Ensuring access to euthanasia by encouraging physician participation: it’s complicated

Sean Murphy*

In July, 2017, Canadian euthanasia/assisted suicide (EAS) practitioners and advocates alleged that patient access to euthanasia and assisted suicide was in danger because of “barriers” and “disincentives” to physician participation. Dr. Stefanie Green, president of their professional association, described the situation as “a crisis.”1 There was, in fact, no crisis — only a false perception of crisis fuelled by unrealistic expectations about levels of physician participation in euthanasia and assisted suicide.2

Nonetheless, it is reasonable for policy makers to respond to their concerns that physicians are discouraged from participating in euthanasia and assisted suicide. Indeed, objecting physicians are less likely to experience disadvantage and coercion if policy-makers seriously consider suggestions by EAS practitioners and advocates about how to encourage physician participation in euthanasia.

Removing barriers and disincentives to physician participation

Minimizing procedural and administrative requirements
Returning to the complaints and concerns of Canadian euthanasia practitioners (see Canada’s Summer of Discontent2), reducing or streamlining procedural requirements and minimizing burdensome paperwork might encourage more physicians to participate. However, this raises a question that may prove difficult to answer. Is a procedural requirement a “barrier” — or a necessary safeguard? A “disincentive” — or an essential ethical prerequisite? The difficulty is illustrated by developments in Belgium. . . .[Full text]

Canada’s summer of discontent: euthanasia practitioners warn of nationwide “crisis”

Shortage of euthanasia practitioners “a real problem”

Sean Murphy*

There were 803 euthanasia/assisted suicide (EAS) deaths in Canada during the first six months after the procedures were legalized. In the second half of the first year (ending in June, 2017) there were 1,179 — a 46.8% increase, and about 0.9% of all deaths. Health Canada correctly states that the latter figure falls within the range found in other jurisdictions where euthanasia/assisted suicide are legal, but the Canadian EAS death rate in the first year was not reached by Belgium for seven to eight years. The dramatic increase of EAS deaths in the last half of the first year would have had a direct impact on EAS practitioners, and this may be why they ended the first year by sounding the alarm about access to the service. . . .[Full text]

Donald Trump’s new guidelines for protecting religious faith restore justice

Washington Times

Editorial

Not so long ago, President Trump’s new guidelines for the Department of Health and Human Services for protecting freedom of religious faith would have been superfluous and unnecessary. A casual observer might have read them in puzzlement, as if the government had reaffirmed its opposition to robbery or murder.

But all that was before the Obama administration sought to bring those of religious faith to heel, ordering employers to pay for contraception devices and abortion-inducing drugs, even if it violated the conscience of employers. Under pressure, the Obama administration grudgingly exempted churches from its mandate, but employers affiliated with religious groups still were required to pay through third-party administrators.

The new guidelines, drawn up by the U.S. Justice Department, change that. The order does not prohibit employers paying such benefits, and many employers will continue to do so. Nor will anyone be deprived by the government of their condoms, diaphragms and other birth-control devices. But “going forward,” as the cliche goes, an employer will not be required by the U.S. Government to violate his conscience for the convenience of those hostile to religious faith. . .[Full text]

California Hospital Sued for Refusing to Assist in Suicide

National Review

Wesley J. Smith

This lawsuit is a little before its time.

Should assisted suicide become widely accepted in this country, activists will try to force all doctors to participate–either by doing the deed or referring to a doctor known to be willing to lethally prescribe.

But it isn’t yet, and so the pretense of the movement that they only want an itsy-bitsy, teensy-weensy change in mores and law continues as SOP.

But sometimes they show their true intentions. Thus, when UCSF oncologists refused to assist a cancer patient’s suicide, the woman died of her disease. Now, her family is suing–using the same attorney (Kathryn Tucker) who tried (unsuccessfully) to obtain an assisted suicide Roe v Wade in 1997 and has brought other pro-assisted sucide cases around the country. . . [Full text]

Ontario Today: Should doctors be forced to refer?

CBC Radio

Outline of the programme

00:00 Introduction

03:00  Dr. Sephora Tang, psychiatrist (objecting physician).  Discussion points include potential problem of access to euthanasia/assisted suicide faced by frail and isolated patients, those in rural areas or  “negative elements” in families, central referral service alternative, issue of complicity, physician-patient relationship.

12:16  Caller Dr. Terry, primary care (objecting physician). Discussion points include erosion of medical ethics, erosion of trust in physician-patient relationship, relationship between law and ethics, distinction in skill sets needed for euthanasia/assisted suicide vs. abortion.

19:25  Interviewer outlines points in position of the Canadian Medical Association

20:19  Caller Vivi. Favours compulsory referral because access to euthanasia/assisted suicide should be considered from patient perspective, not doctor’s.

22:32  Dr. Sephora Tang responds to points made by caller.

24:14  Interviewer outlines policy on effective referral of College of Physicians & Surgeons of Ontario [There are two relevant documents: POHR and MAID; Administrator]

24:34  Caller Dr. Ramona Coelho (objecting physician). Explains why she will not make effective referral.

25:42  Caller Dr. David Roussell, President, College of Physicians & Surgeons of Ontario (CPSO).  Interviewer puts to him opposition to effective referral by the Canadian Medical Association, more liberal policies in other provinces.  Dr. Roussell discusses College policy requiring effective referral.  Asserts that the College is primarily concerned with access to euthanasia/assisted suicide etc. by patients who might have difficulty doing do if their physician does not assist.  Notes that both Nova Scotia and Quebec have similar requirements, so Ontario is not alone.  Notes that referral does not always result in procedure being obtained.  Characterizes objections to effective referral as oversensitive.  Acknowledges that loss of licence to practice is one possible outcome of complaint against a physician for refusing to refer.

35:12  Caller Dr. Christine (objecting physician).  Emphasizes central care coordinating system and self-referral by patients would be more efficient and avoid conflicts of conscience.

37:20  Caller Dr. Roussell agrees that central coordination system and self-referral is promising, but asserts that this can “fall apart” in some cases.

38:25 Caller David.  Opposed to compulsory referral.  Believes it is safer to ensure diversity of views in society, especially in life and death matters, by protecting freedom of conscience.

41:30  Interviewer asks Dr. Roussell to respond to concerns about freedom of conscience.

42:00  Caller Dr. Roussell notes “private beliefs, religious or otherwise, are not the purview, shouldn’t be the purview of the College or the government . . . What we’re talking about here is from the public’s point of view. There’s a legally available service to, in most people’s minds, alleviate suffering, which is what medicine is supposed to be about.  And the battle’s been fought, the war’s been won, the law has been passed.  Why are we throwing up obstacles to a legally accessible service?  Especially throwing up obstacles at the last moment to people who are in some sense suffering.”

43:04 Caller Joel (medical student).  Supports compulsory referral.  “Doctors in Canada should not be practising medicine in Canada if they feel that their moral code supersedes what is law.”  He adds, “It is great for doctors to unite and object on some things” and refers to the Alberta system (which has proved acceptable to objecting physicians).  He believes that effective referral for euthanasia or assisted suicide does not make a physician a “conduit of death,” but means that the patient can access a specialist with appropriate training.  He characterizes acceptance of conscientious objection as a “slippery slope.”

44:45  Caller Erica.  Supports compulsory referral.  Her mother (whom she identified as a Christian) was suffering from multiple sclerosis.  She was joyful when euthanasia was legalized [Criminal Code amendments given Royal Assent in June, 2016; Administrator].  She was not euthanized/assisted with suicide until the end of December, 2016 because her physician (whom Erica also identified as a Christian) refused, and refused to refer her. Erica stated that this “absolutely shattered her.  It took her days to pick herself up and decide she was going to keep trying to find somebody.” Asserts that denying such people access to a medical procedure is unfair.

46:31  Interviewer notes that less than 75 physicians in Ontario are actually providing euthanasia/assisted suicide. Erica explains that a doctor was found after a CBC interview made her situation public.

47:28  Dr. Sephora Tang responds.  Notes that patients want access, and she does not wish to impede.  The system set up by the government made it impossible for patients to access euthanasia/assisted suicide on their own. If society wants people to have access, there are alternative ways to ensure access that should be considered.

48:07  Interviewer asks about patients being fearful of the “judgement” of their physicians.

48:27  Dr. Sephora Tang emphasizes importance of trust in physician-patient relationship.   It is better for the patient to know where she stands on some issues, so there “no guessing around that.”  It is possible to agree to disagree.

49:16  Dr. Chantal (euthanasia/assisted suicide provider).  Supports compulsory referral, because “patients need access.”  Abortion clinics are not an appropriate comparison.  Referral must include all relevant medical information.  “No medical information is necessary for a physician to do an abortion,” but is needed prior to performing euthanasia/assisted suicide.  To expect patients to go to hospitals and doctors to gather all of the relevant medical information is “completely unreasonable.”  Patients would be “significantly compromised” if objecting physicians refused to provide the relevant information.

Postscript from Dr. Christine (Reproduced with permission)

Just because a physician may conscientiously object to formal participation by the administrative/legal/ethical agreement implied by a documentation-based referral (re: linking billing numbers between 2 practitioners for review +/- enactment of a desired procedure),this does NOT mean that an objecting physician would ever dare to obstruct the subsequently requested movement of health file information (which is first and foremost a property that emanates from the patient!) to the clinician to whom the patient wishes to receive lethal injections from. 

Furthermore:  If a patient seeks a care pathway that may end in MAiD, through a care coordination service in the ideal case, then there are administrative health professionals in all the offices who can and do link with each other to physically get the records moving. 

(Again, a physician is not the one pulling the files in a Norman Rockwell/1950’s-style office; we now have digital spigots to move information, and physicians are not required to unlock the content in our current collaborative environment of ConnectingOntario/PRO/OLIS).

 My original point in the call is that forcing a physician to fill out referrals (and limiting the power/responsibility to do this, to physicians) is ironically creating (rather than removing) a barrier to care. 

 (Incidentally – and not all people know this – it is also quite typical and not an exception for most referrals to come with inadequate background case information, even in non-controversial indications; doctors know how to probe for what’s missing [and often have to ask for information in several iterations and from multiple parties], and gaps from healthcare fragmentation are not so much a product of malfeasance as simply laziness…)

 

To dispense or not to dispense…

Eastern Daily Press

Nick Conrad

I was drawn to a news story which snuck under the radar this week. This issue is a classic ‘contract’ versus ‘conscience’ battle facing some pharmacists, which was brilliantly highlighted on the BBC Radio Norfolk Sunday Breakfast programme.

I pen this week’s article with genuine interest, a will to impartially provoke a healthy debate rather than trying to influence opinion. In a U-turn on proposed policy, Britain’s pharmacy regulator has declared that pharmacists should not be forced to dispense medicine and substances against their consciences. This includes drugs such as the morning-after pill or even contraceptives. The pharmacist can object if it goes against their religious beliefs, forcing the customer to go elsewhere. . . [Full text]

 

Abortion notice law clashes with free speech and right-of-conscience laws at suburban pregnancy centers

Chicago on the Radar

April Leachman

After the Supreme Court legalized abortion in Roe v. Wade in 1973, federal legislation was passed to represent the interests of doctors and other healthcare workers who have religious or moral objections to the controversial procedure.  These “right-of-conscience” laws  provide a measure of protection for medical personnel who do not want to perform abortions or offer abortion referrals.

In Illinois, all that changed on January 1 of this year, when  Governor Bruce Rauner’s amendment to the legislation officially took effect, requiring clinicians, regardless of their moral convictions, to inform pregnant women  about “all their options,” including abortion.

Healthcare entities must at least provide women with abortion referrals.   There seems to be some concern that patients are not being apprised of all the courses of action they can pursue when they find themselves in a crisis pregnancy.

Two Christian pregnancy centers– 1st Way Pregnancy Support Services (McHenry County) and Pregnancy Aid South Suburbs (Lansing)– and a physician who serves patients at various clinics, have since filed suit in opposition to the enactment.  Plaintiffs point out that the Illinois legislation is a clear violation of federal law.  Furthermore, it tramples on clinicians’ First Amendment Rights, requiring providers to inform patients about a procedure that they believe is morally wrong. . . [Full Text]

 

Freedom for conscientious objectors needs protection

Waterloo Region Record

Stephen Woodworth

Last week five doctors and several rights groups were in Ontario’s Divisional Court challenging rules imposed by the College of Physicians and Surgeons of Ontario to punish doctors who refuse to help arrange assisted suicide. The Court reserved its ruling, which will be released at a later date.

Ontario’s new assisted suicide law amended various Acts in response to the federal legislation on assisted suicide. Pleas to guarantee freedom of conscientious objection for doctors who defy orders to provide “effective referral” were ignored by the legislature, so penalties imposed by the College of Physicians and Surgeons of Ontario against conscientious objectors remain in force.

Remarkably, in just two short years Canadians have gone from punishing those who helped arrange assisted suicide to punishing those who refuse to arrange assisted suicide. . . [Full text]

 

Doctors who conscientiously object to providing euthanasia referrals should not be forced to do so

National Post

Barbara Kay

From June 12 to 15, the Ontario Superior Court of Justice heard legal arguments relating to conscience rights for doctors in Ontario. Five doctors and three physicians’ organizations want the court to declare portions of policies created by the College of Physicians and Surgeons of Ontario (CPSO) a violation of doctors’ rights enshrined in the Charter. A decision is expected later this year.

CPSO, the respondent in the case, has stated they may suspend or sanction a doctor that refuses to participate in an assisted suicide, which they — duplicitously in my opinion — call “medical aid in dying” (MAID). Euthanasiasts prefer the euphemism because “aid in dying” sounds softer and gentler than “kill.” But the true definition of MAID is palliative care, whose future as a medical discipline has been thrown into uncertainty by the CPSO’s bullish stance on assisted suicide.

The CPSO’s conscience-hostile position is both unnecessary and unjust. . .  [Full text]

 

Protecting The Right to Conscientious Objection

Reproduced with permission

Kelvin Goertzen, MLA

In 2015 the Supreme Court of Canada ruled that Canadians could access a medical assisted death with the help of a physician. As part of that decision, the Supreme Court tasked Parliament with developing the legislative framework by which the medical assisted death (otherwise known as MAID) could happen in Canada.

The decision has resulted in a number of different concerns regarding the right to conscientious objection for medical professionals and others. As Minister of Health for Manitoba over the past year, I have heard from many in the healthcare profession who are concerned that they may in the future be required to participate in a MAID procedure as a requirement of their occupation.

While the provincial governments have been mandated by the Supreme Court decision to ensure there is access to MAID, they also have a responsibility to ensure that those who are unable to participate in a medically assisted death due to their personal beliefs or values have protection.

That is why during this past session of the Manitoba Legislature, I introduced Bill 34 (currently in second reading) which is about providing protection to medical professionals and others who may not want to participate, for whatever reason, in a medical assisted death. There was no robust legislation in Manitoba or anywhere else that protected medical professionals so that they would not be required to act in a medical assisted death. Not just doctors, but nurses and other health professionals have asked for legislative means to ensure that this protection exists, not just for today but for the future as well.

The legislation would ensure that now and into the future, an individual could refuse to participate in a medically assisted death without any disciplinary or employment repercussions. It also prohibits a professional regulatory body from requiring its members to participate in a medically assisted death.

In Manitoba we have been a leader in ensuring that a balance is struck between meeting the legal responsibilities flowing from the Supreme Court of Canada and Parliament’s subsequent action and ensuring that medical professionals are able to also act in a way that is in keeping with their own personal convictions and the purpose for which they entered the medical field. The work of the individual professional colleges in Manitoba has been helpful to date in working to protect the rights of medical professionals and the legislation which I have introduced will help to support that work.

I look forward to this legislation being further considered in the fall session of the Manitoba Legislature and to ensuring that medical professionals have their conscientious rights protected.