Redefining the Practice of Medicine

Euthanasia in Quebec

An Act Respecting End-of-Life Care (June, 2014)

Sean Murphy*

Full Text

Part 8: Hospitality and Lethal Injection

Introduction

A review of the situation of Quebec hospices provides some insight into the effect of the legalization of euthanasia on those who object to the procedure for reasons of conscience, notably the pressures that will be brought to bear on objectors by the law and public or professional opinion.

Exemptions for palliative care hospices

ARELC Section 13

Recall that palliative care hospices are "community organizations" as defined in the Act Respecting Health Services and Social Services.  Although they receive government funding, they remain free to define their "orientations, policies and approaches."  Consistent with this, section 13 of ALERC permits palliative care hospices to determine what end-of-life care they will provide, and requires them to notify patients of their practice before admitting them.1  This means that, while they may permit MAD services on their premises, they do not have to do so.  The section is extremely important for palliative care hospices because their administration and staff are normally opposed to assisted suicide and euthanasia.

It appears that pragmatic considerations underlie this provision in the law.  Hospices are not formally part of the state health care system, though they are subject to state regulation and are dependent to varying degrees on public funds to provide their services.  If the government were to demand that they provide euthanasia, there is a risk that they would close or lose critical members of their palliative care teams, so that, as Dr. Bolduc explained, "excellent resources that are doing excellent work" would be lost.2  Aside from the loss of resources for patients, the government would likely have to incur additional expense to replace them.

ARELC Section 72

Section 72 of the Act is a grandfather clause that concerns any institution operating a "general and specialized hospital centre" that offers only palliative care.  Such institutions "may continue to offer that care exclusively" (i.e., need not provide euthanasia), as long as they notify patients of this before admitting them.3  Véronique Hivon, when Minister of Health, explained that the section is intended to apply only to a single institution:

Article [72] is a clarification.  The only institution affected by Article [72] is La Maison Michel Sarrazin; no other public institutions can avoid [providing physician-assisted dying]. In fact, it is the Michel Sarrazin clause to that preserves its status as the only hospice that has a status of [a public] institution. Why? Because it was the first, and does research, it is an academic institute. And we have no choice. We wanted to give it ... put it on the same footing as other hospices. So this is why there is this clause there. And [the law] cannot be applied because it is the only institution that offers only palliative care, so it's a grandfather clause, actually.4

Note that the term "public institution" is a category used for administrative purposes under the Act Respecting Health Services and Social Services.  It does not mean state-owned.  La Maison Michel Sarrazin is a private, not-for profit palliative care hospital with 15 beds.  Operating for almost 30 years, it is funded largely by the Michel Sarrazin foundation and relies extensively on volunteers.  From its inception, in has been the leader in the development of palliative care in Quebec; 8,000 patients have spent their last days there.  The institution is adamantly opposed to euthanasia and assisted suicide.5

Minister Hivon's comment, "we have no choice," probably reflects the government's judgement that, in addition to the purely pragmatic considerations applicable to other palliative care hospices, to compel La Maison Michel-Sarrazin to kill its patients would have been politically disastrous.  Recall the warning of Yves Bolduc against forcing physicians to lethally inject patients: "If we start with that principle, then you will destroy the bill."6

Exemptions challenged

Demands that hospices provide MAD

Nonetheless, the exemption for hospices, including Michel Sarrazin, was criticized by the Institute for Care Planning, which complained that hospices were not being obliged to kill their patients, and that the government had been "very timid and insufficiently firm" (très pudiques et très peu audacieux)  by releasing them from this obligation.7  The Quebec Association for the Right to Die with Dignity also criticized the government for "allowing a loophole for hospices and some institutions."8

In explaining its position on hospices, the Institute for Care Planning inadvertently revealed an underlying premise based on a false dichotomy that is in fundamental conflict with the philosophy of hospice and palliative care and even the provision of health care generally.  Recollecting the community origins of hospices and designation as community organizations, the Institute said, "It is now difficult to regard them as community organizations."

They are in a certain sense, when they decide to make gardens, places for accommodation for families, etc.., It is wonderful, the community participates. But with respect to care, in my opinion, their status is much more related to health and increasingly, they have obligations and constraints of approval, control and everything.9

In its complaint, the Institute reveals a purely functional -not to say bureaucratic and statist - view of health care, as a mere government service that is paid for and must be delivered when paid for, not - as others might see it - a personal encounter between two human beings that demands a human face, and  fully human engagement.  The Institute seems to have forgotten that "hospice", "hospital" and "hospitality" have the same linguistic and historical roots.  But this has not been forgotten by hospices, which associate hospitality with making people welcome and comfortable rather than with lethal injections.

Consistent with the Institute's  "government service" paradigm of health care, the Quebec Association for the Right to Die with Dignity asserted, "an institution such as a hospice or a health facility, which receives significant public funding should not be able to escape this new obligation to provide the range of services," including euthanasia.10

According to the Association, if the staff at such an institution is not willing to kill a patient who qualifies under the MAD criteria, it "has an obligation to provide means and results, namely that of putting at the disposal of those who so request a real possibility, a convenient way to get medical help to die from a professional whose ethics and empathy will be compatible with this noble goal."11

The Association and the Institute for Care Planning acknowledged the requirement for prior notification of patients, so that a patient might ask for admission to a hospice in good faith, uninterested in euthanasia and knowing that MAD services were unavailable there.  However, they warned, subsequent developments might cause the patient to want euthanasia.  The Institute argued that it would not be appropriate to transfer him to a hospital emergency room.  Instead, a consultant could be brought in to provide the service.  After all, the Institute asked, what does the hospice do? 

"It provides a location, that's all," was the answer.12

"That's all" abruptly dismisses what hospice staff probably consider the most important elements of their vocation.

Suggestions that hospices allow MAD

The scenario proposed by the Association for the Right to Die with Dignity and the Institute for Care Planning was put by committee member Hélène Daneault to Lucie Wiseman, representing the Alliance of Quebec Hospices.  Ms. Daneault asked if, in such circumstances, Alliance hospices would admit a "flying squad" to provide MAD.13 The question was unanticipated.  Ms. Wiseman was clearly disturbed by the question and unable to respond definitively on behalf of all the Alliance houses, or even to predict how they might respond, beyond assuring legislators that "we are human beings, above all, with compassion."14

In contrast, speaking for La Maison Michel Sarrazin, Dr. Michel L'Heureux was clear that  euthanasia flying squads would not be allowed to operate in the facility.

 I put in parenthesis at the outset, in relation to the previous discussion with Alliance of Hospices, to make euthanasia or assisted suicide available by means of a third party like a flying squad would be no more admissible to me than doing it oneself.  You know, families in the living room, in the dining room. Everyone knows in a house. And you can not maintain an image or a strong message like this and at the same time be doing things that are undermining the credibility of that message. So for me, it is inconsistent to think that we could allow people from a third party to come and do this within the walls of a house. That would have an impact on all the other patients, on the other families.15

Dr. L'Hereux explained that if a patient at Michel Sarrazin were to request euthanasia he would refuse the request.

"I would not have an obligation to find another doctor in another institution . . . or find a hospital ready to take  the patients," he said, "because otherwise it comes in the back door, it is imposed indirectly."16

Nonetheless, he remained concerned: "I think I can see it coming."17

Suggestion that the hospice association should accept MAD

As will be seen presently, Dr. Yves Bolduc rejected suggestions that hospices should be compelled to provide euthanasia, but had a question for the Alliance of Quebec Hospices.  Observing that the law permitted a hospice to offer euthanasia,18 he asked if the Alliance would allow a hospice that provided MAD services to be called a hospice and remain a member of the Alliance: that such a hospice would not be excluded from the association.19  Lucie Wiseman confirmed that membership would be allowed.20  What she could not confirm - perhaps did not consider - was the possibility of a schism within the Alliance and the formation of two different hospice associations based on fundamental differences about euthanasia and the nature of hospice work.

"Environmental pressures"

The foregoing summary of key points of the discussion during the hearings into Bill 52 illustrates what Dr. Michel L'Heureux called "environmental pressures" (des pressions de l'environnement) on hospices and palliative care generated by ARELC.21  Dr. L'Heureux predicted that the pressures would increase after the passage of the bill, and that hospices would have to navigate in an increasingly hostile social and political climate.

Because activism does not stop the day after the bill is passed. Because activism continues, because after that, there is a will to expand, new amendments, to want to widen it and put pressure on institutions that do not offer it. This is the reality of Belgium. It is the reality of Quebec.22

The prediction does not seem unreasonable in view of the expansive tendencies evident during the committee hearings (See Part 3), the complaints of the Institute for Care Planning and the Association for the Right to Die with Dignity.  Perhaps reflecting what he has already experienced, Dr. L'Heureux mused about being told "that what we do is not acceptable, is inhuman, that we have no sympathy,"23 or that palliative care being offered is "futile and cruel," and, finally, the threat: "Well, if you let them die slowly like this, we will cut your funding."24

Such comments are characterized by the Association for the Right to Die with Dignity as "a filibuster by the palliative care network" that threatens to obstruct "smooth implementation of the continuity of care at end of life."25  The Association alleges that "there is a law of silence squarely within the palliative care network" that prevents palliative care workers who support euthanasia from speaking up.26 

"Autonomy" for all

Committee member Dr. Yves Bolduc was firm in his responses to complaints about the exemptions and the concerns of hospice representatives.  He described his approach as one that combined idealism and pragmatism,27 reflecting the conflicting demands of a pluralist society.28

"[W]e have patients who want to have a choice," he said.  "We have patients who do not really want to have the choice because they are against the idea. We have professionals who say I never will, we have professionals who are willing to do it."29

He explicitly rejected the claim that receipt of public funding justified imposing the MAD regime on hospices,30 and assured the Alliance of Quebec Hospices that they would have not obligation to provide euthanasia, "and this will not be linked to financing so that you are not blackmailed by the back door."31

In taking his stand, Dr. Bolduc appealed to autonomy and freedom of choice, the very concepts relied upon by those insisting that hospices provide MAD.

 Well, I find it sad that people who defend the autonomy of individuals, are not also able to defend the autonomy of groups that are independent of the health system, and even if there is funding that comes from the health system, such as is provided to community organizations, I want people to respect the choice of those people.32

Committee member Stéphanie Vallée told the Association for the Right to Die with Dignity that if, as they claimed, many people working in palliative care were willing to provide euthanasia,  such people were free to persuade house management to provide it.33  Thus, some hospices could provide euthanasia even if most did not, and the requirement for notification prior to admission made it possible for patients to choose which they preferred.  Dr. Bolduc argued that the arrangement allows respect for both the autonomy of the patient and the autonomy of the hospices and their employees.34

"Autonomy," he said, "is good for everyone."35

Note, however, that consideration of freedom of conscience is irrelevant to this approach.  Moreover, Dr. Bolduc's description of the problem as a conflict of autonomy actually precludes a successful resolution of the conflict by appealing to the principle giving rise to it.  Dr. Iain Benson explains:

The real issue, where there is a conflict of views between people regarding involvement with a procedure or drug, is not settled by reference to one person's "autonomy" but by reference to another principle, that of "justice" (defined as "rendering a person their due"). For it is there, in the order of justice, that competing claims must be reconciled in a manner that accords with the rule of law (including professional ethics and respect for professional disagreement), the provision of health-care and the developed understanding of a civil society.36

ARELC and the integrity of hospices

There is no doubt that Dr. Bolduc was sincere, but he was also realistic enough to know that, even as a former minister of health, his promises as an opposition member on a legislative committee were insufficient to provide the kind of guarantee needed by the hospices.  Hence, he wanted the Alliance of Quebec Hospices to explain how arrangements respecting their autonomy could be set out in the law.  Otherwise, he feared, a regulation would be made somewhere, possibly by "a lot people who want to impose on others their own opinions."37

In the end, the only change introduced into the Act Respecting End of Life Care that seems related to Dr. Bolduc's concern is a requirement that regional health authorities consult with institutions and palliative care hospices in their territories before determining the rules for access to end-of-life care.38 Of course, mere consultation may be insufficient to protect the integrity of hospices in the long term.

Notes

1.  ALERC, Section 13

2.  Consultations & hearings on Quebec Bill 52 (Hereinafter "Consultations"), Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#139

3.  ARELC, Section 72

4.  Note: in Bill 52, the original section number was 65. Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38: Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#030, T#032

5.   Pelchat, Pierre, "Aide médicale à mourir: la Maison Michel-Sarrazin dit non." Le Soleil, 12 October, 2013. (Accessed 2014-07-27)

6.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#102

7.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#011, T#121

8.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#018

9.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#123

10.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#019

11.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#020

12.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#123, T#124  T#125;  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#036

13.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#144, T#147

14.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#149, T#151, T#152

15.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#058

16.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#090

17.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#091

18.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#124

19.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#131

20.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#135

21.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#091

22.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#059

23.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#091

24.  Consultations, 1 October 2013 - Vol. 43 no. 40: Michel Sarrazin Home (Dr. Michel L'Heureux, Dr. M. Louis-André Richard), T#059

25.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#018

26.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#018, T#037

27.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#119

28.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), #107;  Consultations, Tuesday 24 September 2013 - Vol. 43 no. 37: Quebec Rally Against Euthanasia (Dr. Claude Morin, Dr. Marc Bergeron, Daniel Arsenault, Clément Vermette), T#105

29.  Consultations, Wednesday, 2 October 2013 - Vol. 43 no. 4: NOVA Montreal (Dr. Michael Laplante, Marie-Claude Mainville), T#106

30.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#123

31.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#136

32.  Consultations, Tuesday, 8 October 2013 - Vol. 43 No. 44: Institute for Care Planning (Danielle Chalifoux, Denise Boulet, Louise Boyd), T#138

33.  Consultations, Wednesday, 25 September 2013 - Vol. 43 no. 38:  Quebec Association for the Right to Die with Dignity (Hélène Bolduc, Dr. Marcel Boisvert, Dr. Georges L'Espérance), T#058

34.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#124

35.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#125

36.  Benson, I.T.  "'Autonomy', 'Justice' and the Legal Requirement to Accommodate the Conscience and Religious Beliefs of Professionals in Health Care."  Protection of Conscience Project.

37.  Consultations, Tuesday, 1 October 2013 - Vol. 43 no. 40: Alliance of Quebec Hospices (Lucie Wiseman, Suzanne Fitzback, Pierre Hébert), T#125

38.  ARELC, Section 17.