grim Reaper at bay. The article points out that some patients sometimes respond to drugs in ways that the anesthesiologist least expects; each individual is truly different in how the drugs play out in their systems. "We can foresee potential complications" they warned, in a process that is never simple.

"Depending on what kind of safeguards are in place, and who's present, you can have reactions to overdose -- convulsions, vomiting, aspirations", Dr. Mack warned, of the consequences that can ensue when a doctor prescribes a fatal drug overdose, depending on the patient to self-administer. With lethal injection there is the possibility of "awareness" representing an unusual complication of general anesthesia during surgery when sleep drugs fail, leaving the patient paralyzed and awake.

The three-step process most common with euthanasia; a drug to relax the patient; a general anesthetic to induce artificial coma; and a neuromuscular block to cause respiratory arrest, cardiac arrest and death, can go awry for nothing, no protocol is failsafe, just as all humans are differentiated by their reactions to common procedures. "We take a lot of care with our monitoring and our assessment of the patient to judge depths of anesthesia", Dr. Mack stated.

If an error occurs during the euthanasia process; the muscle relaxant injected before the coma is sufficiently deep to prevent the patient from being aware of the effects, that person could die by suffocation in a paralyzed state while remaining conscious of what is happening. Quebec has proceeded with providing euthanasia services since the act became legal in December. The provincial guidelines state that while the risk of loss of consciousness may be "inadequate" is low, should the IV catheter be inserted improperly or the drugs injected too slowly, effectiveness would be complicated.

Physician-assisted death could, in the space of a year in Canada, result in 7,000 such assists annually. In the Netherlands, where euthanasia and assisted suicide represent roughly three percent of total yearly deaths, their experience might serve as an anticipatory template for the procedure in Canada. Among those who deplore the very concept of assisted death and euthanasia, other solutions to coping with the end-of-life and unmitigated suffering are raised, most notably the need to bolster a country-wide palliative care program.