Quebec Euthanasia Guidelines

Practice guide issued by Quebec health care profession regulators

Introduction

Sean Murphy*

Quebec’s Act Respecting End of Life Care (ARELC) was passed in June, 2014 and comes into effect in December, 2015.  When enacted, the  law purported to legalize euthanasia in the province, but its actual legal effect was questionable because Canadian provinces do not have jurisdiction over criminal law.  Only the Canadian federal government can make laws governing homicide and suicide.

However, in February, 2015, the Supreme Court of Canada released its decision in the case of Carter vs. Canada. The Court struck down the criminal prohibition of homicide and assisted suicide to the extent that it prevents the provision of physician assisted suicide and physician administered euthanasia for a certain class of patients.  The Court specified that the law cannot prevent the procedures for competent adults who are suffering intolerably as a result of a grievous and irremediable medical condition, which cannot be relieved by other means acceptable to the patient.  The declaration of invalidity was suspended for one year to allow the government time to revise the law.

The federal government under Conservative Prime Minister Stephen Harper took no action until mid-July, when it appointed a panel to study the issue and offer advice about legislative options.  The government was defeated in the federal election in October, and it remains unclear what direction the new Liberal government will take.

ARELC thus comes into force about two months before the Supreme Court ruling in Carter takes effect, while the criminal prohibition of euthanasia and assisted suicide is still in place.  However, the guidelines for euthanasia in ARELC are actually more restrictive than those proposed by the Supreme Court of Canada in Carter, so it seems doubtful that the federal government will challenge the Quebec law.

In August, 2015, the state regulators of the professions of medicine, pharmacy and nursing jointly issued an 88 page Medical Aid in Dying Practice Guide to direct the provision of euthanasia in Quebec.  The Guide appears to be available only in French, and is currently accessible only through a password protected portal on the Collège des médecins du Québec website, or by making an access to information request.  However, the Guide also states that it can be reproduced as long as the source is acknowledged.

What follows is a partial machine assisted English translation of the Guide set opposite the original French text.  For ease of reference, each translated segment is identified by a translation number (T#).  Only those parts of the Guide that appear to have some relevance to freedom of conscience are reproduced here.

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Redefining the Practice of Medicine- Euthanasia in Quebec, Part 9: Codes of Ethics and Killing

Abstract

Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators.  It is not clear that Quebec legislators or professional regulators understand this.

A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsehere. The President of the Collège was pleased that law will allow physicians to shift responsibilty for finding someone willing to kill a patient to a health system administrator, avoiding an anticipated problem caused by the requirement for referral in the Code of Ethics.  However, the law does not displace the demand for referral in the Code, and can be interpreted to support it.

The Collège des médecins Code of Ethics demand for referral conflicts with the generally accepted view of culpable indirect participation.  Despite this, it continues to be used as a paradigm by other  professions, notably pharmacy.  It is thus not surprising that the College of Pharmacists also anticipates difficulty over the issue of referral.  Like the Collège des médecins, the College of Pharmacists would like to avoid these problems by allowing an objecting pharmacist to shift responsibility for obtaining lethal drugs to a health systems administrator.

Nurses cannot be delegated the task of killing a patient, it is not unreasonable to believe that nurses may be asked to participate in euthanasia in other ways. Thus, there remain concerns about indirect but morally significant participation in killing.  Their Code of Ethics imposes a duty to ensure both continuity of care and “treatment,” which is to include euthanasia.  However, under ARELC, an objecting nurse is required to ensure only continuity of care.  This should not be interpreted to require nurses to participate in euthanasia, though they may be pressured to do so.

As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence.  It was a serious error to include this a requirement in code of ethics for Quebec physicians and pharmacists. The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.

A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins  is not only erroneous, but dangerous.  It establishes the priniciple that people can be compelled to do what they believe to be wrong – even gravely wrong – and punish them if they refuse.  It purports to entrench  a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.

Quebec’s medical establishment can correct the error by removing the mandatory referral provisions of their codes of ethics that nullify freedom of conscience.  This would prevent objecting physicians and pharmacists from being cited for professional misconduct for refusing to facilitate euthanasia or disciplined for refusing to facilitate other procedures to which they object for reasons of conscience, including contraception and abortion.  This would almost certainly antagonize consumers who have been conditioned to expect health care workers to set aside moral convictions.

It remains to be seen whether the Quebec medical establishment will maintain the erroneous provisions, preferring to force objecting health care workers to become parties to homicide rather than risk occasionally inconveniencing people, such as the young Ontario woman and her supporters who were outraged because she had to drive around the block to obtain The Pill. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 7: Refusing to Kill

Abstract

It is important identify problems that the Act poses for those who object to euthanasia for reasons of conscience, and to consider how objecting health care workers might avoid or respond to coercion by the government and the state medical and legal establishments.  The goal here is to ensure that conscientious objectors to euthanasia will be able to continue to work in health care without becoming complicit in what they consider to be wrongdoing.

Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection.  ARELC requires physicians who refuse to provide euthanasia for any reason other than non-eligibility to notify a designated adminstrator, who then becomes responsible for finding a MAD physician.  The idea is to have the institution or health care system completely relieve the physician of responsibility for facilitating the procedure.

It would be preferable to end the involvement of the objecting physician with refusal, accompanied by a suggestion that the patient will have to look for assistance from other sources.  This might be achieved if objecting physicians were to notify both executive directors and patients in advance that they will not provide or facilitate euthanasia.

A more sensitive problem attends the requirement that an objecting physician forward  a euthanasia request form to the designated administrator, since that is more clearly connected to the ulitmate killing of a patient.  Since the requirement to forward the request applies only if it has been given to the physician, this might be avoided if the objecting physician made his position clear in advance, and/or refused to accept such a request.  Such complications could avoided if administrators were to adopt a policy to the effect that a health care professional who witnesses and countersigns a euthanasia request to arrange for MAD services is responsible for arranging them.

The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others.  Other health care professionals may refuse to “take part” (participate) in killing a patient for reasons of conscience.  Physicians may refuse only “to administer” euthanasia – a very specific action –  which seems to suggest that they are expected to participate in other ways.

Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands, even if they do not object to the procedure. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, which exceeds what was recommended by the Select Committee on Dying with Dignity, and some physicians may be unwilling to provide euthanasia without it.

Finally, as long as euthanasia remains a criminal offence, physicians or other entities responsible for issuing or administering MAD guidelines may respond to requests for euthanasia precisely as they would respond to requests to become involved in first degree murder: with total refusal to co-operate.  Even a partial  and scattered response of this kind would likely be administratively troublesome.

Patients may lodge complaints against physicians who refuse to provide or facilitate euthanasia with institutions and the regulatory authority, regardless of the reasons for refusal. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 4: The Problem of Killing

Abstract

Impartiality, complicity and perversityThe original text of Bill 52 did not define “medical aid dying” (MAD), but it was understood that, whatever the law actually said, it was meant to authorize physicians to kill patients who met MAD guidelines.  The Minister of Health admitted that it qualifed as homicide, while others acknowledged that MAD meant intentionally causing the death of a person, and that its purpose was death.  Various witnesses in favour of the bill referred explicitly to lethal injection and the speed of the expected death of a patient.

Given the moral or ethical gravity involved in killing, it is not surprising to find serious disagreement about MAD among health care workers.  Conflicting claims made about the extent of opposition to or support for euthanasia within health care professions are difficult to evaluate, but a review of the transcripts of the legislative committee hearings into Bill 52 is instructive.

One physician member of the committee was shocked by the assertion that there is no  moral, ethical, or legal difference betwen withdrawing life support and lethally injecting a patient.  Hospices and palliative care physicians rejected participation in euthanasia.  Sharp differences of opinion among other health care workers were reported.  Support for killing patients by lethal injection was likened to support for the death penalty; that is, many more agreed with the act in principle than were willing to do the actual killing.  So marked was the evidence of opposition to euthanasia that doubts were raised about the possiblity of implementing the law.

Since the law was passed as a result of assurances from the Quebec medical establishment that it could be implemented, a committee member who is now a minister of the Quebec government warned that they would be called to account if it is found that few physicians are willing to participate.  This political pressure is likely to provide an additional incentive for the medical establishment to secure the compliance of Quebec physicians.

The introduction of euthanasia into Quebec’s health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, which have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners.  Physicians and other health care providers who object to euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on patient rights.

Everyone authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary and complaints procedure can be used to force participation in MAD services.  Those who openly advocate refusal to provide or facilitate euthanasia can be fined from $1,500.00 to $40,000.00 per day under Quebec’s  Professional Code if they are deemed to have helped, encouraged, advised or consented to a member of a profession violating the profession’s code of ethics. [Full Text]

Hearings on Quebec Bill 52: Quebec Order of Nurses

Lucie Tremblay, Claudia Gallant, Suzanne Durand, Sylvie Truchon

Tuesday, 8 October 2013 – Vol. 43 No. 44

Note: The following translation is the product of a first run through Google Translate.  In most cases it is sufficient to identify statements of interest, but more careful translation is required to properly understand the text.  Translation block numbers (T#) have been assigned by the Project as references to facilitate analysis and discussion.

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(Suspension de la séance à 16 h 3)
Le Président (M. Bergman) : …Alors, Mme Tremblay, la présidente-directrice générale, bienvenue encore. Et, s’il vous plaît, donnez-nous vos noms, vos titres. Et le temps est à vous. 001 The Chairman (Mr. Bergman) … So, Ms. Tremblay, President and CEO, welcome again. And, please, give us your name, your title. And time is yours.
Mme Tremblay (Lucie): Merci beaucoup, M. le Président. Je suis Lucie Tremblay, présidente-directrice générale de l’Ordre des infirmières et infirmiers du Québec. Je vous remercie, Mme la ministre, M. Mme les parlementaires. l’Ordre des infirmières et infirmiers du Québec vous remercie de lui permettre de présenter ses réflexions sur le projet de loi no. 52, concernant les soins de fin de vie. Ce projet de loi, c’est une étape importante pour assurer des soins de fin de vie appropriés et de qualité à tous les Québécois. 002 Mrs. Smith (Lucie): Thank you, Mr. President. I’m Lucie Tremblay, President and CEO of the College of Nurses of Quebec. Thank you, Madam Minister Ms. parliamentarians. College of Nurses of Quebec thank you for allowing him to present his thoughts on the Bill. 52 on the end-of-life. This bill is an important step to ensure appropriate end-of-life and quality of all Quebecers.
D’ailleurs, nous profitons de cette commission pour souligner la détermination de la ministre, dans ce dossier, qui est très sensible, mais pourtant c’est un dossier qui est essentiel à l’évolution de notre société. Aujourd’hui, je suis accompagnée, à l’extrême droite, de ma collègue Claudia Gallant, qui est vice-présidente du conseil d’administration; juste à ma droite, de Suzanne Durand, directrice du Développement et soutien professionnel, qui a coordonné d’ailleurs les travaux du mémoire; et de Mme Sylvie Truchon, qui est syndique. 003 Moreover, we take this board to emphasize the determination of the Minister, in this case, which is very sensitive, yet it is an issue that is critical to the evolution of our society. Today, I am accompanied, at the far right, my colleague Claudia Gallant, who is vice president of the board, just to my right, Suzanne Durand, director of professional development and support, which coordinated Moreover, the work of memory and Sylvie Truchon, which is unionized.
L’ordre appuie d’emblée le projet de loi no. 52, qui rejoint certaines des propositions que nous avions énoncées, dans notre mémoire présenté à la Commission spéciale sur la question de mourir dans la dignité, en 2010. L’ordre croit qu’au-delà de l’énoncé du projet de loi, il faut vraiment s’assurer d’une mise en oeuvre concrète et intégrée des soins de fin de vie axés sur les besoins des patients et de leur entourage. Nous profitons donc de l’occasion pour formuler des commentaires susceptibles d’améliorer le projet de loi. 004 The order immediately support the Bill. 52, who joined some of the proposals we set out in our submission to the Select Committee on Dying with dignity in 2010. The order believes that beyond the wording of the bill, you really make a practical implementation, integrated end-of-life focused on the needs of patients and their families. We take this opportunity to provide comments to improve the bill.

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