Protection of Conscience Project
Protection of Conscience Project
Service, not Servitude

Service, not Servitude

Dr. Robert's regrets

Towards death à la carte?

Vers la mort à la carte?
Collège des Médecins du Québec, 10 May, 2017

English translation published by the Physicians' Alliance against Euthanasia, reproduced with permission

Dr. Yves Robert*


As noted in the commentary below, the state medical regulator in the province of Quebec, the Collège des Médecins du Québec, published an reflection in 2009 that effectively encouraged the legalization of euthanasia. During hearings into Quebec's Bill 52, which eventually became the province's euthanasia law (the Act Respecting End of Life Care), Dr.  Charles Bernard, Dr. Yves Robert and Dr. Michelle Marchand appeared on behalf of the Collège.  They were effusive in their support for the proposed law, describing it as "a very important milestone," the product of "outstanding work," and "responsive to the vision we initially proposed."

One of the points Dr. Bernard emphasized was that euthanasia should be "an option of last resort for  exceptionally difficult situations at the end of life. . . in the final stages of a serious and incurable disease that is inflicting refractory suffering."  Dr. Robert himself added that euthanasia should only be considered in what was truly the "last slice of life in the final phase of the life."  Only then, he said, might it be considered an option "from a medical point of view."

Consistent with these views, the original text of the Bill was amended to include a provision that a patient had to be "at the end of life," even though the legislators could not agree on what this meant.  It is not certain that the term is being interpreted consistently throughout the province, though returns from reporting agencies sometimes report refusal to provide euthanasia because a patient is "not at the end of life."  About 8% of refusals in the first half of 2017 were attributed to patient ineligibility, which includes this criterion among others.

In any event, the May, 2017 commentary by Dr. Robert indicates alarm at increasing pressure to provide euthanasia in circumstances and for reasons apparently not envisaged by Collège des Médecins du Québec when it published its 2009 reflection and expressed its support for the new legislation.  Of particular interest, he suggests that, if current trends to broaden criteria for euthanasia continue and are affirmed, it may be appropriate for the medical profession to be replaced by some kind of non-medical (but presumably technically competent) euthanasia service. 

During the legislative hearings into Bill 52, Professor Margaret Somerville suggested that lawyers could be trained for this purpose.  Her suggestion was ignored at the time, but Dr. Robert's comments suggest that he and other euthanasia supporters may now be more open to Dr. Somerville's proposal.  Having a corps of voluntary euthanasia service providers would relieve the pressure now being experienced by physicians and health care workers who object to euthanasia for reasons of conscience.  [Administrator]

If anything has become apparent over the past year, it is this paradoxical discourse that calls for safeguards to avoid abuse, while asking the doctor to act as if there were none. Many are ill at ease with exclusion and paradoxes, especially opinion leaders and media columnists who denounce refusals of MAID and promote death à la carte "to respect the choices of each individual."

Just over a year after the adoption of the Act Respecting End-of-Life Care (hereafter the Act) in Quebec, the Minister of Health and Social Services recently announced his plan for a reflection on expanding the scope of Medical Aid in Dying (MAID). It would seem that we already want to relax the access criteria.

It should be noted that the debate in Quebec was launched in November 2009 following the publication of the Collège des médecins du Québec's reflection on the subject. The logic of care based on seeking the most appropriate care for each patient was the primary motivation for the approach that led to the law authorizing MAID, which came into force on December 10, 2015. With this logic of care, the Quebec legislator sought to recognize a logic of rights, confirming that the patient had a say in how he wished to live his last moments. Thus, the law grants the patient the right to quality end-of-life care: palliative care, including palliative sedation and, exceptionally, if it is not relieved by usual care, medical aid in dying. The Act also established a system of Advance Medical Directives (AMD), through which the physician is bound to respect the wishes expressed therein by a patient, regarding five specific treatments[1] required by his or her state of health if, having become incapable, the patient is in one of two particular clinical situations.[2] MAID is excluded by law from the AMD.

In just over a year, more than 400 patients have received MAID in Quebec. This period was a learning process for all of Quebec society, during which we collectively understood that there were criteria for access to MAID and that, when these criteria were not met, requests were refused. This observation, although obvious, was brutal for many.

Thus, patients suffering from progressive diseases but at an early or intermediate stage were denied MAID. Patients with disabilities, who were not at the end of their lives, were reduced to choosing to die through fasting. Finally, more recently, a patient suffering from dementia, incapable of consenting to care, was allegedly killed out of compassion by her spouse.

Since the coming into force of the Act, and particularly since the debate on the federal bill following the Carter decision of the Supreme Court of Canada, some people have invoked a "new constitutional right": that of obtaining MAID on demand or even to claim it "pre-emptively" shortly after being diagnosed with severe or terminal illness, even before suffering from the dreaded incapacities or limitations. For many, it is about having control over their death and the right to choose its moment and manner. While MAID was reserved for the suffering patient, we see the emergence of pressure demanding a form of death à la carte. But is this really what our society wants?

We all know that at least three questions remain unanswered after the coming into force of the current laws: what happens to incapable persons, to minors, and to those with mental illness? These issues are not simple; we may have to accept that there is no answer. The question of incapable persons, which will be discussed by an expert committee formed by the minister in the coming year, is probably the most complex. It is envisaged to allow persons who are still capable to issue advance directives to request MAID in case of incapacity. In particular, it should be ensured that, where appropriate, the person clearly determine the medical condition for which he or she would want MAID. It's not easy when one is still in good health. For obvious reasons, this possibility could not have the same binding power as an AMD.

  • What then would be the decision-making process to be followed, and by whom, in the name and in the interest of the incapable person?
  • Who would ultimately make the decision?
  • Who would choose the moment?

Medically, other conditions foreseen in the law for those who are capable should also be present, including suffering, which is not always present in dementia depending on the stage of the disease.

  • It is also important to determine who would be suffering the most: the patient or his or her entourage?
  • What if, at the time of the intervention, the patient, unaware of their purpose, resisted the injections?
  • Finally, what would one do with all those patients currently suffering from dementia, who have not had the opportunity to express their wishes beforehand?
  • What would be the response to those who would undoubtedly invoke a concern for fairness and claim a need for compassionate death in the name of a subjective "quality of life" that is so difficult to evaluate?

As can be clearly seen with the situation of incapable persons, broadening access to the MAID raises many issues that should be discussed collectively, and which go well beyond the current legal framework and even the Carter decision. Why and to what extent should new safeguards be introduced when, no matter what the access criteria, there will always be some people excluded by definition? If anything has become apparent over the past year, it is this paradoxical discourse that calls for safeguards to avoid abuse, while asking the doctor to act as if there were none. Many are ill at ease with exclusion and paradoxes, especially opinion leaders and media columnists who denounce refusals of MAID and promote death à la carte "to respect the choices of each individual."

For them, what about the logic of care and of a "continuum of care" that preceded the Act Respecting End-of-Life Care? If the goal is euthanasia on demand based on a right, are we still talking about Medical Aid in Dying, or simply Aid in Dying? What would the medical profession have to do with it?

We should recall that, without the logic of care, physician intervention is not required. If the will of the people is limited to respecting the wishes expressed directly or indirectly by the person, society will have to lucidly consider other options than those which require the participation of the doctor, and transform Medical Aid in Dying into simply a legally authorized aid in dying. This could take the form of assisted suicide services provided by a private company that would deal directly with the person, as in Switzerland… But is it really in this direction that Quebec society wants to go?

What is striking after the first year of operation of this law, recognized as being the source of a "major opening", is the rapidity with which public opinion seems to have judged this opening insufficient. Have we really gone that far? Even before having fully appreciated the application of the current provisions or their consequences?

Let us take the time to reflect carefully before going any further. Death is not that urgent.

Yves Robert, M.D.
Collège des médecins du Québec


1.  Cardiopulmonary resuscitation, respiratory assistance, dialysis, hydration and nutrition

2.  End of life and serious and incurable disease or severe and irreversible impairment of cognitive functions