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]

Why don’t more Ontario doctors provide medically assisted dying? It’s not the money

Ontario government looking at changes to fee and referral system to make it easier for doctors

CBC News

While physicians in other provinces have raised the touchy subject of how much they should get paid for ending a life, Dr. James Downar says that money is not what’s stopping more doctors from providing medically assisted dying in Ontario.

“Nobody is getting rich off this and nobody should think they’re going to get rich off this,” Downar, a critical and palliative care physician in Toronto, said in an interview.

He’s one of just six physicians in Toronto registered to provide medical aid in dying. There are 74 in all of Ontario. . . [Full text]

 

 

How to End a Life

A year since assisted suicide became legal, only a small number of physicians are willing to perform the procedure, and their numbers are shrinking. Taking a life is harder than they thought

Toronto Life

Nicholas Hune-Brown

The first thing April Poelstra noticed was the hitch in her father’s shoulder. Jack’s left arm was drooping, hanging limply at his side, as if he didn’t have the muscle to cinch it into alignment. It was the fall of 2015, and Jack was living in Frankville, Ontario, waking up at 4:30 a.m. to plow roads and work odd jobs for a construction company. . . Jack tried to downplay his shoulder problems. He visited his doctor for a battery of tests, but always changed the subject when April pressed for details. . . .In early 2016, her fears were validated: Jack was diagnosed with ALS. Amyotrophic lateral sclerosis, or Lou Gehrig’s disease . . .On June 17, Bill C-14 became law, making medical assistance in dying, or MAID, legal for mentally competent Canadians. Jack Poelstra was overjoyed. . . [Full text]

 

Canadian surgeons harvesting organs from euthanised patients

BioEdge

Michael Cook

March 29, 2017 (BioEdge) — Taking advantage of the country’s new law, Canadian transplant surgeons have harvested organs from dozens of euthanasia patients. According to the National Post, 26 people in Ontario who died by lethal injection have donated tissue or organs. This involved mostly corneas, skin, heart valves, bones and tendons.

The National Post’s report only covered Ontario. Bioethicists, Transplant Quebec and an ethics committee of the Quebec government in Quebec argued last year that euthanasia could be a good source of organs, so it is quite possible that similar procedures have been carried out in that province as well.

“If we accept people can make decisions to end life, and we accept the idea of cardiac death being sufficient for organ donation, this should be acceptable,” Dr James Downar, of Dying with Dignity Canada, told the Post, to allay fears that patients could be pressured into donating organs.

Oddly enough, this is a topic which did not emerge in discussions about euthanasia before the Supreme Court legalised it in 2015. An influential report by a Royal Society of Canada Expert Panel did not even mention it, for instance, nor the Supreme Court’s decision in Carter vs Canada.

Coordinating organ transplants with euthanised donors has been going on for several years in Belgium and the Netherlands. About 40 cases in the two countries have been reported. Last year Dutch physicians at the Maastricht University Medical Center and the Erasmus University Medical Center Rotterdam published a multidisciplinary manual for the complex procedure.

A recent article in the Impact Ethics blog by Professor Jennifer A. Chandler, of the University of Ottawa, pointed out that combining organ donation with euthanasia could lead to some tricky issues in ethics, law and conscientious objection:

• What if a patient seeks euthanasia to direct his donation to a family member? The potential for abuse is obvious.

• What if a next-of-kin is asked to approve organ donation after a person has been euthanised but has left no instructions?

• What if the transplant surgeon has a conscientious objection to the procedure? Should he be forced to do it?

• What if a recipient objects to receiving an organ from a euthanised patient?


This article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

 

Doctors harvesting organs from Canadian patients who underwent medically assisted death

What if people agree to donate, but then change their mind about euthanasia? Would they feel compelled to follow through, knowing someone is waiting for their organs?

National Post

Sharon Kirkey

Doctors have already harvested organs from dozens of Canadians who underwent medically assisted death, a practice supporters say expands the pool of desperately needed organs, but ethicists worry could make it harder for euthanasia patients to voice a last-minute change of heart.

In Ontario, 26 people who died by lethal injection have donated tissue or organs since the federal law decriminalizing medical assistance in dying, or MAID, came into effect last June, according to information obtained by the Post. A total of 338 have died by medical assistance in the province. . . [Full text]

 

 

‘Take my name off the list, I can’t do any more’: Some doctors backing out of assisted death

National Post

Sharon Kirkey

Some doctors who have helped the gravely ill end their lives are no longer willing to participate in assisted death because of emotional distress or fear of prosecution if their decisions are second-guessed, according to their colleagues.

In Ontario, one of the few provinces to track the information, 24 doctors have permanently been removed from a voluntary referral list of physicians willing to help people die. Another 30 have put their names on temporary hold.

While they do not have to give a reason, a small number have advised the province they now want “a reflection period to decide whether medical assistance in dying is a service they want to provide,” according to a health ministry spokesman. . . [Full text]

 

Science, religion, public funding and force feeding in modern medicine

Responding to Bronca, T. “A conflict of conscience: What place do physicians’ religious beliefs have in modern medicine.” Canadian Health Care Network, 26 May, 2015.

Sean Murphy*

Tristan Bronca writes, “Belief without evidence is becoming incompatible with scientific sensibilities.”1

This notion might be exemplified by Dr. James Downar. Advocating for physician assisted suicide and euthanasia in Canadian Family Practice, he described himself as “a secular North American who supports individual autonomy, subject only to limitations that are justifiable on the basis of empirically provable facts.”2

Dr. Downar’s “Yes” was opposed by Dr. Edward St. Godard’s “No.”3 Since both are palliative care specialists, their differences on the acceptability of physician assisted suicide and euthanasia are not explained by differences in their clinical experience, but by their different moral or ethical beliefs.

However, neither Dr. Downar’s beliefs nor Dr. St. Godard’s can be justified “on the basis of empirically provable facts.” Nor can Dr. Downar’s support for individual autonomy, since empirical evidence demonstrates the primacy of human dependence and interdependence – not autonomy. Empirical evidence can provide raw material needed for adequate answers to moral or ethical questions, but it cannot answer them. As Dr. McCabe told Tristan Bronca, science is necessary – but not sufficient. Moral decision-making requires more than facts.

And the practice of medicine is an inescapably moral enterprise. Every time they provide a treatment, physicians implicitly concede its goodness; they would not otherwise offer it. This is usually unnoticed because physicians habitually conform to standards of medical practice without adverting to the beliefs underpinning them. Hence, the demand that physicians must not be allowed to act upon beliefs is unacceptable because it is impossible; one cannot act morally without reference to beliefs.

But Tristan Bronca asks specifically about whether or not religious beliefs belong in medical practice in a secular society. On this point, the Supreme Court of Canada is unanimous: “Yes.”

“Everyone has ‘belief’ or ‘faith’ in something, be it atheistic, agnostic or religious,” Mr. Justice Gonthier wrote in Chamberlain v. Surrey School District No. 36. “To construe the ‘secular’ as the realm of the ‘unbelief’ is therefore erroneous.”

“Why,” he asked, “should the religiously informed conscience be placed at a public disadvantage or disqualification? To do so would be to distort liberal principles in an illiberal fashion and would provide only a feeble notion of pluralism.”4

Thus, to argue that a “secular” society excludes religious belief perpetuates an error that contributes significantly to climate of anti-religious intolerance.

Guantanamo Restrain Chair Wikipedia Commons

Public funding of services is beneficial for patients, but quite distinct from physician obligations. After all, physicians provide many kinds of elective surgery and health services that are not publicly funded, and physicians are not paid for publicly funded services that they do not provide. Besides, our secular society taxes both religious and non-religious believers, so both have equal claims on “public dollars.”

Most important, public funding does not prove that a procedure is morally or ethically acceptable, any more than public funding proves that force-feeding prisoners in Guantanamo Bay is acceptable. Perhaps that point will come up in military proceedings against a navy nurse who refused orders to do so.5


The Canadian Healthcare Network posted this response in the on-line edition, which is accessible only to health care professionals and managers.


Notes

1.  Bronca, T. “A conflict of conscience: What place do physicians’ religious beliefs have in modern medicine.” Canadian Health Care Network, 26 May, 2015

2. Downar J. “Is physician-assisted death in anyone’s best interest? – Yes.” Canadian Family Physician, Vol. 61: April, 2015, p. 314-316 (Accessed 2015-06-04).

3. St. Godard E. “Is physician-assisted death in anyone’s best interest? – No.” Canadian Family Physician, Vol. 61: April, 2015, p. 316-318 (Accessed 2015-06-04).

4. Chamberlain v. Surrey School District No. 36 [2002] 4 S.C.R. 710 (SCC), para. 137 (Accessed 2014-08-03). “Madam Justice McLachlin, who wrote the decision of the majority, accepted the reasoning of Mr. Justice Gonthier on this point thus making his the reasoning of all nine judges in relation to the interpretation of ‘secular.’” Benson I.T., “Seeing Through the Secular Illusion” (July 29, 2013). NGTT Deel 54 Supplementum 4, 2013  (Accessed 2014-02-18).

5. Rosenberg C. “Top nursing group backs Navy nurse who wouldn’t force-feed at Guantánamo.” Miami Herald, 19 November, 2014 (Accessed 2015-06-04)

 

Canadian physicians warned to get ready for euthanasia and assisted suicide

Re: Downar J, Bailey TM, Kagan J, Librach SL.  Physician-assisted death: time to move beyond Yes or NoCMAJ 2014 May 13;186(8):567-8. doi: 10.1503/cmaj.140204. Epub 2014 Apr 7.

Sean Murphy*

Three physicians and a lawyer have written an article published in the May issue of the Canadian Medical Association Journal. The lead author, Dr. James Downar, is co-chair of a euthanasia/assisted suicide advocacy group.

Anticipating a change in the law, the authors warn that “well-rehearsed debates” about sanctity of life and personal autonomy “may become obsolete.”

“We need to start to answer some challenging questions in preparation for the possibility that physician-assisted death will be available in Canada soon,” they write.

Among the questions they pose, one raises two particularly sensitive issues:

Will physicians who are conscientious objectors be obliged to present physician-assisted death as an option to patients and facilitate transfers of patients to other physicians or facilities?

As a matter of law and ethics, physicians are expected to advise patients of all reasonable legal options for treatment so that patients can provide informed consent to it.  However, many physicians who are strongly opposed to euthanasia and assisted suicide may view the “presentation of an option” for either procedure as inherently abusive of vulnerable patients.  This problem does not usually arise with respect to other morally contested procedures, like abortion or contraception.

A requirement to “facilitate transfers” of patients would probably be acceptable if it involved only the kind of  cooperation normally involved in the transfer of records when a patient is taken on by a different physician; this is all that is required in Belgium, Oregon and Washington State.  However, a demand that objecting physicians refer patients or actively initiate transfers would be resisted by those who would consider such actions to involve unacceptable complicity in killing.  The Supreme Court of the Philippines recognized this issue when it struck down a mandatory referral requirement in the country’s Reproductive Health Law as an unconstitutional violation of freedom of conscience.