Dr. David Amies: Quebec tragedy highlights need for advance requests for assisted dying

In his final regular post for the Dying With Dignity Canada blog, Dr. David Amies offers his reflections on a heartbreaking tragedy in Montréal and how it highlights the need for Canadians with dementia to be allowed to make advance requests for assisted dying.

A rather sad story appeared in the national media last month concerning a man who stands accused of taking his wife’s life in order to end her suffering. Michel Cadotte, aged 55, from Montréal, was charged with second-degree murder in connection with the death of his wife. Cadotte was reported in the French media as saying that he “cracked” when faced with her suffering. She had been in a long-term care institution for some while. Her family had previously asked for, but had been refused, an assisted death. She had difficulty walking, communicating and eating, and it sounds very much as if she was suffering from some form of dementia.

There is no question that ending a loved one’s life out of pity is illegal. Bill C-14, in place across the whole of Canada, states that certain persons under very specific circumstances can have their lives ended legally by registered health practitioners. The law on this matter has been in place for less than one year and may well be subject to revision but not in the immediate future. It makes no provision for advance consent. Consequently, persons who are diagnosed with dementia and who understand fully what the course and consequences of this diagnosis implies, cannot make an advance request stating, for example, that when the condition has deteriorated to a certain point, they want a medically aided death. I do not have the precise details of the Cadotte case, but it does appear likely that a legally enforceable advance request could have saved a good deal of grief and pain.

I would like to see the present law changed to allow for advance directives to act as legitimate triggers. Several people and institutions across Canada, including Dying With Dignity Canada, would like the current law amended to permit that. This idea, along with permitting purely psychiatric diagnoses and granting legal minors access to medical assistance in dying (MAID), are currently being studied by the Council of Canadian Academies, who are expected to finish their work by the end of 2018.

I shall not be surprised if primary psychiatric diagnoses are deemed acceptable triggers for MAID. I think it possible that competent, legal minors will also be granted the right to apply for MAID. However, I foresee much opposition to the idea of accepting advance consent as a trigger from medical practitioners, religious authorities, politicians and ethicists, among others.

The Carter decision, handed down by the Supreme Court of Canada in early 2015, held that competent adult persons with medical conditions that caused enduring and insufferable pain, for which there was no acceptable remedy, should be permitted to end their lives with the help of a medical practitioner.

Furthermore, the Court ruled that it was an infringement of individual human rights to deny patients their wishes. The practitioners who came to their aid could therefore act upon these wishes without fear of legal retribution. As far as widening the scope of the new law to include the use of advance consent, the word “competent” is crucial. Under the law, as it stands now, practitioners are required to obtain consent to MAID right up to the very last moment. They must also be certain that the patient is suffering intolerably and not under duress from another.

It is difficult, perhaps even impossible, to judge the level of suffering present in a person with advanced dementia. Likewise, obtaining valid consent is also problematic under these circumstances. There can be no doubt that persons with early dementia can fully understand the likely course of the disease and be distressed by the effects it will have on family and friends, and seek to reduce these effects by means of an advance request.

Dr. David Amies

But the law will have to be changed radically to allow people with a diagnosis like dementia to access MAID after the loss of capacity. This will likely have to be done with the support of third parties, including healthcare practitioners, family members and friends, who may have to determine whether the sick person has deteriorated enough to meet the “trigger point” outlined in his or her advance request. Without this option, however, individuals with dementia may seek to access assisted death unnecessarily early while they are still able. What a difficult dilemma for sufferers, families and society as a whole.

Lastly, on a personal note, this will be my last regular article for this blog. Well over 50 articles written by me have appeared during the last couple of years and it is now time for another voice. I would like to make very occasional contributions when — and if — some especially striking topic crops up, as they most certainly will. I would like to thank all of those who have commented on my articles as well as those who have 'liked’ them on Facebook. Au revoir.

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

Dying With Dignity Canada extends its heartfelt thanks to Dr. David Amies for his tremendous contributions to our blog over the years. We will miss his signature voice and candor!