L’euthanasie au Canada: une mise en garde

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français

Euthanasia in Canada: a Cautionary Tale

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

We are Canadian physicians who are dismayed and concerned by the impact  – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public  – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . . Continue reading in the World Medical Journal | Français

Canadian Medical Association and euthanasia and assisted suicide in Canada

Critical review of CMA approach to changes in policy and law

Sean Murphy*

Abstract

English | Français | Español | Deutsche | Português | bahasa Indonesia


In December, 2013, the Canadian Medical Association (CMA) Board of Directors decided to shape the debate and law concerning euthanasia and assisted suicide and revisit CMA policy opposing physician participation in the procedures. By the summer of 2014 it was clear that the overwhelming majority of physicians supported the existing policy. However, it appears that the Board decided the policy should be changed before the Supreme Court of Canada decided the case of Carter v. Canada.

The Board sponsored an ostensibly neutral resolution affirming support for the right of physicians to follow their conscience in deciding whether or not to provide euthanasia/assisted suicide if the law changed. The resolution was overwhelmingly approved. Unnoticed at the time was that the resolution was not conditional upon eligibility criteria, such as decision-making capacity or terminal illness.

The CMA intervention at the Supreme Court of Canada in the Carter case emphasized that existing CMA policy against euthanasia and assisted suicide would be changed to reflect the resolution. It conveyed the message that the Association would support physicians who decided to participate in euthanasia or assisted suicide no matter how broadly the Court or legislatures might cast the rules governing the procedures.

The Board reversed CMA policy about two months before the Court ruled. It formally approved physician assisted suicide and euthanasia, subject only to legal constraints. The policy did not exclude minors, the incompetent or the mentally ill, nor did it limit euthanasia and assisted suicide to the terminally ill or those with uncontrollable pain. It classified both as “end of life care,” promising support for patient access to the procedures should they be legalized. Support for physicians refusing to participate in euthanasia or assisted suicide was qualified by the statement that there should be no “undue delay” in providing them. Implicit in all of this was a new ethical paradigm: that in some circumstances, physicians have a professional obligation to kill patients or to help them kill themselves.

The new policy effectively wrote a blank cheque for the Supreme Court of Canada to legalize euthanasia and physician assisted suicide on any terms acceptable to the judges. After the Court struck down the law CMA officials expressed concern about the criteria set by the Court. It was implied that the Supreme Court was to blame for anxiety and profound discomfort among Canadian physicians because it had imposed upon them an obligation to kill, contrary to centuries of medical ethics and practice.

However, the concerns voiced by CMA officials after the Carter ruling existed when the CMA intervened in the case, and the CMA did not raise them then. In fact, the Supreme Court gave legal effect to a policy the CMA had already adopted, and the criteria the Court set for the procedures were actually more restrictive than anything the CMA had proposed. The Court cannot be blamed because CMA leaders were ill-prepared to deal with the consequences of a ruling entirely consistent with their own policy.

The consequences fell most heavily upon physicians who refused, for reasons of conscience, to provide euthanasia and assisted suicide or to collaborate in providing the services by referral or other means. Since Carter, the debate in Canada has been largely about whether or under what circumstances physicians and institutions should be allowed to refuse to provide or facilitate the services. While it is generally agreed that physicians should not be compelled to personally provide them, there are strident demands that physicians unwilling to kill their patients or help them commit suicide should be forced to refer patients to someone who will.

This review demonstrates that the CMA Board of Directors focus in 2014 was on the role physicians would play in providing euthanasia and assisted suicide should the law change. The Board knew that the overwhelming majority of Canadian physicians would refuse to participate in euthanasia or assisted suicide. The fundamental conflict presented by imposing an obligation to kill upon unwilling physicians was foreseeable and had been foreseen by CMA officials. Attacks upon physician freedom of conscience, particularly with respect to referral, were predictable.

However, the 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. Negotiating at a significant disadvantage of their own making, they were desperate to find a policy “acceptable to the regulators” and to objecting physicians whose fundamental freedoms they had rashly jeopardized.

The CMA has since produced a strong defence of physician freedom of conscience in relation to referral for euthanasia and assisted suicide, and sound protection of conscience provisions have been incorporated into a revised CMA policy on the procedures. However, by the time these statements appeared, objecting physicians were on the defensive in a treacherous and even hostile environment, compelled to launch an expensive constitutional challenge to defend fundamental freedoms of conscience and religion. The outcome of that case will determine if they will be able to continue to practise medicine if they refuse to collaborate in killing their patients.

The World Medical Association (WMA) national medical associations are free to decide to change their policies on physician participation in euthanasia or assisted suicide. This review demonstrates that they should not follow the example of the Canadian Medical Association if they wish to safeguard the fundamental freedoms of physicians and health care workers. [Full Text]

New euthanasia/assisted suicide law in Australia

Victoria’s Voluntary Assisted Dying Act 2017

Sean Murphy*

Introduction
On 19 April, 2018, the legislature of the State of Victoria, Australia, passed the Voluntary Assisted Dying Act 2017, which will come into force in June, 2019.  It is currently the most restrictive euthanasia/assisted suicide (EAS) legislation in the world, running to 130 pages.  In brief, the law authorizes physician assisted suicide for terminally ill adults, but permits euthanasia by physicians only when patients are physically unable to self-administer a lethal drug.  In both cases a permit must be obtained in advance.  The main elements of the law are set out below, followed by consideration of its protection of conscience provisions. . .  [Full Text]

Why I will be a conscientious objector to Victoria’s assisted dying law

A palliative care specialist laments the unrealistic individualism and elitism of the euthanasia movement

MercatorNet

Adrian Dabscheck

During a recent period of enforced rest, I had time to reflect on my attitude to the recently enacted voluntary assisted dying legislation in Victoria and consider my response.1 I will detail my reaction to the Act and why I have chosen to become a so-called conscientious objector.

In his essay Western Attitudes Toward Death,2 French historian Philippe Ariès illustrates the evolution of our attitudes to death.

Initially, and for millennia, there had been a general resignation to the destiny of our species for which he used the phrase, Et moriemur, and we shall all die. This was replaced in the 12th Century by the more modern concept of the importance of one’s self, and he used the phrase, la mort de soi, one’s own death.

Ariès then notes that in the 18th Century man gave death a dramatic and disquieting meaning. Man became concerned with the death of the other person, la mort de toi. Death was no longer familiar, nor were the dead. The dead had been torn from life; death had become an important event. By the 19th Century mourning had become difficult and thy death, la mort de toi, is more feared than la mort de soi, one’s own death.

Following this slow evolution in Western attitudes towards death, from being ubiquitous and familiar, with industrialisation, came the concept of the forbidden and shameful death. Life was now meant to be happy and this happiness was interrupted by the emotional disturbance of death and dying. Death was not spoken of, as illustrated by Tolstoy in “The Death of Ivan Ilyich”.3 Death was moved from home to hospital, from the care of one’s family to the sanitised, technical care whereby it is difficult to tell when the dying process actually began due to the interference of modern medicine. Death became part of the medical industrial-movement.

In a 2013 article reviewing the situation in Flanders where euthanasia is embedded in palliative care,4 it was noted:

Healthcare professionals note that family members and proxies tend, much more than before, to consider the dying process as undignified, useless and meaningless, even if it happens peacefully, comfortably and with professional support. Requests made by family members for fast and active interventions from healthcare professionals regarding elderly parents are often very coercive, with little nuance or subtlety. End-of-life interventions such as euthanasia are seen as an instrument to end a process of disease (or old age) that is demanding and difficult to bear, instead of letting it follow its course.’

We could not be further removed from Ariès’ phrase, Et moriemur, and we shall all die. Happiness is now the ultimate goal; we can no longer accept the place of death in our life. Ariès wrote in L’Homme devant la mort:5 “Death must simply become the discreet but dignified exit of a peaceful person from a helpful society. A death without pain or suffering, and ultimately without fear.” Thus the idealised ‘good death’.

Unfortunately, for most, society is unable to achieve such utopian goals, hence the need for the modern palliative care movement. As David Roy noted in the third edition of the Oxford Textbook of Palliative Medicine,6 it is up to society to allow the palliative care movement to flourish, to remove barriers to care, to develop the broad tapestry of interconnected people, resources, services and institutions to care for those who suffer in the face of death.

For this to be successful there must be an effective ethic of care. An ethic that allows relationships to flourish, an ethic that acknowledges the vulnerability of people and views autonomy from a relational rather than an atomistic perspective. Autonomy is a product of our personhood, our development of interests and values gained by interactions with others. None of us can make decisions which are free from influence. Our decisions relating to ourselves are made in the context of relationships. We commence our life completely dependent on others to sustain us. We depend on the non-judgemental love of others to care for us, to allow us to become independent, to become autonomous in the context of family, friends and society.

I continually ask myself, how have we allowed our ethical boundaries to move to such a degree that a law allowing doctors to take life as a way of relieving suffering has been passed by our state legislature? How have we allowed our view of the individual to become so individualistic and self-gratifying, so removed from an acknowledgement of our dependence on others, so self-centred or dare I say narcissistic?

Perhaps we can learn for the world of art and aesthetics. Hans van Meegeren was an accomplished forger of Vermeer, such that Vermeer experts accepted as originals what are obvious from our current perspective as forgeries. David Roy asks:6 “What process was at work that could so distort the faculties of aesthetic perception and poor judgement? It was a process of incremental adaption to incrementally poor forgeries.”

The Netherlands introduced the Termination of Life on Request and Assisted Suicide (Review Procedures) Act in 2001. In 2005, of all deaths, 0.4 percent were the result of the ending of life without an explicit request by the patient.7 In 2013 euthanasia was performed for 97 patients with dementia and 42 patients with psychiatric diseases (percentages not reported).8 Have ethical perceptions been distorted such that incremental creep allowed this to happen, as it did with aesthetics and van Meegeren?

In an article published in May 2017 in the New England Journal of Medicine discussing the experience of the University Health Network in Toronto after the introduction of medical assistance in dying (MAiD) in Canada,9 the authors noted:

[T]hose who received MAiD tended to be white and relatively affluent and indicated that loss of autonomy was the primary reason for their request. Other common reasons included the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life. Few patients cited inadequate control of pain or other symptoms.

I would like to question if the possible consequent good of allowing a highly selected population of privileged people the ability to request and be administered medical assistance in dying is sufficient to overturn millennia of accepted medical practice. Medicine has long been perceived by society to be beneficent and is trusted to avoid actions which would deliberately hasten death. The intent of palliative medicine is the relief of pain and suffering, not the taking of life. Should we risk the incremental creep of our values for the sake of a privileged few?

Do we wish to allow our society to become similar to Belgium, where we are so removed from the human experience that we consider the dying process useless, meaningless and undignified?

In my own city, Melbourne, we can all witness the inadequate provision of palliative care and other health services to more economically challenged sections of our society. A similar picture emerges in rural settings. Can we as a society justify allocating resources to voluntary assisted dying, when basic palliative care and health care are so lacking?

Should we really allow the values of our society to be so radically altered for the few who are so removed from an acceptance of the frailty of the human experience, from an acceptance that we are all dependent on others and vulnerable?

It is for the above reasons that I will be a so-called conscientious objector when the Voluntary Assisted Dying Act comes into operation on 19 June 2019. I will continue to practise medicine as it has been practised for millennia, for the relief of pain and suffering. I would encourage all doctors to in Victoria to do likewise.


Adrian Dabscheck is a Palliative Care Consultant from Victoria

References

1.  Voluntary Assisted Dying Act 2017 (Vic).

2.  Ariès P. Western Attitudes Toward Death from the Middle Ages to the Present. Johns Hopkins University Press, 1974.

3.  Tolstoy L. The Death of Ivan Ilyich. Published in 1886.

4.  Vanden Berghe P, et al. Assisted Dying – the current situation in Flanders: euthanasia embedded in palliative care. European Journal of Palliative Care 2013;20(6):266-272.

5.  Ariès P. L’Homme devant la mort (The Hour of Our Death). Published in 1977.

6.  Doyle D, et al. (eds.) Oxford Textbook of Palliative Medicine. 3rd Edition. Oxford University Press, 2005.

7.  Van der Heide A, et al. End-of-Life Practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 2007;356:1957-1965.

8.  Radbruch L, et al. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine 2016;30(2):104-116.

9.  Li M, et al. Medical assistance in dying – implementing a hospital-based program in Canada. New England Journal of Medicine 2017;376:2082-2088.


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Medical Euthanasia in Canada: Current Issues and Potential Future Expansion

Psychiatric Times

Mark S. Komrad

Dr Mark Komrad explores the relatively new Medical Aid in Dying (MAID) law in Canada, and how it may be on the verge of opening medical euthanasia to certain qualified psychiatric patients, similar to practices in Belgium and The Netherlands (see A Psychiatrist Visits Belgium: The Epicenter of Psychiatric Euthanasia).

He also brings out specific worries about the emerging ethical and legal trends in Ontario, to stop conscientious objecting physicians from refusing to refer cases of patients seeking euthanasia to colleagues who might be willing to provide it.

Dr Komrad is a clinical psychiatrist and an ethicist. He just finished a 6-year tenure on the APA Ethics Committee and also serves on the APA Assembly. In those contexts, he helped to craft the current current APA position on Medical Euthanasia for non-terminally ill patients [PDF]. He is also on the teaching Faculty of Psychiatry at Johns Hopkins, Sheppard Pratt, and the University of Maryland. Dr Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor any of the institutions where he is on the faculty. . . . [Go to Psychiatric Times for Podcast]

 

Isle of Man abortion reform bill passed by House of Keys

BBC News

Plans to change the Isle of Man’s abortion laws have been approved by the House of Keys by a margin of 22-2.

The Abortion Reform Bill would allow women to have terminations within the first 14 weeks of their pregnancy, with other restrictions also being eased.

Under existing Manx law, abortions can only be carried out if a pregnancy is the result of rape or because of mental health concerns.

Members of the Legislative Council will now consider the bill. . . [Full text]

    • Note: the Abortion Reform Bill as passed by the Keys includes a simple  protection of conscience provision covering all “relevant” professionals (registered medical practitioners, nurses, or midwives) and pharmacists.  It requires objecting practitioners to provide information, but not  referral.

HHS rules prevent providers from being forced to do things that violate moral convictions

The Hill

Reproduced with permission

Diana Ruzicka*

In the April 4, 2018 article, HHS rule lowers the bar for care and discriminates against certain people, nursing leaders, Pamela F. Cipriano and Karen Cox, wrote that the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Proposed Rule: Protecting Statutory Conscience Rights in Health Care; Delegations of Authority expands the ability to discriminate, denies patients health care and should be rescinded. These accusations are unfounded and the rule should be supported.

What the rule does is “more effectively and comprehensively enforce Federal health care conscience and associated anti-discrimination laws.” It is not an effort to allow discrimination but an effort to prevent it by enforcing laws already on the books and gives the OCR the authority to oversee such efforts. This is something that nursing should encourage because it supports the Code of Ethics for Nurses (code).

The code reminds us that, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence and continue personal and professional growth.”

It is precisely because nurses are professionals who hold themselves to these standards that patients have come to see nurses as persons worthy of their trust, persons in whose hands they are willing to place their lives. Being granted by the public this weighty and solemn responsibility is humbling and must never be taken lightly. Thus the nurse’s duty to practice in accord with one’s conscience, to be a person of wholeness of character and integrity, is recognized by the.

It is odd that, despite supporting a nurse’s duty to conscience and the right to refuse to participate in an action to which the nurse objects on the grounds of conscience, Cipriano and Cox insist that the nurse, must assure that others make the care available to the patient. This suggests a failure to recognize that referring the patient to someone who will do the objectionable act in place of the nurse can make the nurse complicit.

The culpability of complicity is well recognized in law and ethics, as an accomplice is liable to the same extent as the person who does the deed. Thus, to make a referral and be complicit in an act to which the nurse conscientiously objects, also violates conscience. We doubt nursing leaders actually support this, as the consequences would be chilling.

When persons are made to violate their conscience, to set it aside, to silence it, moral integrity is eroded and moral disengagement progressively sets in. To move from caring for our fellow human beings to acting on them in ways that our conscience tells us we should not, requires powerful cognitive manipulation and restructuring to free ourselves of the guilt associated with this violation of our deeply held moral or religious beliefs.

Moral disengagement has frightening negative consequences, namely a pernicious dehumanization of persons, including oneself and of society as a whole. Rather than a nurse being someone of moral courage, ethical competence and human rights sensitivity, as our code directs, a nurse would have to be someone who is willing to surrender their conscience to expediency, powerful others, or whatever happens to be permitted by law at the time and place.

No longer would patients find that nurses are persons they can trust. It is precisely because nurses practice in accordance with their conscience that the public continues to grant them high scores on honesty and ethics.

None of this is to say that nurses may abandon patients. By promptly seeking a transfer of assignment that does not involve the objectionable act or by transferring the patient elsewhere without making a referral, the nurse continues to uphold the code by “promoting, advocating for and protecting the rights, health and safety of the patient [and, at the same time,] preserving wholeness of character and integrity.”

Clearly, refusal to care for a patient based on an individual attribute is unjust discrimination and has no place in nursing or health care. But that is not what the rule does. It protects the right to object to being forced to participate in an act that violates a person’s deeply held moral convictions or religious beliefs and from discrimination as a result of one’s refusal to participate in such an act.

To call for rescinding the rule, whose purpose is to protect this fundamental human right, would be short-sighted and could make unjust discrimination more likely and harm not only nursing but also the patients we serve.

 

Victoria’s Voluntary Assisted Dying Act 2017

Sean Murphy*

On 19 April, 2018, the legislature of the State of Victoria, Australia, passed the Voluntary Assisted Dying Act 2017, which will come into force in June, 2019.  It is currently the most restrictive euthanasia/assisted suicide (EAS) legislation in the world, running to 130 pages.  In brief, the law authorizes physician assisted suicide for terminally ill adults, but permits euthanasia by physicians only when patients are physically unable to self-administer a lethal drug.  In both cases a permit must be obtained in advance.

When can a doctor conscientiously object?

America

Bernard G. Prusak*

Over the last decade, the culture wars in the United States have broken new ground: They have become battles over the rights of conscience. For example, now that same-sex marriage is a right, the question before the U.S. Supreme Court in the case of Masterpiece Cakeshop is whether its sympathetic, telegenic owner, Jack Phillips, is within his rights to refuse to make a wedding cake for a gay couple. Similarly, under the Obama administration, the court heard arguments more than once over whether employers who object on religious grounds to contraceptives or abortion should be exempted from having to provide employees health insurance that includes such services.

By contrast, debates over conscientious objection in medicine have not had the same notoriety, though they have broken out repeatedly among health care professionals and medical ethicists since the turn of the century, when there was a flare-up over pharmacists’ refusing to fill prescriptions for emergency contraceptives.

A bill currently before the House of Lords has brought conscientious objection in medicine into widespread public discussion in the United Kingdom, if not yet on the other side of the Atlantic. . . [Full text]