958 days without medical assistance in dying policy

Lack of government regulation leaves Nova Scotians without access to legal practice and beset by misinformation.

The Coast

Brooklyn Connolly

It’s been 958 days since Bill C-14 passed federal legislation, yet Nova Scotia still lacks a program for medical assistance in dying—MAiD—as well as MAiD policy and regulation.

Without policy, physicians and nurse practitioners have no way of governing MAiD, creating a series of loopholes and lack of general knowledge surrounding the subject. The Nova Scotia Health Authority, meanwhile, has published false information on its website and staff at St. Martha’s hospital in Antigonish still refuse to perform the assistance at all.

Dalhousie professor Jocelyn Downie has been investigating the legal aspects of this for quite some time, and held an open lecture last week in Halifax to present her information. . . [Full text]

Ban on assisted dying at St. Martha’s hospital should end, says law prof

Religious hospital in Antigonish, N.S., has agreement with province allowing it to forego MAID provision

CBC News

Frances Willick

Nova Scotia’s only Catholic hospital is at risk of being found in violation of the Charter of Rights and Freedoms and human rights legislation by refusing to provide medical assistance in dying, a Halifax law professor says.

St. Martha’s Regional Hospital in Antigonish, N.S., is a publicly funded health-care facility. But due to its religious ties, staff are not permitted to provide MAID. . . [Full text]

Alberta health minister reviewing rules around assisted dying at faith-based facilities

Sarah Hoffman acknowledges public complaints following CBC News investigation

CBC News

Jennie Russell

Health Minister Sarah Hoffman says her ministry is reviewing options that would allow Alberta Health Services to provide medical assistance in dying at faith-based health facilities while respecting religious objections, although she cautions the province is “not there yet.”

In an interview, Hoffman said she has received public feedback urging her to reverse her 2016 exemption that allowed Catholic health provider Covenant Health, which is publicly funded, to opt out of providing access to the procedure. . . [Full text]

Alarming gap in assisted dying in Antigonish

The Chronicle Herald

Jocelyn Downie

Today (Dec. 17) marks two and a half years since the coming into force of Canada’s federal legislation on medical assistance in dying (MAiD).

In Nova Scotia, MAiD has now been requested in about 400 cases and provided in about 200. Unfortunately, there is one particularly notable gap in access to MAiD: St. Martha’s Regional Hospital, a publicly funded faith-based institution in Antigonish, refuses to allow MAiD within its walls. . . [Full text]

World Medical Association to consider policy changes on abortion, euthanasia, assisted suicide

Debate planned for ethics conference in October in Iceland

Sean Murphy*

Following a meeting of the WMA Council in Riga, Latvia, the WMA issued a statement noting that a revised version of the WMA abortion policy would be presented for approval at the WMA annual General Assembly in Reykjavik, Iceland.

In addition, the WMA has announced that there will be a further “open debate” on changing the Association’s policy against physician participation in euthanasia and assisted suicide.  The debate will occur during a WMA conference on medical ethics taking place at the same time and place.  Formal presentations on euthanasia and assisted suicide will be given on 4 October, 2018, but informal discussions among delegates are likely to be important.  The debate appears to be a consequence of lobbying by the Canadian and Royal Dutch Medical Associations to convince the WMA to drop its condemnation of the practices

It is not clear whether or not WMA members appreciate the relationship between abortion policy and euthanasia policy.  Compulsory referral for abortion is essentially a dress rehearsal for compulsory referral for euthanasia and assisted suicide, something clearly demonstrated in Canada.  Accusations of “patient abandonment” formerly aimed at those refusing to refer for abortion1 are now, in addition, being levelled at those who refuse to refer patients to someone willing to kill them or help them commit suicide.2

In 2011, a Royal Society of Canada panel of experts chaired by Udo Schuklenk  recommended legalization of assisted suicide and euthanasia.3  The experts insisted that health care professionals unwilling to provide euthanasia help patients commit suicide must refer them to someone willing to do so.4 This was justified, they said, because it was agreed that objectors are obliged to refer for “reproductive health services.”5  It really was not agreed: the Canadian Medical Association had, in fact, rejected this claim five years earlier6 after it was made by Jocelyn Downie,7 one of Schuklenk’s colleagues on the Royal Society Panel.

By 2015 Schuklenk was arguing that objecting physicians should not be accommodated at all. Among his arguments was that referring for abortion or euthanasia is not a compromise because it involves moral complicity in the act, “barely reduced” by the act of referral.8  This implied that physicians should be forced to provide abortion and euthanasia, notwithstanding religious or conscientious convictions to the contrary, a position Schuklenk explicitly adopted over the next two years.9, 10

At the same time, Ottawa law professor Amir Attaran was insisting that physicians should be forced to kill eligible patients themselves.11 He claimed that this was required by human rights law,12 describing effective referral as an unacceptable form of illicit discrimination.13

In considering changes to euthanasia, assisted suicide and abortion policies in October, WMA delegates will have to take great care to consider not only the most obvious ethical issues of life and death, but less obvious yet important issues like the distinction between acceptable cooperation and unacceptable collaboration, which play out in disputes about mandatory referral for abortion and euthanasia.


Notes
1.  “According to the prevailing norm of beneficence therefore, as well as those of trust, patient autonomy, and not abandoning patients, physicians should refer patients for abortions.”  McLeod C. Referral in the Wake of Conscientious Objection to Abortion. Hypatia, Vol. 23, No. 4 (October-December, 2008) at p. 36 (Accessed 2018-08-022).

2.  Cook M. Canadian court tells doctors they must refer for euthanasia. Mercatornet, 2 February, 2018

3. Schuklenk U, van Delden JJM, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011)[“Royal Society“] p. 96 (Accessed 2014-02-23).

4.  Royal Society, p. 69, 101.

5.  Royal Society, p. 62.

6.  Blackmer J. Clarification of the CMA’s position on induced abortion. CMAJ April 24, 2007 vol. 176 no. 9 doi: 10.1503/cmaj.1070035 (Accessed 2017-12-12).

7.  Rodgers S. Downie J. Abortion: Ensuring Access. CMAJ July 4, 2006 vol. 175 no. 1 doi: 10.1503/cmaj.060548 (Accessed 2017-12-12).

8.  Schuklenk, U. Conscientious objection in medicine: private ideological convictions must not supercede public service obligations (2015) 29:5 Bioethics ii, DOI: 10.1111/bioe.12167

9.  Schuklenk U, Smalling R. Why medical professionals have no claim to conscientious objection accommodation in liberal democracies (2016) 43:4 J Med Ethics 234, DOI: http://dx.doi.org/10.1136/medethics-2016-103560.

10. Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception (2017) 31:3 Bioethics 162, DOI: 10.1111/bioe.12288

11.  Though conceding that a lethal drug might be administered in the physician’s presence by a delegate, and that referral might be necessitated by technical incompetence. Attaran A. The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada (2016 ) 36:3 Health L Can 86 [“Attaran“], p. 87-88, 96.

12.  “[W]hen a doctor refuses to assist a patient who is disabled by a ‘grievous and irremediable medical condition’, just because the patient wants death rather than something else, that arguably discriminates against the disabled patient.” Attaran, p. 89.

13.  Attaran, p. 91–93.

B.C. doctor cleared of wrongdoing for providing assisted death to woman who starved herself

Globe and Mail

Kelly Grant

British Columbia’s physician regulator has cleared a doctor of any wrongdoing for providing medical aid in dying to a woman who did not qualify for the procedure until she starved herself to the brink of death.

A committee of the College of Physicians and Surgeons of British Columbia (CPSBC) found that Ellen Wiebe did not break the regulator’s rules when she helped a 56-year-old patient known as Ms. S to die last year.

The case is the first to be made public in which a medical regulator has ruled on the contentious question of whether doctors should grant assisted deaths to patients who only satisfy all the criteria of the federal law after they stop eating and drinking.

“It was determined that Ms. S met the requisite criteria and was indeed eligible for medical assistance in dying, despite the fact that her refusal of medical treatment, food, and water, undoubtedly hastened her death and contributed to its ‘reasonable foreseeability,'” the college’s inquiry committee wrote in a Feb. 13 report. . . . [Full text]

 

Has stopping eating and drinking become a path to assisted dying?

Policy Options

Jocelyn Downie

Can patients, by stopping eating and drinking, make themselves meet the criteria for a “grievous and irremediable medical condition,” the requirement to access MAiD?

Ms. S. was a 56-year-old woman with advanced multiple sclerosis. In June 2016, when her suffering became intolerable and her state of decline was advanced as a result of her incurable medical condition, she asked Dr. Ellen Wiebe for medical assistance in dying (MAiD). Ms. S. had earlier declined potentially effective treatment. Dr. Wiebe concluded that Ms. S. met most of the eligibility criteria for MAiD in Canada: incurable condition, advanced state of decline in capability, and enduring and intolerable suffering not remediable by any means acceptable to her. However, as she did not believe that Ms. S. would die “in the foreseeable future,” she deemed her not to meet the final eligibility criterion for MAiD: “natural death has become reasonably foreseeable.” Ms. S. asked again for MAiD in December 2016 and January 2017 and each time she was deemed ineligible on the same grounds. . . [Full Text]

Why would my terminally ill father be denied a medically assisted death?

The Globe and Mail

Paul Taylor

The question: My father was in the advanced stages of prostate cancer and wanted a medically assisted death. He was told he needed the approval of two health-care providers. One said yes, but the other said no because he “was not in any distress.” But that decision was so wrong. My father was a very stoic man, and was not one to complain. Did the doctor want him to break down in tears and beg to be put to death? My father died two weeks later in a hospice – instead of his home, the place where he wanted to die.

The answer: It has been over a year and a half since Parliament passed a law that makes medical assistance in dying – called MAID for short – legal across Canada. The story you tell reflects one of the many challenges in creating a standardized system to handle these requests and to ensure that patients and their families are properly informed.

One key failing in your father’s case is that he was not apparently told he could have asked for another assessment after the second MAID assessor turned him down. If another assessor had agreed that he was eligible, he could have proceeded with an assisted death.

It’s impossible to say whether his assessors were unaware he had this option or simply failed to mention it.

Whatever the case, “we need to do a better job educating health-care providers about what they must be disclosing to patients,” says Jocelyn Downie, a professor in the faculties of law and medicine at Dalhousie University in Halifax.

In the meantime, it’s certainly worthwhile reviewing how the process is supposed to work. . . [Full Text]

Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

G. Bravo, C. Rodrigue, M. Arcand, J. Downie, M.-F. Dubois, S. Kaasalaine, C.M. Hertogh,S. Pautex, L. Van den Block

Abstract

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.


Bravo G, Rodrigue C, Arcand M, Downie J, Dubois M-F, Kaasalaine S, Hertogh CM,  Pautex S, L. Van den Block L. Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs. 2018 Jan 3. pii: S0197-4572(17)30319-1. doi: 10.1016/j.gerinurse.2017.12.002.

A “uniquely Canadian approach” to freedom of conscience

Provincial-Territorial Experts recommend coercion to ensure delivery of euthanasia and assisted suicide

Recommendations designed to broaden and maximize impact of Supreme Court ruling

Sean Murphy*

Abstract

The Experts’ recommendations are intended to extend and maximize the impact of the Carter ruling. They will effectively require all institutions, facilities, associations, organizations and individuals providing either health care or residential living for elderly, handicapped or disabled persons to become enablers of euthanasia and assisted suicide. This will entail suppression or significant restriction of fundamental freedoms.

The broader the criteria for the provision of morally contested procedures, and the more people and groups captured in the Experts’ enablers’ net, the greater the likelihood of conflicts of conscience.  Relevant here are recommendations to make euthanasia/assisted suicide available to mentally ill and incompetent persons, and to children and adolescents, even without the knowledge of their parents.

The Experts’ distinction between “faith-based” and “non-faith-based” facilities is meaningless. They impose identical obligations on both. All will be forced to allow homicide and suicide on their premises, or compelled to arrange for euthanasia or assisted suicide elsewhere.
Likewise, they recommend that objecting physicians be forced to actively enable homicide or suicide by providing referrals, arranging direct transfers or enlisting or arranging the enlistment of patients in a euthanasia/assisted suicide delivery system.

The Supreme Court did not rule that people ought to be compelled to become parties to homicide and suicide, but that is what the Experts recommend. This is not a reasonable limitation of fundamental freedoms, but a reprehensible attack on them and a serious violation of human dignity.

Other countries make euthanasia and assisted suicide available without attacking fundamental freedoms. In this respect, the Experts’ claim to have produced “a uniquely Canadian approach to this important issue” is regrettably accurate. They fail to provide any evidence that the suppression of freedom of fundamental freedoms they propose can be demonstrably justified in a free and democratic society.


Table of Contents

I.    Background

I.1    Formation and work of the Advisory Group

II.    Overview of the Final Report

II.1    Moral/ethical unanimity
II.2    “Statement of Principles and Values”
II.3    Recommendations broadening the Carter criteria
II.4    Recommendations impacting freedom of conscience and religion

III.    The Experts’ “uniquely Canadian approach”

III.1     Expanded criteria and increasing likelihood of conflict

III.1.1    “Irremediable medical condition”.
III.1.3     Euthanasia approved for future suffering.
III.1.7     No waiting/reflection period.
III.1.10     Adolescents and children.
III.1.13     Euthanasia/assisted suicide by non-physicians.
III.1.15     Doctor shopping.
III.1.18     Physicians need not be present at suicides.
III.1.20     Euthanasia/assisted suicide wherever people live.
III.1.22     Families, caregivers may not be advised.

III.2    Institutions, associations, organizations

III.2.1     The meaning of institution.
III.2.3    All “institutions” must allow/arrange euthanasia/assisted suicide
III.2.6     All “institutions” must disclose policies.
III.2.8     “Institutions” may not manifest or enforce commitments

III.3    Objecting physicians: information, disclosure, non-discrimination

III.3.3    Objecting physicians must provide information.
III.3.8    Objecting physicians must disclose views and their implications.
III.3.11    Objecting physicians must not illicitly discriminate.

III.4    Objecting physicians must become critical enablers

III.4.4    Referral or direct transfer of care.
III.4.5    Referral to “system/third party.”
III.4.8    The Experts’ proposal and the CMA’s proposal.

IV.    Project response

IV.1    Expert recommendations broadening Carter criteria
IV.2    Expert recommendations and fundamental freedoms in general
IV.3    Expert recommendations and freedom of conscience

V.    Conclusion


Appendix “A”  Supreme Court of Canada, Carter v. Canada (Attorney General), 2015 SCC 5

A1.    Carter criteria for euthanasia and physician assisted suicide
A2.    Carter and the criminal law
A3.    Carter and freedom of conscience and religion

Appendix “B”  Expert recommendations re: broadening Carter criteria

B1.     Expanding the Carter criteria

B1.1    “Grievous and irremediable medical condition” includes mental illness
B1.2    Suffering not a prerequisite
B1.3    Competence not a prerequisite: euthanasia for dementia
B1.4    Euthanasia and assisted suicide for children and adolescents
B1.5    Assessment, euthanasia and assisted suicide by non-physicians

B2.    Increasing the impact of Carter

B2.3    Doctor shopping
B2.4    No “waiting/reflection” period
B2.5    Physicians need not be present at suicides
B2.6    Euthanasia & assisted suicide in hospitals, hospices, etc.
B2.7    Families and caregivers may not be advised

Appendix “C”    Expert recommendations re: freedom of conscience and religion

C1.    Institutions

C1.1    Meaning of “institution”
C1.2    “Institutions” must allow or arrange for euthanasia or assisted suicide
C1.3    All “institutions” must disclose position on euthanasia and assisted suicide
C1.4    “Institutions” must not require patients/residents to give up “the right to access,” interfere with employees providing eutanasia or assisted suicide elsewhere

C2.    Objecting physicians/health care providers

C2.1    Must provide information on “all options”
C2.2    Must disclose views on euthanasia and assisted suicide
C2.3    Must not discriminate
C2.4    Must act as critical enablers

C2.4.1  Three alternatives
C2.4.2  Referral
C2.4.3  Direct transfer of care
C2.4.4  Transfer to “a publicly-funded system” or “third party”
C2.4.5  The Experts’ “system/third party” and the CMA’s “central service”

Appendix “D”    Canadian Medical Association on euthanasia and assisted suicide

D1.    CMA policy: Euthanasia and Assisted Death (2014)
D2.    CMA Annual General Council, 2015

D2.1    Surveys on support for euthanasia/assisted suicide
D2.2    Physician freedom of conscience

D3.    CMA rejects “effective referral”

Appendix “E”    International comparisons

E1.    Netherlands
E2.    Luxembourg
E3.    Belgium
E4.    Oregon
E5.    Washington
E6.    Vermont
E7.    California

Appendix “F”    An Act to Safeguard Against Homicide and Suicide