TORONTO - In just weeks, barring an extension from the Supreme Court that would alter the timetable, Canadian doctors will enter a new era in the practice of medicine - one that gives them the legal right to help patients with unbearable suffering to end their lives.
But what will be the effect on participating physicians - who have long practised under Hippocrates' admonition to "First, do no harm" - when assisted death becomes a cold, hard reality?
Dr. Ellen Wiebe said she has watched a lot of deaths in her 40 years as a family practitioner and has seen much suffering as patients with terminal diseases like cancer approached the end of their lives.
The Vancouver physician believes that patients should have a choice as to when and how they die - and insists she has no qualms about helping them fulfil their final wish.
"I don't consider giving someone a good death to be causing harm," said Wiebe, one of several like-minded doctors who have formed the group Hemlock AID to provide B.C. patients with information about and access to assisted death.
"That's the main aim of helping somebody at the end of life, to help them have a good death.... If what they want is to die sooner rather than later and do it comfortably, then that's a good death for them."
Dr. Jeff Blackmer said that level of comfort is not what he's hearing from doctors in his role helping the Canadian Medical Association and its 81,000 members navigate the many pitfalls surrounding assisted dying.
"In the thousands of physicians I've spoken with about this I haven't heard anyone tell me they're going to be fine," said Blackmer, the CMA's vice-president of medical professionalism.
"I've had lots of discussions with physicians on all ends of the spectrum on this issue and even those who strongly support the right to assisted dying for compassionate reasons, and who have said they will participate, they're very aware of the likely impact that this will have on them."
Some colleagues have told him they are already experiencing symptoms of post-traumatic stress disorder, "almost pre-emptively," as they worry about the emotional and psychological fallout from terminating a patient's life for the first time.
"And I know doctors who are losing sleep about this and who have already started to talk to therapists about their feelings."
The reality of assisted death and euthanasia - and the dilemma many doctors find themselves in - hit home on Feb. 6 when the Supreme Court of Canada struck down the law prohibiting medical aid in dying, saying competent and consenting patients with intolerable suffering from a grievous and irremediable medical condition have the constitutional right to seek help to end their lives.
The court gave Parliament a year to draft a legal framework to govern the provision of physician-assisted death. The new Liberal government has asked for a six-month extension on that moratorium, which would give legislators until August if the court grants its request. It's expected that no doctors will be forced to help a patient die if they object to the practice on principle.
In the meantime, the CMA is trying to prepare doctors with educational sessions on how to prescribe and/or administer the lethal medications - for those willing to participate.
"Every physician in Canada who is currently practising medicine went into the profession not expecting to have to provide aid in dying," said Blackmer. "This wasn't part of the agreement ... before the Supreme Court ruling, so that's a pretty big sea change for an entire group of professionals.
"And I think not just that, but for any individual, any human being to be asked to be responsible to take the life of another - even with their consent - it's a very significant event and a very significant responsibility."
Rob Jonquiere, a retired family physician in the Netherlands where assisted suicide and euthanasia have been legal since 2002, agreed that ending a patient's life is not easy, nor is it taken lightly.
The first patient who asked him for euthanasia was a nurse who had terminal bowel cancer and knew the kind of excruciating pain and other debilitating symptoms she would likely face.
That was in the late 1970s, when assisted dying and euthanasia weren't yet legal, although the practice was going on below the radar of authorities, on compassionate grounds.
"At that moment, I really did not know how to do it," Jonquiere recalled in an interview from Amsterdam. "We were not trained in that. We were trained as doctors to heal people, to make people better.
"Like your Canadian doctors - they are afraid, they don't know how to do it."
When the nurse could no longer tolerate her suffering, Jonquiere went to her home and began injecting high doses of morphine in the belief the drug would gently carry her off.
"I must say that was the most horrible experience I had because she did not die after my giving her a heavy overdose," he admitted.
As his patient lay comatose, he contacted an anesthesiologist, who told Jonquiere he also needed to administer a muscle relaxant that would stop respiration and the heart, allowing death to follow.
Anxious about the act he was about to perform, he had not slept well the night before. But following her death, he was most upset at his failure to give his patient a quicker death - it took about 30 hours - not that he had terminated a life.
"Certainly no guilt, never," stressed Jonquiere, communications director of the World Federation of the Right to Die Societies.
"You get yourself to the moment where you think it is not human anymore to have suffering continue.... Yes, of course, it is not something you do regularly. It is not something which you do easily.
"But then you come at a moment where you say there really is no alternative and applying euthanasia actually is an act of empathy, of compassion. It's the only thing you can do to take the suffering away."
Compassion is the reason that Dr. Gerald Ashe, a 38-year family practitioner who provides palliative care in Brockville, Ont., is prepared to help terminally ill patients die, once appropriate legislation and guidelines are in place.
"I've looked after hundreds and hundreds of patients who have died over the years," said Ashe. "During that time, there were a few patients whose suffering - whether that be spiritual or emotional or physical - couldn't be controlled by palliative care.
"And in my career, I've probably had a handful of patients that I know of who have committed suicide," he said.
"So I will do it. But it will not be easy."
Ashe believes writing a prescription for life-ending drugs for patients to take them on their own would be less traumatic than having to deliver a lethal injection, which he conceded would be a "difficult thing to do."
But he pointed out that it's not uncommon to administer "palliative sedation" for the dying - increasing doses of medication that control a patient's symptoms by rendering them unconscious until death. That process, however, can take from a few days to up to two weeks and puts a terrible strain on loved ones at the bedside.
As far as the Hippocratic oath, Ashe said doctors do harm to patients every day in the form of administering drugs with terrible side-effects and with other interventions meant to prolong life, but that merely prolong misery.
"So this idea of 'do no harm' ... I don't consider it harm. I consider it as helping the patient and acquiescing to their sincere request."
But what about the emotional fallout after he delivers his first few patients into the arms of Death - does he worry there will be a psychological price to pay?
"I don't think so. Honestly, I would be surprised, mainly because I have seen so much in my career and seen a lot of suffering and I really feel that I will be able to handle it."
Still, Blackmer of the CMA expects there will be emotional repercussions for most doctors. His organization hopes to develop a network of participating physicians who can offer support to each other.
"We want to make sure we've got physicians communicating, whether by phone, electronically or in person, to say: 'How did you deal with the stress' or 'How did you deal with the strain? What are your coping mechanisms and how do you get support?'
"We see that as a crucial component to be able to connect these doctors who are going to be the first Canadian physicians to have to deal with these types of feelings and the emotional trauma that's going to come along with this."
