Redefining the Practice of Medicine- Euthanasia in Quebec, Part 2: ARELC in Detail


An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec.  It replaces the original Bill 52, the subject of a previous commentary by the Project. ARELC purports to establish a right to euthanasia for a certain class of patients by including it under the umbrella of “end-of-life care.”  ALERC calls euthanasia for competent patients “medical aid in dying” (MAD).  ALERC provides for but does not  identify euthanasia for incompetent patients, called here Euthanasia Below the Radar (EBTR).
ARELC’s definition of palliative care clearly distinguishes palliative care from MAD.  In defining MAD, the statute does not say “kill,”  but employs a euphemism: “hastening death.”  Nonetheless, it is obvious that ARELC authorizes a physician to kill patients.

The MAD guidelines for euthanasia restrict it to legally competent persons at least 18 years old who are insured under the provincial Health Insurance Act.  Beyond age, legal competence and residency/insurance, someone seeking euthanasia must be at “the end of life,” suffering from an incurable serious illness, in an advanced state of irreversible decline and suffering from constant and unbearable physical or psychological pain.  The patient need not be terminally ill and is free to refuse effective palliative treatments.

A qualifying patient must personally make a written request for MAD “in a free and informed manner.” It must be signed in the presence of professional, who must also sign the request. The attending physician must confirm the eligibility of the patient and the free and informed nature of the request. He must verify the persistence of suffering and a continuing desire for euthanasia, speak to other members of the health care team and see that the patient is able to discuss the decision with others. However, the physician cannot advise family members unless the patient so wishes. Thus, a physician may kill a patient without the knowledge of the family. Finally, the attending physician must obtain a written opinion of an independent physician confirming eligibility for euthanasia.

Only physicians may administer the lethal drugs or substances, and, having done so, must remain with a patient until he dies. Physicians who provide MAD must report the fact to institutional authorities or the College of Physicians, as well as the Commission on End-of-Life Care.

A central role in the provision of euthanasia is assigned to institutional councils of physicians, dentists and pharmacists (or, in their absence, institutional directors of care).  They are to adopt MAD guidelines, and then review reports from physicians who have provided the procedures to “assess the quality of the care provided.” The Collège des médecins is also to receive such reports from physicians and, apparently, to establish or at least recognize “clinical standards” relative to the procedures.

In addition to the MAD protocol, ARELC permits a substitute decision-maker to order that an incompetent patient be starved and dehydrated to death.  This provides an alternative form of euthanasia subject to none of the restrictions or conditions imposed by MAD guidelines: hence the term used here – “Euthanasia Below the Radar” (EBTR).  Since death by starvation and dehydration would be a painful process, it is likely that, in such circumstances, continous palliative sedation (CPS) would be used to anesthetize the patient. This may lead to the under-reporting of the actual number of euthanasia cases and further confusion about continuous palliative sedation.

Canadian criminal law is not affected by ARELCA physician who does what ARELC requires in the MAD protocol will have provided excellent evidence that the killing was intentional, planned and deliberate. Conforming to the Act Respecting End-of-Life Care would seem to increase the likelihood that a physician – and anyone counselling, aiding, abetting his act – could be charged and convicted for first degree murder, for which the punishment is life imprisonment without parole for 25 years. [Full Text]