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VIII.    STRATEGY AND TACTICS

VIII.1    Strategy for change

VIII.3.1    The core element of the foundational statement is a passage very similar to a 2014 CMA Board of Directors' resolution (VI.4.3).  The resolution was introduced as a neutral statement that left CMA policy against euthanasia untouched; CMA officials minimized its significance.  Only later did the CMA president admit that approval of the resolution was a "sea change." The Board used the resolution as the basis for reversing CMA policy and approving euthanasia and assisted suicide as end of life care (B5, B6, B7, B9).

VIII.3.2    It appears that a very similar strategy is being followed by the CMA and RDMA at the World Medical Association. The C/RDMA proposal appears to be a Trojan horse intended to reverse WMA policy and secure its support for euthanasia and assisted suicide, notwithstanding its claim  that "[t]he WMA does not support or sanction" the procedures (VII.2). 

VIII.3.3    In 2014 the CMA Board of Directors knew that the overwhelming majority of Canadian physicians would refuse to participate in euthanasia or assisted suicide, just as the WMA knows that most of the world's physicians will refuse.  The fundamental conflict presented by imposing an obligation to kill upon unwilling physicians was foreseeable and was foreseen by CMA officials, just as it can be foreseen now. Attacks upon physician freedom of conscience, particularly with respect to referral, were predictable; they are now occurring in Canada and demonstrated by the RDMA policy on referral (VII.4.11).1

VIII.3.4    Nonetheless, the CMA Board failed to consider physician freedom of conscience in relation to assisted suicide and euthanasia except the extent that it could be used to further its policy goals. As a result, after the Carter ruling, CMA officials were quite unprepared to mount a cogent, articulate and persuasive defence of physician freedom of conscience, especially in relation to referral. They discovered that state authorities and the public were often unreceptive and even hostile to physicians unwilling to arrange for patients to be killed by someone else.  The WMA and national medical associations that follow the CMA's lead will most probably find themselves in the same position.1

VIII.1.5    The risk now is that the WMA or national medical associations might follow the CMA's lead by precipitously approving the C/RDMA proposal or some similar policy document without adequately considering the consequences, with the same unfortunate results.

VIII.2    Tactics

VIII.2.1    Incrementalism

VIII.2.1.1    CMA/RDMA strategy includes a number of commonly encountered tactics: working out of the public eye,2 manipulation of consultation processes,3 discounting adverse majorities,4 emphasis on the ideal or exceptional5,6,while minimizing or excluding reference to troubling cases,7,8 and omission of relevant information.9,10,11,12,13

VIII.2.1.2    In addition, almost from the first, the CMA and RDMA have been careful to advance incrementally in attempting to change WMA policy. This warrants close attention because the significance of a current proposal is likely to be missed if preceding statements and proposals are not considered.

VIII.2.1.3     C/RDMA policy development demonstrates incrementally significant progressions from suicide to euthanasia, from non-support of physician participation in euthanasia and assisted suicide to a recommendation that they perform the procedures, and the transformation of euthanasia and assisted suicide from treatments of last resort to ordinary treatment options.

VIII.2.2    From suicide to euthanasia

VIII.2.2.1    At the time of the consultation request, both euthanasia and assisted suicide were legal in the Netherlands and supported by the RDMA, and both had been approved by the CMA and authorized by the Supreme Court of Canada. However, while the RDMA recommended major revisions of both policies in their response to the Secretariat request , the CMA recommended a "more nuanced approach" only to assisted suicide, recommending no change to the euthanasia policy (II.1.2). 

VIII.2.2.2    By the time of the Council meeting in April, 2015, it appears that the CMA and RDMA had agreed to work together and adopt the incremental approach indicated in the CMA’s consultation response. Thus, when the RDMA representative introduced the subject at the Council meeting, he did not raise it in relation to euthanasia policy (which was also on the agenda) but confined his attention to assisted suicide (II.1.5).

VIII.2.2.3    Restricting the presentation to suicide made good sense. A 2014 CMA poll had indicated that more physicians (27%) were willing to participate in assisted suicide than in euthanasia (20%).14 By the April meeting in Oslo, Dr. Blackmer realized that physicians were "profoundly more uneasy" about euthanasia than assisted suicide.15

VIII.2.2.4    Given the higher physician discomfort known to be associated with direct lethal infusion of patients, the CMA and RDMA were prudent to begin with assisted suicide, something known to be less distressing to practitioners.  Moreover, speaking of assisted suicide, the RDMA representative was able to offer further comfort to the uneasy: that, where physician assisted suicide is allowed, "very few people make use of the option." (II.1.5) He could well have been referring to the Netherlands, where assisted suicide is legal, and very few people do, in fact, make use of the option.  What he left out was that very few in the Netherlands opt for assisted suicide because virtually all opt for euthanasia (over 96% in 2016).16  The same pattern is evident in Canada.17

VIII.2.2.5    Similarly, Professor Urban Wiesing, speaking two years later at the European regional meeting at the Vatican, claimed that many patients approved for assisted suicide - up to 80% - do not actually go on to commit suicide.18   This is questionable. While it is true that some patients prescribed lethal medication do not actually commit suicide, 80% seems either highly selective or grossly inaccurate.19 Euthanasia is different; in Quebec, for example, only 5% to 6% of patients approved for euthanasia in 2016 and 2017 later withdrew their requests.20

VIII.2.2.6    The CMA and RDMA began by pressing for a review of the policy on assisted suicide, but when they submitted their first proposal in 2016 it proposed changes to both euthanasia and assisted suicide policies. There is no record of their explanation for the change, but it is not surprising.

VIII.2.2.7   The trial court decision in Carter v Canada (Attorney General)19 21 demonstrates that accepting assisted suicide provides the basis for accepting euthanasia.  Beginning with the premise that suicide can be a rational, moral and beneficial act, the judge found that assisted suicide in such cases would also be rational, moral and beneficial.  If the person seeking suicide in such circumstances is unable to perform the lethal act even with assistance, euthanasia in response to a request from that person would seem to be moral.  Thus, beginning with the premise that suicide can be moral and beneficial, the judge concluded that assisted suicide and euthanasia can be moral and beneficial.22 Further, it is likely that euthanasia will be wanted at least as a backup for failed assisted suicide, just as abortion is wanted as a backup for failed contraception; this is reflected in professional guidelines in the Netherlands.23

VIII.2.2.8    This reasoning is evident in the approach of one of Canada’s most active EAS practitioners. In 2016 she predicted that the EAS death rate in Canada would be closer to that of the Netherlands than Oregon because both euthanasia and assisted suicide are permitted in Canada. Her explanation was that the availability of euthanasia makes it possible for patients to avoid "cruel choices" forced upon them in assisted-suicide only regimes, where they must commit suicide sooner rather than later, before they lose the ability to self-administer lethal medication.24

VIII.2.3    From "The WMA does not support" to physicians should perform

VIII.2.3.1    The 2016 disclaimer "The WMA does not support euthanasia or physician assisted suicide" was somewhat broadened and softened in 2018 to "The WMA does not support or sanction physician assisted death." (Emphasis added)

VIII.2.3.2    However, a new paragraph added to the 2018 proposal would have the WMA affirm, that euthanasia and physician assisted suicide should be performed by competent physicians or health care providers where the procedures are legal.

VIII.2.4    From "last resort" to optional treatment

VIII.2.4.1    The 2016 proposal stated that euthanasia and assisted suicide "should be seen as a last resort for those whose intractable and hopeless suffering cannot be alleviated through any other ordinary means." This restriction has been dropped in the 2018 proposal.

VIII.2.4.2    Had the WMA approved the 2016 proposal it would have included this restrictive cautionary note. If it accepts the 2018 proposal its affirmation will be unrestricted, effectively authorizing euthanasia and assisted suicide as optional treatments where palliative care is available, and as acceptable treatments when it is not (VII.3.3). In either case, comparing the 2016 and 2018 proposals demonstrates that, over the course of two years, euthanasia and assisted suicide have been transformed from interventions of last resort to ordinary medical treatments.

VIII.3    The need for due diligence

VIII.3.1    The WMA has been warned that it will "lose credibility, become "irrelevant" or lose valuable members if its policies are not progressive (II.1.7, II.1.15), apparently to inculcate fear and a sense of urgency sufficient to accomplish a rapid change of policy.

VIII.3.2    The exercise of due diligence by those considering changes in WMA or national association policy requires that they make themselves aware of the strategy and tactics used to shape debate and decision-making, especially tactics that discourage adequate reflection and foresight.

VIII.3.3     On this point, the Project agrees that the WMA and its constituent members can learn something from the CMA's approach to shaping the debate and law on euthanasia and assisted suicide. In reversing its policy against euthanasia and assisted suicide, the CMA acted precipitously and without adequate reflection or foresight, apparently to meet a deadline imposed by a pending Supreme Court decision (B2.6). This has had serious adverse consequences for objecting physicians in Canada.1 Regardless what the WMA ultimately decides, it should not follow the CMA example in this respect. 

Notes

1.    Murphy S.  Canadian Medical Association and euthanasia and assisted suicide in Canada: Critical review of CMA approach to changes in policy and law [Internet]. Protection of Conscience Project; 2018 Sep 26 [Cited 2018 Sep 29].

2.    WMA policy development occurs largely out of the public eye, and only WMA constituent and associate members have access to relevant documents.  While this is neither unusual nor improper, it is especially advantageous to those controlling the information because they can, by limiting what they disclose, avoid awkward questions and minimize or prevent opposition to their initiatives arising within their own organizations or the public. For example, it is highly unlikely that most CMA members are aware that, on their behalf, their executive implied that the CMA might withdraw from the WMA if it continued to resist changes to its policies on euthanasia and assisted suicide (II.1.16).

3.    Only three of 111 constituent WMA members expressed dissatisfaction with the assisted suicide and euthanasia policies. Dr. Blackmer argued that this was sufficient to warrant a review of the policy on euthanasia and assisted suicide because only 16 national medical associations had replied, some of the members of the Medical Ethics Committee who approved it might have been unduly influenced by the Secretariat, and decisions had sometimes been modified following discussion. Had the majority of the 16 respondents indicated dissatisfaction with the policy or had the Medical Ethics Committee been significantly divided on the issue, the argument might have had some force. As it was, to arbitrarily approve policy reviews based on such speculative claims would make a mockery of any systematic consultation process and enable manipulation of policy-making by the powerful or well-placed. The majority quite properly rejected the argument, eliciting a protest from the CMA (II.1.11, II.1.12, II.1.14).

4.    During its member consultation in 2014, the CMA leadership acknowledged but discounted the fact that the great majority of Canadian physicians was opposed to changing CMA policy against assisted suicide and euthanasia and continued to work toward changing it (B2.4-5; B5.6-7). Similarly, efforts continue to change WMA policy despite strong opposition from the majority of WMA constituent members (III.1.2), and reference to the majority view has been miminized in the revised proposal (VI.3.4.3).

5.    The RDMA bioethicists writing in the World Medical Journal stressed that euthanasia in the Netherlands is allowed only "in the case of unbearable suffering without any prospect of improvement and when there is no reasonable alternative." de Jong A, van Dijt G. Euthanasia in the Netherlands: balancing autonomy and compassion. World Medical J [Internet]. 2017 Oct [Cited 2018 Sep 29]; 63(3)10-15 [de Jong-van Digt].

6.    Similarly, Dr. Blackmer describes the services as "providing assisted dying for consenting adults at the end of their lives who are suffering intolerably." Blackmer J.  Letter from Dr. Jeff Blackmer, Vice President, Medical Professionalism, Canadian Medical Association, to Physicians' Alliance Against Euthanasia [Internet]. Collectif des Médecins Contre L'Euthanasie; 2018 Apr 30 [Cited 2018 Sep28].

7.    The RDMA bioethicists mentioned cases of euthanasia for  patients who "cannot communicate adequately" but minimize them as rare and "highly controversial." de Jong-van Digt at p. 13. They did not refer to euthanasia provided to Dutch couples who want to die together, nor to the Belgian twins who were lethally injected because they were going blind.  See Waterfield B. Euthanasia twins 'had nothing to live for.'  The Telegraph [Internet] 2013 Jan 14 [Cited 2018 Sep 28]; Cook M. Dutch couple choose euthanasia together. [Internet]. BioEdge; 2017 Aug 19 [Cited 2018 Sep 28].

8.    Dr. Blackmer did not raise the case of an elderly couple, who, like the Dutch, were lethally injected so they could die at the same time. Grant K. Medically assisted death allows couple married almost 73 years to die together.  The Globe and Mail [Internet]. 2018 Apr 1 [Cited 2018 Sep 28].

9.    The RDMA bioethicists did not acknowledge increasing pressure in the Netherlands to broaden the criteria for euthanasia based on a widespread belief that people have a right to it (IV.3.5), a point relevant to their assertion that there is no need to be concerned about a "slippery slope" if euthanasia is legalized.  They did not disclose that the RDMA demands that objecting physicians facilitate euthanasia by referring patients to non-objecting colleagues(IV.3.6-7), a position that contradicts the CMA/RDMA proposal (VII.4.3.4).

10.    In his World Medical Journal article, Dr. Blackmer did not disclose that the CMA told the Supreme Court of Canada that it seemed wrong to deny assisted suicide and euthanasia to "grievously ill" (not terminally ill) patients simply because palliative care is unavailable, or that the CMA Board of Directors had reversed Association policy and approved euthanasia and assisted suicide before the ruling. Nor did he disclose problems caused for objecting physicians as a result of the CMA change of policy and legalization of the procedures (IV.3.18, B8.6, B10.5-9, B10.19).

11.    Dr. Blackmer did not mention that some Quebec emergency physicians were, for a time, failing to treat suicide victims.  See Hamilton G. Some Quebec doctors let suicide victims die though treatment was available: college. National Post [Internet]. 2016 Mar 17 [Cited 2018 Sep 29].  

12.    Dr. Blackmer did not disclose concerns that people in Quebec were choosing euthanasia because palliative care was unavailable.  See Lack of palliative care pushing Quebecers toward medically assisted death, College of Physicians says. CBC News [Internet]. 2018 May 31 [Cited 2018 Sep 29].  

13.    Nor did Dr. Blackmer note that the pressure for euthanasia was alarming even euthanasia supporters.  See Robert Y. Vers la mort à la carte? Collège des Médecins du Québec [Internet]. 2017 May 10 [Cited 2018 Sep 29]. English translation Towards death à la carte? Physicians' Alliance against Euthanasia [Internet]. 2017 Jun 12 [Cited 2018 Sep 29].

14.    In a 2014 poll of 5,000 CMA members, 27% of physicians surveyed said they were willing to participate in assisted suicide, while 20% were willing to participate in euthanasia. Moore E. Doctor is hoping feds will guide on assisted suicide legislation. Moore E. Doctor is hoping feds will guide on assisted suicide legislation. Edson Leader [Internet]. 2015 Feb 12 [Cited 2015 Jul 16].

15.    Kirkey S. How far should a doctor go? MDs say they 'need clarity' on Supreme Court's assisted suicide ruling. National Post [Internet]. 2015 Feb 23 [Cited 2018 Sep 29].

16.    Regional Euthanasia Review Committees. Annual Report 2016 [Internet]. 2017 Apr [Cited 2018 Sep 29] p. 11.

17.    Health Canada. 2nd Interim Report on Medical Assistance in Dying in Canada [Internet]. 2017 Oct p. 6 [Cited 2018 Sep 29] Table 2. 

18.    Wiesing U.  Is there a right to determine one's own death? The ethical perspective(s). Paper presented at: WMA European Region Meeting on End of life Questions. 2017 Nov 16-17; Vatican [Internet]. [Cited 2018 Sep 28].

19.    For example, returns in Oregon from 1998 to 2016 recorded 12 of 19 years in which persons prescribed lethal medication were known to still be alive.  The size of this group fluctuated widely from a low of about 6% (1999) to a high of about 26% (2005).  From 2010 to 2016, none were known to be alive, but the status (living or dead) of 14% to 22% was simply unknown.  Murphy S. Assisted suicide reported in Oregon, USA: statistics compiled from the Oregon Public Health Division Annual Death Dignity Act Reports [Internet]. Protection of Conscience Project; 2017 Aug [Cited 2018 Sep 29].

20.    Murphy S. Euthanasia reported in Quebec: statistics compiled from the Rapports aux directeur général au Conseil d'administration de l'établissement et à la Commission sur les soins de fin de vie (10 December, 2015 to 10 December, 2018) [Internet]. Protection of Conscience Project; 2018 Apr 3 [Cited 2018 Sep 29].

21.    Carter v. Canada (Attorney General), 2012 BCSC 886 (CanLII) [Internet] [Cited 2018 Sep 29].

22.    Murphy S. Legalization of Assisted Suicide and Euthanasia: Foundational Issues and Implications.  Brigham Young University J Pub Law  [Internet] 2017 Apr 01 [Cited 2018 Sep 29]; 31(2):333-394 at 361-365.

23.    If death does not occur within an agreed-upon time (a maximum of two hours), Dutch  physicians are to provide a lethal infusion. Royal Dutch Medical Association [Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG)]. The Role of the Physician in the Voluntary Termination of Life [Internet]. Utrecht, Netherlands:KNMG; 2011 Jun 23 [Cited 2018 Sep 29] [RDMA-Role of the Physician] p. 17-18.

24.    BC Pharmacy Association Webinar. Physician Assisted Dying How pharmacists & physicians can work together. Speaker: Dr. Ellen Wiebe. Thursday, March 10, 2016 6:00 PM - 7:00 PM Pacific Time.