Dr. David Amies: B.C. couple's case reveals even more barriers to assisted dying access

In this blog post, Dr. David Amies examines the heart-wrenching case of the Sievewrights, who were forced to die four days apart because of legal concerns. Their case, which came to light in a lengthy, nuanced feature in the Globe and Mail, highlights even more barriers to assisted dying access.

During their 55-year marriage, Kay and Ernie Sievewright did just about everything together. Although they had no children, they raised dogs, went fishing, sailed in the waters off the coast of British Columbia and undertook several camper van trips to Mexico and back. By their own admission, they had a wonderful life.

In middle age, Kay developed severe multiple sclerosis, and shortly afterwards, Ernie developed spinal stenosis and kidney and heart problems. As time passed, their declining health forced them to rely more and more on others to cope with the needs of daily living. Ultimately, they decided to apply for medical aid in dying (MAID), and when both were approved, they hoped to have a quiet and gentle death together. Unfortunately, they were frustrated by various legal problems and Ernie was forced to live on for a few days after Kay’s assisted death.

Most of the legal concerns were raised by the Canadian Medical Protective Association (CMPA), the body that looks after legal and disciplinary matters for practicing Canadian physicians. The professional staff of CMPA has pointed out that Canada's MAID law is new, vague and, as yet, has few established legal precedents. Thus, they are advising extreme caution. The associate executive director of the CMPA feared that arranging for two simultaneous assisted deaths for partners could raise the possibility of coercion and look like a suicide pact.

The doctors who provided MAID for the Sievewrights spent weeks consulting with the CMPA on how to best handle their cases and how to assure punctilious compliance with the letter of the law. In the end, Kay died in the presence of Ernie, while he held her hand. His death took place four days later.

I do not wish to repeat the provisions of the new law concerning medical aid in dying other than to say it is rather unclear. For example, what exactly does "reasonably foreseeable" mean? Why should there have been such concern that the Sievewrights were in some way colluding criminally? I hope that as time passes and more cases are accomplished that a body of precedent will be established that will allow more boldness in the minds of the lawyers who work for the CMPA.

More barriers

I have already written blog posts about other barriers to the provision of MAID. Most notorious are the objections raised by the managers of religiously affiliated institutions to having the practice performed on their premises. I have written about the difficulties that such attitudes can pose for people living in small towns, well away from major centres, where perhaps the only available institution is run by Catholics. This is a problem that is unlikely to go away very soon and is likely to end up in front of the Supreme Court.

There is another problem that has not been examined and that is the question of doctors’ payment for performing MAID. A quick digression on the economics of medical practice in Canada is in place here. Most Canadian physicians are remunerated on a fee-for-service basis. They are, therefore, small business people, who have one commodity for sale: their time. Furthermore, for every $30 they receive in fees, $10 go to paying for the cost of running an office: rent, utilities, supplies, staff wages. Ten more go to the federal government in taxes, leaving the remaining 10 for the physician’s personal use. If the average fee earned by a general practitioner is $35 and there are 200 working days each year, the practitioner must see 15 patients on each of those days to gross $100,000. The demand for the services of general practitioners is such that they are likely to see 30 patients daily, thereby producing a gross income of $200,000.

The fees paid by the various provincial authorities for the performance of MAID vary, but in British Columbia, they amount to just over $100. As was pointed out in the Sievewrights' case, the doctor who provided their assisted deaths spent hours and days negotiating with the CMPA. Even if that had not been necessary, a great deal of preparatory work is required from the physician when arranging for an assisted death. I have spoken to one practitioner who has performed several of these cases, and he told me that his activities in the field have caused him a significant loss of revenue. Perhaps it could be argued that the commission of MAID should involve an element of pro bono work, which is a discussion that is likely to go on for some time. However, if religiously affiliated institutions are putting up barriers, and physicians, even those that have no conscientious objections, are put off by financial concerns, access to MAID will become increasingly restricted.

It may be thought to be indelicate to discuss mere mammon about this vital service, but it would be unrealistic, short-sighted and obtuse not to do so.

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

(Header photo credit: Dr.Farouk via Flickr)

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