Quebec opens door to expanding end-of-life law to Alzheimer’s disease

Montreal Gazette

Joceleyne Richer

A consensus is emerging among Quebec parliamentarians to launch a public debate on the appropriateness of legalizing medically assisted suicide for persons unable to give informed consent, such as patients suffering from Alzheimer’s disease.

Without making any commitment, Health Minister Gaétan Barrette opened the door on Thursday for a public debate after calls by the two main opposition parties, the Parti Québécois and the Coalition avenir Québec. . . [Full text]

 

Slaying of nursing-home patient renews questions about medical assistance in dying

Montreal Gazette

Aaron Derfel

The alleged murder of an ailing nursing-home patient by her spouse on Monday has renewed questions about Quebec’s law on medical assistance in dying, especially when it comes to those who might be suffering from dementia.

On Tuesday, Michel Cadotte was charged with second-degree murder in the death of Jocelyne Lizotte, a patient of the east-end Centre d’hébergement émilie-Gamelin. Lizotte was reportedly suffering from Alzheimer’s disease and was denied a request for assisted dying.

Under Quebec’s “end-of-life care” act, which came into effect on Dec. 10, 2015, a patient seeking medical assistance in dying must make the request “in a free and informed manner.” . . . [Full text]

 

Barrette chastises MUHC over policy not to provide medically assisted death

Montreal Gazette

Caroline Plante

QUEBEC — The McGill University Health Centre is being forced to backtrack on a policy that exempts its palliative care unit from helping patients die.

Health Minister Gaétan Barrette issued a strongly worded letter to the MUHC’s director general Wednesday, urging him to change the policy, which he says does not respect the law.

“To say that medical aid to die will not be offered in a particular unit … poses a serious problem when it comes to respecting patients’ lawful right to receive end-of-life care,” the minister wrote. . . [Full text]

“Now you want to crush every tiny focus of opposition”

Physicians’ Alliance Against Euthanasia Open letter to Mme Véronique Hivon

Note: Véronique Hivon, now a member of the Quebec National Assembly, was Minister of Health in the previous government and was responsible for bringing forward Quebec’s euthanasia law.

Mme Hivon:

You label as « ideology » the decision made by the McGill University Health Centre to not euthanize patients on the palliative care ward.

“The patients at the end of life are the ones who should have their rights respected and be at the centre of the organization of care”, you say. If that is what you really believe,

  • where were you when the number of palliative care beds at the MUHC was reduced for budgetary reasons?
  • When the specialized geriatrics unit was closed completely?
  • Why do you not speak out when patients are transferred all over the hospital and the city for trivial reasons, as is regularly done in Quebec?

What other than ideology could make you want to force hospitals, not only to kill patients, but to kill them in the one place where they most need to be protected?

Palliative care professionals are experts in easing the pain and suffering of terminally ill patients, accompanying them to the very end of their lives, with no need to kill them in order to do so. Now they are struggling, all over Quebec, to continue providing the same peace at the end of life in a situation where death is being promoted. Yes, promoted. This law was passed against the better judgment of those who know best how to care for the dying. Now you want to eliminate even the little safe space that is left for patients and professionals. All they ask for is one place in the hospital where there is no risk of being killed.

You got what you wanted when this law passed. Now you want to crush every tiny focus of opposition to your favourite project.

That is more than ideology. It’s intolerance, pure and simple.

We support the freedom of the palliative care professionals at the MUHC (and at every hospital) to ensure there are safe spaces for patients.

Yours truly,

[Original text and over sixty signatories]

 

MUHC to allow medically assisted dying in palliative care unit

Montreal Gazette

John Meagher

The McGill University Health Centre said Monday it will change its policy and allow medically assisted dying in its palliative care unit after coming under fire from Health Minister Gaétan Barrette last week.

The uproar came about after a patient at the Glen site had to be transferred out of the palliative care unit to receive medical aid in dying in April.

Barrette sent a letter to the MUHC’s director general last week, asking the hospital network to change its policy, because it does not respect the new law. . . [Full text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 5: An Obligation to Kill

Abstract

Statistics from jurisdictions where euthanasia and/or assisted suicide are legal suggest that the majority of physicians do not participate directly in the procedures.  Statistics in Oregon and Washington state indicate that the proportion of licensed physicians directly involved in assisted suicide is extremely small.  At most, 2.31% of all Belgian physicians were directly involved in reported euthanasia cases, and the actual number could be much lower.  A maximum of 9% to 12% of all Dutch physicians have been directly involved, most of them general practitioners.  The current situation in Belgium and the Netherlands suggests that, for some time to come, a substantial majority of Quebec physicians will probably not lethally inject patients or provide second opinions supporting the practice.

It is anticipated that between 150 and 600 patients will be killed annually in Quebec by lethal injection or otherwise under the MAD protocol authorized by ARELC.  While these estimates amount to only a small percentage of the deaths in the province each year, and while Quebec has about 8,000 physicians in general practice, there is concern that only a minority of physicians will be willing to provide euthanasia, and it may be difficult to implement ARELC.

The reason for the concern appears to be that ARELC purports to establish MAD as a legal “right” that can be exercised and enforced anywhere in the province, but physicians willing to provide the service are unlikely to be found everywhere.  As a result, in some areas, if no physicians are willing to provide MAD services, patients wanting euthanasia may be unable to exercise the “right” guaranteed by the statute.

Rather than deny either patients’ access to euthanasia or physicians’ freedom of conscience, several mechanisms have been proposed to accommodate both.  Delegation is not permitted by law, and transfer of patients will not normally be feasible.  However, workable alternatives include the advance identification of willing physicians in each region, the use of electronic communcation services to permit remote consultation and the establishment of mobile “flying squads” of euthanatists to provide services not otherwise available in some parts of the province.

Euthanasia proponents deny that they intend to force physicians to personally kill patients, but the exercise of freedom of conscience by objecting physicians who refuse to kill patients can lead to unjust discrimination against them.  Discriminatory screening of physicians unwilling to kill patients can be effected by denying them employment in their specialties and denying them hospital privileges.  By such strategies one can truthfully affirm that physicians are not actually being forced to kill, although those unwilling to do so may be forced to change specialties, leave the profession or emigrate. [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]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 3: Evolution or Slippery Slope?

Abstract

Euthanasia laws frequently include guidelines and safeguards intended to prevent abuse.  Eligibility criteria are the most basic guidelines or safeguards.  In considering their stability, it is important to consider not only the elasticity of existing statutory provisions, but recommendations for expansion that might ultimately result in changes to the law.
ARELC’s requirement for legal competence can be sidestepped through the provision allowing substitute decision makers to order the starvation and dehydration of legally incompetent patients (Euthanasia Beneath the Radar- EBTR).  Beyond this, there are strong indications that the reach of the law will be expanded to include legally incompetent patients.

The Quebec Commission on Human Rights and Youth Rights has indicated that it would consider refusal of euthanasia to the legally incompetent, uninsured persons or minors, including children, to be unlawful discrimination

No agreement was reached during legislative hearings about when a patient is “at the end of life,” so this added criterion provides only an opportunity for disagreement and judicial interpretation.

A “serious and incurable illness” could conceivably include clinical depression, which could cause “unbearable psychological pain” that cannot be relieved because the patient finds the side-effects of anti-depressants intolerable.  Such a patient qualify for euthanasia, and the Quebec Ombudsman recommended that the possibilty of euthanasia for the mentally ill be seriously studied.

Expanding the law’s reach in these directions is supported by a number of powerful and influential organizations in Quebec; a number of them recommended an incremental approach to accomplish this.

For these reasons, it is reasonable to believe that ARELC’s criteria for euthanasia will be broadened by interpretation, by statutory amendments and by court rulings, so that, as time goes on, there will be more euthanasia, not less.  Depending upon one’s moral  or ethical perspective, this can be described as a slippery slope, a process of natural evolution (for better or worse) or progressive democracy in action.

It is not necessary here to determine which of these conflicting perspectives is the most accurate.  It is sufficient to observe that the expansion of the eligibility criteria for euthanasia can be safely predicted.  This is relevant to concerns about freedom of conscience because increasing the range of circumstances under which euthanasia can be provided increases the likelihood of conflicts of conscience and conscientious objection. [Full Text]