Canadian Doctors for the Protection of Vulnerable Persons in Medical Assistance in Dying
To the Right Honourable Justin Trudeau, Prime Minister
Honourable Jody Wilson-Raybould, Minister of Justice and Attorney-General of Canada
Honourable Jane Philpott, Minister of Health
To the Members of Parliament and Members of the Senate of Canada:
We are writing this letter as Canadian physicians with grave concerns regarding the recent legalization of euthanasia and assisted suicide or “Medical Assistance in Dying” (MAiD) in Canada.
The Canadian Medical Association, Canadian Society of Palliative Care Physicians, Canadian Pediatric Society, Canadian Psychiatric Association, and Canadian Hospice Palliative Care Association, amongst others, have all emphasized the critical importance of safeguards in the context of MAiD. We believe that the voices of Canadian physicians regarding risks to vulnerable persons and society at large have not been adequately heeded in political debate thus far.
We stand firmly behind the Vulnerable Persons Standard (VPS) recommendations (informed by the diverse experience of over 40 Canadian experts in medicine, law, public policy, and ethics):
1. Bill C-14 must pass as federal legislation is absolutely necessary in order to protect vulnerable persons and Canadian society, and to comply with the Carter requirement that a system of safeguards is in place to minimize risks evidenced in other jurisdictions.
2. Only amendments which strengthen safeguards and the protection of vulnerable persons and society should be supported, and any potential amendments that broaden eligibility criteria of Bill C-14 should be strongly rejected.
As the Senate closes deliberations and debate continues in the House of Commons, we urge you to consider the following:
1. The Senate amendment removing the requirement of death being “reasonably foreseeable” is a catastrophic change to Bill C-14 that many physicians hope will be rejected by the House of Commons and subsequently remedied when received back by the Senate. Any legislation on MAiD must maintain an end-of-life requirement in order to safeguard against the normalization of suicide in society and to comply with the Carter v. Canada stipulation that the ruling spoke only to the “factual circumstances” of the two cases involved – both of which involved patients at the end of their lives. Especially given that the amendment to include judicial review was so closely voted down (with abstentions) – and was intended to accompany the removal of an end-of-life requirement – it is incumbent that the Senate reinstate this substantive safeguard of Bill C-14.
2. Any amendments to broaden eligibility (e.g. to include mature minors, advance requests, and where mental illness is the sole underlying medical condition) must be rejected in the interest of patient safety, given the risks evidenced in other jurisdictions.
I. Mature Minors
The Canadian Pediatric Society has cautioned against including mature minors, and we strongly urge all to heed this important physician voice of expertise.
II. Mental illness as the sole underlying condition
The Canadian Psychiatric Association has cautioned that there is no established standard of care in Canada for defining when typical psychiatric conditions are irremediable.
Dr. K. Sonu Gaind, president of the Canadian Psychiatric Association, addresses the challenge of determining irremediability in a letter to the Globe and Mail published May 30th, 2016: "Assessing irremediability in mental illness is very difficult...
Remediability goes beyond biomedical symptoms. Social isolation, underemployment, poverty or lack of housing all have an impact on the suffering from mental illness."
He emphasizes the potential dangers of making decisions regarding MAiD for the mentally ill in the absence of established standards. "Opening the door to assisted suicide for people with mental illness, involving inconsistent application of non-existent standards, would itself be discriminatory against this vulnerable population...Complex decisions without standards become value judgments or best guesses, and we should not be gambling with the vulnerable lives."
III. Advance requests
We strongly support the Senate's decision to reject the inclusion of advance directive in assisted dying. From a physician perspective, excluding MAiD by advance directive is necessary in a regulatory regime aligned with Carter v. Canada, for reasons that include the following:
a) The ruling limits eligibility to persons who experience “suffering that is intolerable to the individual in the circumstances of his or her condition” (para 127).
This requirement speaks to the ability of a person to subjectively and personally report on suffering as being intolerable to him or her in current circumstances and in his or her current condition. Competency is required in order to accurately relay this level of subjective experience. Without a fully competent patient, healthcare professionals and caregivers must rely on objective means of assessing suffering, thereby nullifying any ability to accurately determine if the person’s suffering is truly subjectively “intolerable to the individual” in current circumstances.
b) The SCC ruling notes that “the informed consent standard could be applied in the context of physician-assisted death, so long as care was taken to ‘ensure a patient is properly informed of her diagnosis and prognosis’ and the treatment options described included all reasonable palliative care interventions” (para 27).
Informed consent – critical to the SCC ruling – cannot be done in advance in this context as it would be impossible for a patient to know in advance at a future date the entire scope of “all reasonable palliative care interventions” that might exist at a later time when caregivers consider exercising MAiD as an option.
c) “Coercion, undue influence and ambivalence” are also listed as factors that require physician assessment in determining eligibility for MAiD (para 27), and it would be impossible for any physician – or anyone at all – to be able to predict future sources of coercion or undue influence that might be driving a request for MAiD to be executed. A person who is no longer competent due to dementia would be extremely vulnerable to no longer being able to adequately voice future ambivalence regarding a prior decision for MAiD.
3. Amendments that would support the conscience protection of healthcare professionals and institutions should be supported in order to address the Charter rights of vulnerable patients who wish to continue to have access to healthcare services in which their rights to life, liberty, and security of person are in no way compromised by the legalization of MAiD. It is extremely unfortunate that the voice of vulnerable persons who truly fear the impact of MAiD on maintaining their access to traditional pre-Carter medical care has not been adequately represented by the media. As seen in other jurisdictions where euthanasia and assisted suicide is legal, the majority of people will still wish to die a natural death. Doctors and institutions such as hospices and hospitals have been faithfully assisting patients in dying well for many years through quality palliative care. The CMA recognizes that assisted death as defined by the Supreme Court is distinct from palliative care. The World Health Organization states that palliative care intends neither to hasten or postpone death. Doctors and institutions that provide end-of-life care without seeking to hasten death should be able to continue to do so without being forced to participate in MAiD, directly or indirectly. We support the creation of a patient self-referred central mechanism for persons wishing to seek MAiD. A centralized intake system, as recommended by the CMA, would reconcile the issue of conscience protection and effective access. Ideally, such a system would permit access to a referral for MAiD only after providing a comprehensive interdisciplinary assessment to detect and address potential vulnerability to external pressure or other forms of inducements that may be driving a request for hastened death.
4. We strongly support the amendment requiring the procedural safeguard of palliative care consultation, but caution that this amendment cannot be received as a “trade-off” for any amendments that compromise other safeguards e.g. removing the substantive safeguard of requiring that death be "reasonably foreseeable."
Finally, we believe that physicians have a fiduciary responsibility to present physician concerns in important matters of healthcare policy, and that politicians likewise have a fiduciary responsibility to carefully consider the advice of medical experts. As busy clinicians, many of us have relied on the hard work of the leadership of our national representative body, the Canadian Medical Association, in bringing forward our concerns. However, as we see that not all CMA recommendations have been heeded at this stage of debate, many of us are compelled to carve out time to speak out in this critical time. The legalization of “Medical Assistance in Dying” (MAiD) is by far the most profoundly impacting healthcare policy change of this era, and we trust that the physician voice will be visibly heeded as debate continues over Bill C-14.
Respectfully submitted by,
Dr. Ed Dubland, MD, AAHPMc, MCFP (Palliative Care)
Dr. Constant H. Leung, MD, CCFP (COE), FCFP
The institutional affiliations associated with petition signatures are noted for information purposes and do not imply institutional endorsement of the views reflected in this letter.
This petition is not sponsored by any organization or association and is a grassroots initiative of individual physicians with common concerns regarding Bill C-14. Enquiries regarding this petition may be directed to Dr. Constant Leung and Dr. Ed Dubland.