Dr. Yves Robert*
Introduction
As noted in the commentary below, the state medical
regulator in the province of Quebec, the Collège des
Médecins du Québec, published an reflection in 2009 that
effectively encouraged the legalization of euthanasia.
During hearings into Quebec's Bill 52, which eventually
became the province's euthanasia law (the Act
Respecting End of Life Care), Dr. Charles
Bernard,
Dr. Yves Robert and Dr. Michelle Marchand appeared on
behalf of the Collège. They were effusive in their
support for the proposed law,
describing it as "a very important milestone," the
product of "outstanding work," and "responsive to the
vision we initially proposed."
One of the points Dr. Bernard
emphasized was that euthanasia should be "an option
of last resort for exceptionally difficult
situations at the end of life. . . in the final stages
of a serious and incurable disease that is inflicting
refractory suffering." Dr. Robert himself
added that euthanasia should only be considered in
what was truly the "last slice of life in the final
phase of the life." Only then, he said, might it
be considered an option "from a medical point of view."
Consistent with these views, the original text of the
Bill was
amended to include a provision that a patient had to
be "at the end of life," even though the legislators
could
not agree on what this meant. It is not
certain that the term is being interpreted consistently
throughout the province, though returns from reporting
agencies sometimes report refusal to provide euthanasia
because a patient is "not at the end of life."
About 8% of refusals in the first half of 2017
were attributed to patient ineligibility, which
includes this criterion among others.
In any event, the May, 2017 commentary by Dr. Robert
indicates alarm at increasing pressure to provide
euthanasia in circumstances and for reasons apparently
not envisaged by Collège des Médecins du Québec when it
published its 2009 reflection and expressed its support
for the new legislation. Of particular interest,
he suggests that, if current trends to broaden criteria
for euthanasia continue and are affirmed, it may be
appropriate for the medical profession to be replaced by
some kind of non-medical (but presumably technically
competent) euthanasia service.
During the legislative hearings into Bill 52,
Professor Margaret Somerville
suggested that lawyers could be trained for this
purpose. Her suggestion was ignored at the time,
but Dr. Robert's comments suggest that he and other
euthanasia supporters may now be more open to Dr.
Somerville's proposal. Having a corps of voluntary
euthanasia service providers would relieve the pressure
now being experienced by physicians and health care
workers who object to euthanasia for reasons of
conscience. [Administrator]
If anything has become apparent over
the past year, it is this paradoxical discourse that calls
for safeguards to avoid abuse, while asking the doctor to
act as if there were none. Many are ill at ease with
exclusion and paradoxes, especially opinion leaders and
media columnists who denounce refusals of MAID and promote
death à la carte "to
respect the choices of each individual."
Just over a year after the adoption of the
Act
Respecting End-of-Life Care (hereafter the Act) in
Quebec, the Minister of Health and Social Services recently
announced his plan for a reflection on expanding the scope
of Medical Aid in Dying (MAID). It would seem that we
already want to relax the access criteria.
It should be noted that the debate in Quebec was launched
in November 2009 following the publication of
the
Collège des médecins du Québec's reflection on the
subject. The logic of care based on seeking the most
appropriate care for each patient was the primary motivation
for the approach that led to the law authorizing MAID, which
came into force on December 10, 2015. With this logic of
care, the Quebec legislator sought to recognize a logic of
rights, confirming that the patient had a say in how he
wished to live his last moments. Thus, the law grants the
patient the right to quality end-of-life care: palliative
care, including palliative sedation and, exceptionally, if
it is not relieved by usual care, medical aid in dying. The
Act also established a system of Advance Medical Directives
(AMD), through which the physician is bound to respect the
wishes expressed therein by a patient, regarding five
specific treatments[1]
required by his or her state of health if, having become
incapable, the patient is in one of two particular clinical
situations.[2]
MAID is excluded by law from the AMD.
In just over a year,
more than 400 patients have received
MAID in Quebec. This period was a learning process for all
of Quebec society, during which we collectively understood
that there were criteria for access to MAID and that, when
these criteria were not met,
requests were refused. This
observation, although obvious, was brutal for many.
Thus, patients suffering from progressive diseases but at
an early or intermediate stage were denied MAID. Patients
with disabilities, who were not at the end of their lives,
were reduced to choosing to die through fasting. Finally,
more recently, a patient suffering from dementia, incapable
of consenting to care,
was allegedly killed out of
compassion by her spouse.
Since the coming into force of the Act, and particularly
since the debate on the federal bill following the Carter
decision of the Supreme Court of Canada, some people have
invoked a "new constitutional right": that of obtaining MAID
on demand or even to claim it "pre-emptively" shortly after
being diagnosed with severe or terminal illness, even before
suffering from the dreaded incapacities or limitations. For
many, it is about having control over their death and the
right to choose its moment and manner. While MAID was
reserved for the suffering patient, we see the emergence of
pressure demanding a form of death à la carte. But
is this really what our society wants?
We all know that at least three questions remain
unanswered after the coming into force of the current laws:
what happens to incapable persons, to minors, and to those
with mental illness? These issues are not simple; we may
have to accept that there is no answer. The question of
incapable persons, which will be discussed by an expert
committee formed by the minister in the coming year, is
probably the most complex. It is envisaged to allow persons
who are still capable to issue advance directives to request
MAID in case of incapacity. In particular, it should be
ensured that, where appropriate, the person clearly
determine the medical condition for which he or she would
want MAID. It's not easy when one is still in good health.
For obvious reasons, this possibility could not have the
same binding power as an AMD.
- What then would be the
decision-making process to be followed, and by whom, in the
name and in the interest of the incapable person?
- Who would
ultimately make the decision?
- Who would choose the moment?
Medically, other conditions foreseen in the law for those
who are capable should also be present, including suffering,
which is not always present in dementia depending on the
stage of the disease.
- It is also important to determine who
would be suffering the most: the patient or his or her
entourage?
- What if, at the time of the intervention, the
patient, unaware of their purpose, resisted the injections?
- Finally, what would one do with all those patients currently
suffering from dementia, who have not had the opportunity to
express their wishes beforehand?
- What would be the response
to those who would undoubtedly invoke a concern for fairness
and claim a need for compassionate death in the name of a
subjective "quality of life" that is so difficult to
evaluate?
As can be clearly seen with the situation of incapable
persons, broadening access to the MAID raises many issues
that should be discussed collectively, and which go well
beyond the current legal framework and even the Carter
decision. Why and to what extent should new safeguards be
introduced when, no matter what the access criteria, there
will always be some people excluded by definition? If
anything has become apparent over the past year, it is this
paradoxical discourse that calls for safeguards to avoid
abuse, while asking the doctor to act as if there were none.
Many are ill at ease with exclusion and paradoxes,
especially opinion leaders and media columnists who denounce
refusals of MAID and promote death à la carte "to
respect the choices of each individual."
For them, what about the logic of care and of a
"continuum of care" that preceded the Act Respecting
End-of-Life Care? If the goal is euthanasia on demand
based on a right, are we still talking about Medical Aid in
Dying, or simply Aid in Dying? What would the medical
profession have to do with it?
We should recall that, without the logic of care,
physician intervention is not required. If the will of the
people is limited to respecting the wishes expressed
directly or indirectly by the person, society will have to
lucidly consider other options than those which require the
participation of the doctor, and transform Medical Aid in
Dying into simply a legally authorized aid in dying. This
could take the form of assisted suicide services provided by
a private company that would deal directly with the person,
as in Switzerland… But is it really in this direction that
Quebec society wants to go?
What is striking after the first year of operation of
this law, recognized as being the source of a "major
opening", is the rapidity with which public opinion seems to
have judged this opening insufficient. Have we really gone
that far? Even before having fully appreciated the
application of the current provisions or their consequences?
Let us take the time to reflect carefully before going
any further. Death is not that urgent.
Yves Robert, M.D.
Secretary
Collège des médecins du Québec
Notes
1. Cardiopulmonary resuscitation, respiratory
assistance, dialysis, hydration and nutrition
2. End of life and serious and incurable disease or
severe and irreversible impairment of cognitive functions
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