Dr. David Amies: Interesting times for Canada's right-to-die movement

In his first blog post of 2016, Dr. David Amies provides a timely summary of what's going on across the country to prepare Canada for legal assisted dying.

Those who have followed the story of physician-assisted dying in Canada will know that important dates are on the horizon. In February 2015, the Supreme Court of Canada struck down the existing legislation concerning assisted suicide and gave the federal and provincial governments one year to adapt to the new reality. Stephen Harper's Conservative government, in power at the time, wasted several months before appointing an advisory committee to look into the matter. Almost immediately afterwards, Harper called a general election and set up one of the longest campaigns in recent history, further delaying any concrete action.

Where Ottawa faltered, provinces stepped up

During the past year, individual provinces and colleges of physicians and surgeons across the country have been working at their own arrangements and asking for public input. In the last little while, there has been a flurry of announcements. Most noticeable among these has been Quebec's decision to go ahead with its own laws and, consequently, physician assisted dying is now legal in that province from December 10. Unsurprisingly, further legal challenges to this are already in place and matters may change.

The New Brunswick College of Physicians and Surgeons has recently released its own guidelines which suggest that a patient suffering from a grievous illness with no hope of remedy may apply to a physician for help in dying. The physician may decline such a request but will remain responsible for the care of the patient until alternate arrangements can be made. Requests must come from the patient and not via a third-party. Requests for assistance must be made twice with an interval of at least two weeks between such requests and then again when the process is about to begin. A second opinion is required, backed up where appropriate, by a specialist’s opinion to confirm competence. Both the physician and the patient must be made aware of any legal implications of the decision (e.g. life insurance).

An expert panel advising provincial and territory governments set up by the province of Ontario released its report on December 14. It made 43 recommendations. Its aim was to ensure that there be uniformity across Canada and that consideration be given to other healthcare professionals (e.g. nurse practitioners and physician assistants) having the right to administer appropriate medications under medical supervision. It defines “a grievous and irremediable medical condition” as a very severe or serious illness disease or disability that cannot be alleviated by any means acceptable to the patient. It recommends safeguards, which include assessment by two separate doctors and a witnessed declaration from the patient. It makes no recommendation about a minimum age; rather it suggests that eligibility depends upon competence rather than an arbitrary age limit.

Jennifer Gibson, co-chair of the panel, and Director of the University of Toronto joint Centre for Bioethics said that the panel was motivated by a desire not to have a patchwork of rules across the country. She pointed out that the panel could see no reason why video-based consultations could not be used where necessary, for example by patients living in remote areas. The panel also felt that it was unnecessary to have a physician present at the time of death. It recognized that some faith-based institutions would have moral and perhaps religious objections to having assisted dying take place on their premises. However, such institutions would be obliged to make arrangements for an expeditious transfer to another facility.

Another contentious recommendation from the panel was that a patient diagnosed with a grievous and irremediable condition be allowed to consent to an assisted death in advance via a binding patient declaration (which would be valid in cases of incapacity). For example, someone with early dementia could make a request for assisted dying to be carried out when their mental state had deteriorated to a certain point such as when they no longer recognize their children.

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David Amies is a retired physician in Lethbridge, Alta.

Some of the recommendations of this expert panel cover new ground and if adopted universally would lead to Canada having the most progressive legislation anywhere in the World.

Lastly, the Alberta College of Physicians and Surgeons published a revised advice to its members on the subject of assisted dying. Its initial recommendations were very conservative and more concerned about the comfort of physicians than that of severely ill patients. It has modified its language somewhat but it is still very cautious. Surprisingly, however, it appears to suggest that mature minors should be allowed to make a request and that such a request be considered. It continues to insist that all patients must retain an on-going mental capacity before physician-assisted dying can be provided.

More delays ahead?

The new federal government has applied to the Supreme Court for an extension of six months beyond February 6 so that it can write new laws. The court is set to hear arguments about the request when winter session commences on January 11. 

Now that we are within a few short weeks from the key date of February 6, it seems a great pity that the last government chose to drag its feet for so long. Progress is being made, perforce, in a rather helter-skelter fashion, quite unsuitable for so grave a question. The Ontario expert panel travelled widely and consulted broadly and I hope that the government of Canada will be prepared to take its advice and not set up yet another group to go over the same ground again. However, it does seem very likely that rules and regulations for physician-assisted dying will be in place shortly. It needs to be emphasized that those persons, who have religious or moral objections, will be under no obligation to avail themselves of assistance in dying when placed in a dire end of life situation. On the other hand, such persons should not expect to have their reservations applicable to those with a different worldview.

Of necessity, a blog post of this nature, must cherry pick from the various reports and emphasize the most important. Those requiring full details must go to the sources, all of which are available on-line.

We live in interesting times.

Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.


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