Dr. David Amies: Are attitudes toward assisted dying changing?

Informal polls conducted at the Canadian Medical Association's annual general meeting on August 23 show rising support among doctors for medical assistance in dying. Dr. David Amies writes about the significance of these results and wonders if this is a tell-tale sign of changing attitudes toward the once polarizing issue of assisted dying.

The Canadian Medical Association (CMA) has just completed its annual general meeting, held this year in Québec City. Some interesting numbers concerning medical assistance in dying (MAID) emerged. The CMA represents about 85,000 physicians, residents and medical students, and previously was not a keen supporter of MAID. Perhaps this view is changing.

André Picard, public health reporter for The Globe and Mail made the following points in his article.

  • Straw polls of the 600 delegates revealed that 83 per cent of the respondents are now in favour of allowing patients to make an advance request for assisted dying. In other words, patients with early dementia, for example, could state that once their position has deteriorated to a certain level, then their advance request would be sufficient to trigger MAID.
  • A further poll revealed that 67 per cent of the delegates were in favour of allowing ‘mature minors’ to ask for and receive assisted death. The current law in Canada does not allow this.  
  • Lastly, a third poll showed that only 51 per cent of respondents said that individuals whose principal illness was psychiatric should be allowed to receive MAID.
  • Some further numbers of interest are that, in 2013, 34 per cent of physicians were in favour of medically assisted death. By 2014, this number had risen to 45 per cent.
  • By the end of last year, 970 cases of MAID had taken place across the country or 0.6 per cent of all deaths from any cause. This is well in line with figures from such countries as the Netherlands, Belgium and Luxembourg, and American states such as Oregon, all of whom have much more experience with MAID than Canada.

In discussing the numbers from the CMA annual congress, it should be acknowledged that the sample sizes were small. In spite of that, in all instances the trend was upwards. It was also noted that debate around all of the issues was calm and orderly, whereas in the past, it had been heated and emotional.

A flawed law

As is well known by now, Canada’s MAID law came into effect in June 2016 and was prompted by the Supreme Court’s Carter decision in February 2015. Before the ink was dry on the legislation, objections were voiced about its scope. First, there is the vague requirement that death be reasonably foreseeable. There is also no provision for advance requests, and severe uncontrollable mental disease has also been disallowed as a trigger. Lastly, only those individuals who are 18 years or older currently qualify. At the time of the law’s passing, the federal government included provisions for further examination of certain aspects of the law. Consequently, the Council of Canadian Academies (CCA) has been charged with conducting reviews, which are now underway, and its reports are due by the end of 2018.

I am not surprised by the straw poll findings from the CMA meeting that two-thirds of those who responded see no reason why an aware 16 or 17 year old should not be granted the relief of medically assisted dying where circumstances warrant it. There is no inherent logic in declaring that a person who has reached the age of 18 can make the decision to die with medical assistance, but one who is 17-years-and-nine-months old may not.

Dr. David Amies

On the other hand, learning that 83 per cent of polled delegates are in favour of using advance requests as a trigger does surprise me. I should say at once that I am with the 83 per cent. However, the law does require that the person undertaking an assisted death be able to withdraw consent right up until the very last moment. That means that he or she is perfectly aware of the consequence of their choice to the very end. The advance request puts the action of ‘pulling the trigger’ into the hands of a third party — a friend or relative, for example — who must decide that the moment outlined in the request has arrived. This is a very grave duty from which there is no turning back. The request would have to be written very clearly and the agent would have to be entirely trustworthy; both qualities in short supply!

Consider the case of someone following a catastrophic accident or stroke and in the intensive care unit. Having a third party decide that the life support systems should be turned off is relatively easy when it is perfectly apparent that no recovery is possible. Contrast that with the scenario of a person who has advanced dementia, but is showing no outward signs of distress. How much harder is it for the third party to act in such circumstances?

I am surprised that almost half of those polled were leery about allowing severe mental illness to be a sufficient reason for asking for assisted death. Most psychiatric illnesses can be reasonably well controlled, but there are some cases that are almost entirely refractory. Such patients undergo a great deal of anguish and torment. Many commit suicide. Would it not be more compassionate to allow them relief through an assisted death? As far as I know, fears that persons with major psychoses always lack capacity to make important life and death decisions are unfounded. There will be times in their lives when that is the case, but others when it is most certainly not. I believe that we need members of the psychiatric community to elucidate this point for the benefit of the rest of the medical profession and the general public. Perhaps the subgroup of the CCA looking into this conundrum will provide the help we need.

Shifting attitudes                                                                     

Many in the medical profession have been confused by the meaning of the ‘reasonably foreseeable’ clause. Most are interpreting that requirement to mean that a patient must be terminally ill in order to qualify for an assisted death. The recent case of AB, a 77-year-old Ontario woman, suffering from great pain from osteoarthritis but not in imminent danger of dying, has thrown some light on this matter after a ground-breaking decision by Ontario Superior Court Justice Paul Perrell. I have learned through personal contact that his ruling has enabled some physicians, who provide medical assistance in dying, to take a more relaxed view of the ‘reasonably foreseeable’ clause and not insist that applicants be at the point of death.

In summary, now that medically assisted death has been on the statute books for more than a year and has been seen to be working, the outlook toward the procedure among members of the medical profession appears to be changing. My guess is that the report from the CCA will encourage the government to widen the scope of the current law while at the same time taking note of the objections from organizations and individuals who object to all such laws on grounds of conscience. The knotty problem of ‘institutional’ conscience’ will remain to be settled.

However, the situation existing before the Carter decision and that of today is very different and there are now legal avenues of escape for those who find their lives no longer worth living, by virtue of intolerable suffering.

The answer, then, to the question posed at the outset of this piece — ‘Are attitudes changing?’ — seems to be ‘Yes.’ And that, surely, is compassionate, reasonable and as it should be.

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

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