Canada's Medical Assistance in Dying...Like It Or Not

"I feel like I'm falling through the cracks, so if I'm not able to access health care, am I then able to access death care? And that's what led me to look into MAID [Medical Assistance in Dying, Canada's assisted suicide program]."

"It is far easier to let go than keep fighting."

"When I imagine my final days I see music, I see the ocean."

Jennifer Hatch, 37, Ehlers-Danlos syndrome sufferer 

 

"There were no other treatment recommendations or interventions that were suitable to the patient's needs or to her financial constraints."

Fraser Health  MAID approval, British Columbia 

The video featuring Jennyfer Hatch and her closest friends was shot near Tofino, B.C., in the month before her death. (Submitted by Tama Recker)

 

Canada's health care system is fractured, too many calls on its vital services, too few physicians and nurses battling too many health-care fires. Patients are being under-served, turned away, surgical procedures postponed. In particular the urgency in specialized children's hospitals has emerged as a nightmare. Too many admissions, for children suffering respiratory illnesses, from infants to teens. 

An explosion of mental-health issues that medical specialists are unable to keep pace with. The nation's vaunted universal medicare is becoming a wan shadow of itself. And in the midst of all this, the assisted suicide program of the federal government -- Medical Assistance in Dying (MAID) is in the process of expanding its criteria for eligibility. Initial guidelines mandating imminent death from an incurable illness has been relaxed.

And from March forward individuals suffering from mental illness will qualify for medically assisted death with the support of two doctors or nurse practitioners. 

Hatch sat along the shores of a beach as part of the Simons video. (Simons)

 

"This is a case where not only are the provinces not ready for this, not only are professionals not ready, according to the association of chairs of psychiatry, but the federal government itself, it doesn't seem to know what's doing", charged an opposition Member of Parliament, Rob Moore, speaking of clear indicators that doctors and hospitals were not in a position to launch a more inclusive euthanasia program.

A number of military veterans after service with the Canadian Armed Forces, suffering from post-traumatic syndrome and seeking assistance from Veterans Affairs have been taken aback by recommendations or suggestions that they consider the efficacy of solving their mental  health problems by simply ending their lives under MAID. Similarly some people who feel they've come to the end of their tether in the medical system have opted to end it all.

One of these was a 37-year-old British Columbia woman whose diagnosis a decade earlier of Ehlers-Danlos syndrome and whose search for medical help after exposure to a stream of specialists none of whom were able to access her medical records when she was left without primary care when her family doctor moved and she was left without a medical contact, felt she had exhausted all avenues open and closed to her. 

When her condition became terminal the health system was unable to offer palliative care. It did, however, positively respond in approving her application for MAID. She arranged for a 'goodbye' gathering of her friends on a beach at Tofino, British Columbia. A three-minute film of the event was taken and aired under the title of All is Beauty. A testimonial on the efficacy of assisted suicide.

Actually, a testimonial on the lack of humanity in the health care system stretched to its limits by unforeseen demands on an system that was teetering on inadequacy before the onset of the SARS-CoV-2 pandemic. A situation where some people in Canada, though treasuring life, feel that without the medical assistance they need for quality of life, little option remains to them but to apply for MAID.

Another woman in the same province unable to find treatment for chronic mental health issues, succeeded in receiving quick approval for assisted suicide in an Abbotsford hospital. This, without the prior knowledge of her family, who following her death, referred the case for investigation to the federal police force, the RCMP.

Former Paralympian Christine Gauthier was offered MAID by a Veterans Affairs caseworker when she complained of delays in installing an in-home chairlift. "Madam, if you are really so desperate, we can give you medical assistance in dying now", she was told by the caseworker.

The cello was one of Hatch's 'favourite things,' according to her friends. In one of the scenes of the video, Hatch was led to a cello player, who helped her feel the vibration of the instrument. (Simons)

A Procedure That Kills People

"[Such a measure -- upturning the Criminal Code ban on doctor-assisted suicide -- would violate the Charter of Rights and Freedoms] underlying hypothesis [of the sanctity of human life]."

"Given the concerns about abuse and the great difficulty in creating appropriate safeguards, the blanket prohibition on assisted suicide is not arbitrary or unfair."

Supreme Court of Canada 1992 ruling 

"[The Supreme Court agrees] that a permissive regime with properly designed and administered safeguards was capable of protecting vulnerable people from abuse and error."

"We should not lightly assume that the regulatory regime will function defectively."

Supreme Court of Canada, 2015

"The risk we have is sending a message to the country that life is expendable, that we are prepared to say that we do not care enough for people to take care of them."

Member of Parliament Joe Comartin, NDP

Vancouver man Ray Chwartkowski holds up a picture of his sister Cheryl (seen as a child in the picture with her mother, Rose). Cheryl received medical assistance in dying in 2019 at age 50 and Chwartkowski believes his sister (who suffered from lifelong mental health issues) should not have been eligible as she did not have a terminal illness.  Photo by Jason Payne/ PNG

It's a long and wicked, winding road that leads to federal legislation legalizing assisted suicide. Most Canadians weighed their thoughts over the grave issue involved...should people suffer horribly from end-of-life pain and anguish when it is clear they haven't much longer to live and see no value to them in continuing to live out the very last days, weeks or months of an existence that promises them nothing but pain and misery until mind and body can absorb no more and nature takes its course?

 

That same empathetic public could not have foreseen that enacting legislation for assisted suicide would gradually undergo 'adjustments' in widening eligibility from those suffering from untreatable conditions in agony with a foreseeable end, to accepting requests for an expedited death from an increasingly wider group of people dissatisfied with life itself and looking for state agency in ushering them out of existence. To the point where people with mental illness that is treatable, including youth, are given the option of medical assistance in dying. 

Criminal Code bans on doctor-assisted suicide was enabled by a 2015 Supreme Court decision. A decision that led the current government to encode legal euthanasia into law. This, after two decades earlier the Supreme Court unequivocally rejected the legal concept of assisted suicide.  Until the Supreme Court interpreted the denial to citizens of an option to end their own lives, violated Charter guarantees against the "security of the person", after all.

Belgium had already experienced years of legalized euthanasia. And there a number of controversial cases where state-sanctioned death was extended to citizens with no terminal illnesses had arisen. When the Supreme Court was debating within itself the direction it should take on the issue, it sought consultations. One of which was Belgian bioethicist Etienne Montero, flown in to speak before the Court.

"Strict safeguards", he averred, was illusory. "Once euthanasia is allowed, it becomes very difficult to maintain a strict interpretation of the statutory conditions." A forewarning gained through unfortunate experience. Enter this gate and expect to remain there; for there is no exit. The Canadian justices chose to dismiss the Belgian experience as "the product of a very different medico-legal culture", offering no lessons for Canada.

Consequently, federal legislation extended medical assistance in dying (MAID) only to "competent adults whose deaths are reasonably forseeable", meant to defend the "interests of vulnerable persons in need of protection". A non-partisan cross-section of Members of Parliament during parliamentary debates over the bill spoke to their fears of green-lighting an assisted suicide regime that might over time extend to the disabled or the mentally ill.

 

In 2019, the Quebec Superior Court ruled that a violation of the "security of the person" was in fact a fault of the legislation in extending assisted suicide only to Canadians with terminal illnesses. "The fact that doubts have been raised is one thing, but any possible slippery slope' remains theoretical", read the court statement. The federal Supreme Court took notice and so advised the government.

 

The government reaction was to remove terminal illness as the qualifying requirement for MAID. Beginning in 2023 MAID will extend assisted death to Canadians with a sole underlying condition of mental illness. People with severe disabilities have already joined the roster of eligible candidates for euthanasia, to the shock and horror of disability advocates.

 

In June, Trish Nichols whose suicidal and severely mentally ill brother was granted assisted death at a British Columbia hospital when MAID was still theoretically limited only to those with terminal illnesses, spoke to the Medical Assistance in Dying Committee. His family had brought her brother to hospital following a psychiatric episode. Minutes prior to a lethal injection he screamed uncontrollably though the hospital gave assurances he had chosen a medically assisted death "of sound mind". 

 

In this 2020 photo, Minister of Justice David Lametti gives a thumbs up as he rises to vote in favour of a motion on Bill C-7, which dramatically liberalized euthanasia access in Canada. Photo by The Canadian Press/Justin Tang

"Would you feel safe now, bringing your suicidal loved one to seek medical care for recovery when there are no oversights or stringent safeguards surrounding a procedure that kills people?"

Trish Nichols testifying before the Medical Assistance in Dying Committee

The Penalty is Freya's

"[Freya] posed a continued threat to human safety. Through on-site observations the past week it was made clear that the public has disregarded the current recommendations to keep a clear distance to the walrus."

"Therefore, the directorate has concluded, the possibility for potential harm to people was high and animal welfare was not being maintained."

"We have considered all possible solutions carefully. We concluded that we could not ensure the animal's welfare through any means available."

"We have great regard for animal welfare, but human life and safety must take precedence. [The operation was] conducted in a humane fashion."

Frank Bakke-Jensen, director, Norwegian Fisheries

Freya, named after a Norse goddess, became a celebrity after being seen in viral videos climbing into small boats to nap. NTB/AFP via Getty Images

The 'operation' in question was a reference to the decision to euthanize the young walrus that has become such an endearing curiosity with its presence -- its comfort in the presence of humans and its propensity to want to join humans in their aquatic activities -- that people out of curiosity flocked to see her. In so doing, placing her in danger. She no more was aware of her strength and the potential for inadvertently harming people through close contact, than were the people who ignored cautionary signs and requests that they stay beyond a safe distance from the animal.

The difference being, of course, that Freya the Walrus was innocent of intent to harm, not understanding she could accidentally cause grief, the prospect of which would be beyond her animal brain -- and humans whose intellectual capacity was evidently no greater than Freya's continuing to ignore the pleas to protect themselves while protecting the walrus, placing both themselves and the trusting animal in harm's way.

Tourists and locals both, in Norway, have all been responsible for the reluctant decision by authorities to remove Freya from the danger people placed her in, while endangering themselves at the same time. Leaving animal welfare activists to mourn the loss of life of this friendly animal as being "infinitely sad". People had taken to swimming alongside the mammal and did not hesitate to bring children within touching distance. And as ignorant people are wont to do, some threw objects at her.

 

TOR ERIK SCHRDER/NTB/AFP via Getty Images

 

Freya weighed in at about 1,300 pounds. She occasionally climbed onto boats, getting herself comfortable to bask in the sun or to have a nap, lying in the boat. On occasion those boats would sink; no harm to Freya. Walruses have a protected status in Norway. Unfortunately, people enthused at her presence allowed their curiosity to get the better of their common sense, and in the process consigned her to death.

Officials hoped that she might leave of her own volition, considering euthanasia to be a last resort. Authorities' pleas to maintain a safe distance went ignored and Freya continued to attract attention. An image of Freya crowded by people within touching distance of the walrus was released a week ago by Norway's fisheries minister in a last-gasp effort to attempt to persuade people to be reasonable. 

Normally walruses live in the Arctic, so Freya's extended journey to Norway was highly unusual when she showed up after travelling into the North and Baltic Seas. She had been sighted in the United Kingdom, the Netherlands, Denmark and Sweden. But she spent part of the summer in Norway. In mid-July she was first seen in Oslo. She was estimated to be five years old, when she died.

Photo: TOR ERIK SCHRDER/NTB/AFP via Getty Images

Assisted Death -- Relaxing Rules and Regulations

A court in The Hague ruled that the doctor did not have to re-establish the wishes of her patient at the time of administering euthanasia.    Credit...Aleks Furtula/Associated Press

"This freedom has been there in law [Netherlands euthanasia law] from the beginning, but the law is being interpreted more and more broadly."

"Nobody can look inside the head of someone with dementia."

Jaap Schuurmans, researcher

"[In cases where a patient has advanced dementia], It is not necessary for the doctor to agree with the patient the time or manner in which euthanasia will be given."

Netherlands right-to-die medical code change

The Netherlands recently updated their euthanasia rules to permit doctors to use sleeping pills for patients to prevent patients suffering from dementia from becoming violent preparatory to receiving lethal injections to end their lives. Dissolving pills in a patient's drinks will serve to pacify their urge to violence, avoiding the inconvenience of an awkward end to their lives. The amended code supports the use of sedatives in food or drink of patients with advanced dementia should any concerns arise that the patient might be "disturbed, agitated or aggressive".

"It's only two or three cases a year but this might  help doctors to have less fear of a penal case", suggested Jacob Kohnstamm, chair of the regional euthanasia review committee, stating this to be a needed clarification to relieve fears of prosecution in the instance of reasonable, professional judgement carried out by doctors when faced with such situations requiring action to be taken to end a sufferer's life humanely.

The changes were occasioned when a court ruling overturned a murder charge against a nursing home doctor. Marinou Arends had surreptitiously placed a sedative into a 74-year-old's coffee, who was suffering from dementia, before he proceeded to administer a lethal injection. Having reached an advanced stage of dementia, the woman was no longer capable of any kind of informed consent on the treatment's timing. The doctor was in possession of an instruction from the woman who had stated she wished to die when she felt "the time was right".

Dr. Arends received a written reprimand by the Dutch medical board for having acted on "advance directives". According to critics of the doctor's actions, the patient had been victimized, a dignified end that euthanasia is meant to provide, having been denied her. A relative present during the procedure had pushed the woman back down on the bed when the had sat up in an effort to avoid being given the injection. There was obviously no comfort given the dementia patient as death was delivered.

According to the Dutch Supreme Court, the doctor had acted within the country's euthanasia law, enacted in 2002. The court ruled that should a patient no longer be capable of consent due to dementia, medical professionals were given discretion to determine for themselves when the correct time had arrived to terminate said patient's life. Opponents of euthanasia were alarmed at the ruling. The Netherlands, a pioneer in the practice of euthanasia, according to opponents has taken to interpreting set rules ever more inclusively.

Contradicting the critics, the country's euthanasia review committee is of the belief that the amendments to its code provides doctors with additional legal support in such instances where it is deemed to be "pointless" to attempt consent by the patient. Some Dutch medical practitioners have opposed the ruling. Over 200 doctors issued a statement that no doctor should be allowed to secretly sedate patients before euthanasia, when news of Arends's case emerged in 2018.

Coincidentally, in Germany, two terminally ill patients being treated for COVID-19, ages 47 and 50 were administered medication by a senior doctor that led to their immediate deaths. Employed at the University Hospital in Essen city in North Rhine-Westphalia, the 44-year-old doctor was arrested and charged with manslaughter this past week, and remain in custody. Essen police have divulged that in one case the doctor stated his intention was to end further suffering of the patient and his relatives.

A newspaper account described the two patients as suffering from coronavirus infections, their condition in his ward, according to the doctor "very critical". No further information was forthcoming relative to the treatment the patients had received. In Germany, seriously ill patients have the freedom to request assistance in ending their lives, under a court ruling of last year. Whether this happened in the doctor's case is as yet unclear; several steps are required before the provision of such assistance. An investigation is ongoing.

The doctor was employed at the Essen University Hospital

The unnamed doctor is facing manslaughter charges, in a country where assisted death is an extremely sensitive topic, considering the legacy of six million European Jews experimented on, used as starved slave labour in Nazi Germany's munitions factories, and finally annihilated by the regime during the Holocaust years amidst the Second World War.

Innocuous MAID, Finality of Euthanasia

"[An extension draft policy on the legal age restrictions for] medical-aid in dying: MAID [was developed] with an eye to a future when MAID may well become accessible to capable minors."
"Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID."
"[There are doubts a difference of any meaning exists for the patient] between being consensually assisted in dying [in the case of MAID] and being consensually allowed to die [in the case of refusing life-sustaining interventions]."
"[In Ontario], young people can be and are found capable of making their own medical decisions, even when those decisions may result in their death."
"How should health-care providers respond if a capable patient requests MAID but their parents clearly oppose this request? Are there situations in which MAID requests and administration would be kept secret from parents and other family members, for example, if a capable patient were to indicate that they do not want family members involved?"
Hospital for Sick Children, Toronto, draft policy team

Doctors from Toronto’s Sick Kids Hospital have outlined policies and procedures for medically assisted death for children. Photo from Wikipedia

"A young person experiencing grievous and irremediable suffering is unimaginably tragic."
"[However, assisted dying requests from minors would be certain to relate to] very, very small numbers [such that any changes to the law] would, of course, require corresponding changes to hospital policy."
Randi Zlotnik Shaul, director, bioethics, Hospital for Sick Children

"I have no doubt that a child might ask for it, but whether they could really fulfill that competency test for such a major life-shattering decision, the U.S. says no."
"[Legalization of euthanasia for children under 18 would be] enormously controversial."
Arthur Caplan, bioethicist, New York University

"I'm worried about how far people may be pushing this. [When the Supreme Court of Canada struck down the Criminal Code prohibitions in 2015, it] clearly did not equate medical assistance in dying with just any other form of medical care."
"We do put limits on individual choices of mature minors that expose them to harm. I think we have to carefully reflect on what it would mean to allow this particular practice without involvement of the parents."
Trudo Lemmens, professor in health law and policy, University of Toronto

The only two jurisdictions in the world which have legislated for assisted suicide for minors are the Netherlands and Belgium. Belgium permits terminally ill children whatever their age to request euthanasia, as long as they have secured their parents' consent, while the Netherlands has enacted a law requiring parental consent for 12- to 15-year-olds while permitting 16- and 17-year-olds to request a doctor-assisted death.

Now it is the largest children's hospital in Canada where a policy has been drafted foreseeing the time when children could be entitled by law to be euthanized on their own initiative. The Sick Kids' team was comprised of bioethicists, palliative care doctors and health professionals in related fields, the report published in the Journal of Medical Ethics. The working group within the hospital points out that there are willing doctors who could "safely and effectively" perform euthanasia for terminally ill youth 18 and older, meeting criteria as set out in federal law.

It would be "antithetical" to the hospital's philosophy of care should age of patient kick in to force a transfer of young patients to an unfamiliar adult hospital, stated in support of the hospital's willingness to have such permissive legislation put into effect. Mature minors in most provinces are now permitted by law to make decisions relating to their medical care, including the withdrawal or withholding of life support. A minor is considered "capable" of providing consent in Ontario, if possessed of the maturity and intelligence to make decision on treatment, able to appreciate "reasonably foreseeable consequences" of their decision.

Generally, families are involved in such decisions, with every effort spent in encouraging youth to involve their family; however, "ultimately the wishes of capable patients with respect to confidentiality must be respected", the report emphasizes. As it does that the same rules should apply to MAID since no meaningful ethical or practical distinction exists between assisted dying and procedures effectively resulting in ending life such as palliative sedation (drugged to sleep until death arrives) or withholding or withdrawing life-sustaining treatments.

An expert panel report struck to present the Liberal government with the reasoning leading to exploring euthanasia being extended to mature minors in December coincides with this Sick Kids' report, where the Canadian Council of Academies was requested to examine cases where mental illness represents the sole underlying medical condition, along with "advance requests" to end life, in the future. For the purpose of protecting staff from "potential violence and social harassment", the names of doctors who volunteer to provide MAID are not to be made public, according to the draft.

Some doctors whose work brings them into direct care for terminally ill children express outright horror at the very idea of euthanasia provided for children, arguing that when all hope for a cure is exhausted, pain and other symptoms are manageable in minimizing suffering. And in those rare instances where suffering is clearly not to be borne, a child can be sedated to sleep until death occurs. An injection of barbiturates in assisted dying, ends life immediately.

Toronto’s Hospital for Sick Children has developed a draft policy on doctor-assisted dying that applies exclusively to youth aged 18 and older, but it could one day apply to minors.   Getty Images

MAID: Medical Assistance in Dying and Organ Harvesting

"If we accept people can make decisions to end life, and we accept the idea of cardiac death being sufficient for organ donation, t his should be acceptable."
"The concern that comes up is, could the decision for one drive the decision for the other?"
"There's a lot riding on this. If somebody has organs that would be appropriate to donate, you'll never get better organs than you would by this process [harvest post-] MAID."
Dr. James Downar, co-chair, Canadian Blood Services committee organ donation guidelines

"This [feeling compelled to pursue decision] is a theoretical possibility. Imagine a situation where the workup is done -- people have gone out and done the medical tests and found the recipients and set everything up. And then you change your mind."
"One wonders if perhaps that might create pressure to continue with the MAID. It would be very important in these scenarios to make it very clear to people that they can change their mind at any time -- that someone shouldn't stick with MAID just because they feel an obligation, having set the process in motion."
"I'm torn between a sense of, is it any harm to let people know [the donor died by assisted death]? After all, if it really bothers them, there will be someone else who will benefit greatly from this donation. They will just bypass the person who objects and go to the next."
Jennifer Chandler, professor, centre for health law, policy and ethics, University of Ottawa

"I think it's really important we keep the public's trust, in all of this."
"We have to be transparent. And it has to be clear that the two must be kept separate, that there is no pressure to go for MAID to procure organs [for transplantation]."
"[The terminally ill] may feel they would better serve society by dying and saving other people's lives." 
Dr. Marie-Chantal Fortin, transplant nephrologist, Centre hospitalier de l'Universite de Montreal

Medical team performing surgery on patient who had undergone medically assisted suicide. Getty Images

The conventional major source of transplant organs has been people who have been declared "brain dead", where patients are removed from ventilators and similar life support mechanisms meant to keep hearts and lungs functioning. Live-donor donations have more recently become another means to produce organs for transplant, when people decide to voluntarily donate pieces of their liver or a lung out of a sense of public duty and charity sometimes related to a specific patient, sometimes altruistically.

The Canadian medical community has recently adopted a practise of urging organ donation after cardiac death involving people on life support for whom the chance of recovery is medically dim. When life support is withdrawn and the heart stops beating, a five- to 10-minute "no touch" period ensues, after which the organ/s can be harvested. Because death takes its time; up to two to three hours; vital organs such as the heart and lungs begin deteriorating, resulting from lack of blood flow and oxygen.

When assisted dying is involved, organs have the potential of being retrieved swiftly once the heart stops within two to three minutes of the injection. What troubles ethicists, however, is the coupling of assisted death and organ donations. What is also to be considered is whether those organ recipients whose moral or religious objections to euthanasia entitles them to be informed that the organ offer has come from someone who chose an medically assisted death. In most instances cause of death is not routinely revealed, such as in the case of suicide, barring a valid medical reason for disclosure.

Even so, the pool of organs to be transplanted from those undergoing medically assisted dying is not a large one, given that most patients requesting assisted dying are suffering from advanced stages of cancer, making their organs transplant-unsuitable. Those, however, suffering from neurological disorders such as multiple sclerosis, have organs that are good candidates for transplant. Over 4,500 people were awaiting an organ donation in Canada in 2014, and from among them 278 died, while waiting for a transplant that never materialized.

So far, in Ontario, 26 people who chose to die by lethal injection have been donors of tissue or organs since decriminalization was passed last June. Since that time, 338 people have died through medical assistance altogether, in the province. Tissue donations represent eyes, skin, heart valves, bones and tendons. Experts feel that those who qualify for aid in dying could gain a sense of psychological comfort in the knowledge they have, through donating their organs, saved someone else's life.

And that comes up hard against those concerned that organ donation decisions might place pressure on those who qualify for assisted death. The issue appears to be, should someone agree to donate their organs, would they feel compelled by those circumstances involving the health and life of other people, to continue the procedure of assisted dying even though they may have decided they would prefer not to proceed?

Two countries that have long since legalized medically assisted death requests -- Belgium and the Netherlands -- appear to have solved the dilemma of their own concerns relating to the issue, and have long harvested organs after euthanasia. Infamously, China operates a thriving organ transplant/tourism 'business' in organs harvested from prisoners who have somehow died while incarcerated. The country stands accused of harvesting organs from still-living prisoners, as well.

“MAID (medical aid in dying) has the potential to provide additional organs available for transplantation. Accepting to procure organ donation after MAID is a way to respect the autonomy of patients, for whom organ donation is an important value. Organ donation after MAID would be ethically acceptable if the patient who has offered to donate is competent and not under any external pressure to choose MAID or organ donation”. Julie Allard and Marie-Chantal Fortin, bioethicists at the University of Montreal

Objecting Conscientiously

"The whole idea of basically sending them [patients in morbid end-of-life decline] to their death, I abhor."
"[Families already have asked] what about this euthanasia legislation [in Canada]? They would say, 'what do you think about it? And, if mom starts having a lot of suffering, can we count on you to be the provider?"
"I loved my patients. I feel very strongly people are a precious commodity. I thought, 'I don't want to be faced with this'."
Dr. Nancy Naylor, family physician, Strathroy, Ontario

"The prohibition against assisting someone to commit suicide is millennia old. You don't just strike out those conscientious beliefs with the stroke of a pen after they've existed for hundreds and hundreds of years."
Jay Cameron, lawyer, Justice Centre for Constitutional Freedoms

"The idea that doctors are somehow special and that their private views matter more than doing their jobs is ridiculous. [ The Hippocratic oath is] a very old document written by members of a Greek sect, with its own peculiar history [with no legitimate bearing on the practise of modern medicine. It isn't fit for today's purpose, and even if it was, those deploying it as a means to avoid providing particular professional services pick and choose only those bits they agree with and ignore the rest."
"It seems weird that  you would choose to become a professional in a particular discipline voluntarily, you know the scope of practice can be changed by society. And then you turn around and tell people in that society that enabled you to do all these things, 'Stuff you, because, quite frankly, my private beliefs are so much more important'."
Udo Schuklenk, bioethicist, Queen's University

Dr. Schuklenk has no sympathy whatever with the private consciences of physicians and other health-providers who will be called upon to participate in Canada's new assisted suicide laws guaranteeing the escape of death to people whose health has failed catastrophically leaving them with no future other than a continued steep descent into the finality of death. There are many such health providers who wince in pain at the very prospect of this law coming into full regulatory force.

These physicians and other health practitioners who will be expected to use their medical expertise and the trust that patients hold them in, to usher patients with hopeless medical conditions toward death on request feel instinctively that this will transform them from healers to killers, and they refuse to either condone or participate in the new protocol of euthanasia. Even that part of the protocol that would permit them to step away from active participation by referring to another doctor who has no such qualms horrifies them.

The manner in which such protocols have spiralled into the kind of use that has granted legally-assisted death to people who simply are sick of life, people who refuse to compromise with reduced quality of life, including accepting the death wishes of children whose lives are painful torments rather than proffer to them, as needy patients, all the survivability that medical science can offer with palliative care, stuns these objectors.

Dr. Schuklenk and a colleague Ricardo Smalling have written a paper published in the Journal of Medical Ethics that no regulated and lawful health system should permit any doctors to choose to be exempt from taking professional part in assisted suicide, that their pleas for accommodation should be rejected. "In more rural communities you could easily have 100 percent conscientious objectors", he pointed out.

On the other hand, the Canadian Medical Association feels that his argument is strictly in the realm of pure theory "Until I hear of an example that, in such-and-such a place there are ten doctors and none of them want to participate, then I would say we just don't have evidence that will happen", was the tart rejoinder by Dr. Jeff Blackmer, head of medical professionalism at the CMA, rejecting that defense of Dr. Schuklenk's contention.

The perspective of Dr. Brad Burke is that voluntary euthanasia and assisted suicide had not even remotely entered the conversation when he began medical school in 991. "No one ever thought this could happen." This Windsor Ontario physician practices medicine and rehabilitation, treating people suffering the aftermath of severe strokes, spinal cord injuries and head trauma. The very health demographic he feels representing those who could very well "ask me to kill them, or refer to someone who would."

Tyler Brownbridge / Windsor Star    Dr. Brad Burke argues assisted suicide and voluntary euthanasia were nowhere on the horizon when he entered medical school in 1991. 'No one ever thought this would happen.'

"I believe that everyone is created in the image of God. I have no problem trying to do my best to care for patients and to be compassionate. I just don't feel killing them is compassionate", he added. He renewed his medical licence in Michigan this year, where assisted suicide is illegal. As for Dr. Naylor, a practising physician for the last 37 years, with this new law coming into effect, she feels she has no option but to hang her shingle up high on a shelf to gather the dust of regret.

Is 'Assisted Death' Legalized Murder?

"A five-year-old? A seven-year-old? They would never be seen as having the capacity or competence of making these decisions."
"I could definitely see 12-year-olds having that capacity [to exhibit maturity and mental competence], and I could see 16-year-olds not have that capacity."
"We [nine-member advisory committee] just didn't feel that to make an arbitrary decision that, at 17 years and 364 days you wouldn't meet the criteria [as an adult], but the next day you would. We felt that wasn't the way to go." 
"We heard from stakeholders on both sides who agreed with each other that there shouldn't be a list of conditions set out -- don't list cancer and don't list Lou Gehrig's disease' -- because that list will always change. What is incurable today might become curable tomorrow. Everybody said don't come up with a list, it wouldn't be workable."
Maureen Taylor, physician assistant, assisted-death advocate

"That's already well established in our system [the 'mature minor' making their own medical decisions including discontinuing life support]."
"The idea of an arbitrary age limit, and people suffering intolerably and waiting days, weeks or months to die because they haven't reached that limit, seems morally unacceptable."
"End-of-life decisions are being made every day in Canada by mature minors. Doctors make decisions about competence and capacity all the time."
"I'm asking readers to imagine a patient with metastatic cancer that has spread throughout her body, who has received the best possible care but who is suffering intolerably and is almost certain to be dead in two weeks, and who requests assistance to hasten her dying." 
Arthur Schafer, ethicist, panel member, director of Centre for Professional and Applied Ethics, University of Manitoba

The Levenseindekliniek, an 'end-of-life clinic' opened in 2012 in Amsterdam, offering services to patients whose doctors refuse to cooperate with requests for euthanasia or assisted suicide. The suitcase with necessities the GP of the End-of-life clinic' uses when the life of a patient is terminated. Jean Pierre JANS/REA/Redux

The nine-member expert panel assigned to produce a report on euthanasia in Canada came up with a number of recommendations, the most controversial of which is that there should be no "arbitrary age limits" for assisted death. Eligibility, in their considered opinion, should logically be based on maturity and mental competence, and not age. The criteria by which maturity and mental competence would be based in any such instance presumably would be a matter for the consulting physician to judge augmented by the parents' assurances should they agree.

Last February the Supreme Court of Canada granted the right of mentally competent adults suffering from "grievous and irremediable" conditions the constitutional right to request a doctor-assisted death. The federal government was given a year in which to see an appropriate law drafted. The advisory panel's purpose was to give guidance to the provinces and territories to come to terms with the prospect of legalizing assisted death. On the issue of who might be age-eligible, the Supreme Court did not specify any age limit, speaking only of "adult" competence; the age of maturity in most provinces being 18.

The panel's argument hinges on the issue of the "mature minor" concept, where minors are held capable, if they comprehend the full nature of their illness and the repercussions of their decisions, to make a life-ending decision to discontinue life support. No age restriction currently mandates when someone can decide to discontinue the often-terminal use of a respirator or ventilator, or to refuse an antibiotic or to halt kidney dialysis, goes the panel's argument. Why should it be any different for requesting an end to suffering by doctor-assisted suicide, since decisions as noted above also lead to death.

In a 2009 case, the Supreme Court had ruled that children under 16 who were capable of demonstrating sufficient intellectual maturity should have their wishes respected with relation to their medical treatment. Experts and organizations across Canada were consulted by the advisory panel. The end result was a final report listing 43 recommendations ranging from qualification criteria for lethal injection or doctor-prescribed drug-overdose, to the ethical obligation of doctors objecting on religious or moral grounds to become involved other than referring a patient to another doctor.

Belgium became the first country in the world, in 2014, to legalize euthanasia by lethal injection for children. Belgium's Parliament approved the law passed previously by its Senate. Under this law young children are permitted to end their lives with the assistance of a doctor. In 2015 the Netherlands sought to follow Belgium's example:
"We feel that an arbitrary age limit such as 12 should be changed and that each child’s ability to ask to die should be evaluated in a case-by-case basis", said Eduard Verhagen, paediatrics professor at Groningen University.

Assisted suicide deaths and euthanasia has doubled in the Netherlands in five years. In Belgium the increase has been over 150-percent in the same time-frame. Most Belgian patients suffered from cancer, but people were also euthanized who were suffering from autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness and deafness, and manic depression. One 44-year-old man was euthanized as a result of being devastated by the failure of his sex-change surgeries.

In 2014, 13 percent of Belgians euthanized had no terminal health condition; about three percent suffered from psychiatric disorders. Euthanasia accounts for close to five percent of all deaths in Flanders.  Last year, De Standaard, a Flemish newspaper, saw fit to publish a human-interest story as a tribute to a depressed mother who was euthanized after having been abandoned by her boyfriend and becoming disillusioned by the psychiatric care she was given.

The Final Parting

"Jesus, what is it with these doctors? On the one hand they say the patient has the right to identify 'intolerable suffering' and on the other hand they say it is within the doctor's gift to decide what is 'grievous'."
"So are we to infer, then, that there could be intolerable but not grievous suffering, where the doctor is entitled not to act?"
"These colleges think that they're not simply God, but that they're an assembly of gods. They simply do not understand that in the eyes of the law, they're not gods, they're service providers."
Amir Attaran, professor of law, University of Ottawa, Canada Research Chair in Law, Population Health and Global Development Policy

"[It is incorrect and] ethically unsustainable [for the colleges to state doctors are to decide what is in a mentally competent patient's best interests]. That is the role and the right of the patient."
"But I think we have to be very careful not to see slippage of some kind of judgement going into the assessment of grievous."
"If you say there is a higher standard with respect to consent -- meaning you have to be more rational, more reasonable than you do when making a decision about something that's not 'divisive' -- then fewer people are going to have access."
Jocelyn Downie, professor, faculties of law and medicine, Dalhousie University, Halifax

"This is our first stab at this [draft advice to doctors]. In the consideration of whether you assist a patient to end his or her life, there has to be a balancing of these competing interests, and an understanding that, just because the patient wants it, in not every circumstance is that the right decision."
Dr. Trevor Theman, registrar, College of Physicians & Surgeons of Alberta 

"In some cases, the physician and patient will have a different understanding of whether PAD [physician assisted death] is in the patient's best interests. [Such situations may require] reconciliation through the courts."
"To be explicit: in some situations a physician may offer the opinion the patient does not suffer from a grievous and irremediable condition in which case physician-assisted death should not be offered."
Draft advice, The College of Physicians & Surgeons of Alberta

Fotolia   As the provinces wrestle with who decides when a patient is ready to depart this world, ethicists say the regulators are playing God

The issue is end-of-life decision-making. The Supreme Court of Canada gave notice of the right of severely ill people facing end of life situations to hasten their deaths through their identification of "intolerable" suffering from which they wish to escape life, prematurely to what might be considered the natural process of reaching death. On the premise that who is better positioned to identify "intolerable suffering"; the very people hastening death by their decision to request the assistance to die, yet there is an onus to demonstrate such a decision is "reasoned".

While various provincial medical associations have made an effort to guide their medical membership, some experts in the field of ethics believe that in so doing, they are co-opting authorization from the patients themselves.  Saskatchewan feels that competent adults should be free to make their decisions about their body; "to the extent possible, all those who meet the criteria for physician-assisted dying and request it", should have unquestioned access.

Dr. Theman, college registrar for Alberta, agrees but equivocates; claiming the fundamental value of the Supreme Court ruling; patient autonomy -- still comes up and competes against a physician's professional duty to be aware and act in the patient's best interests; the two are sometimes at odds; patient autonomy and a doctor's duty, and a balancing act then results to adequately and fairly reflect both sides of the same issue.

The Province of Quebec comes up hard against the Alberta interpretation respecting who is to determine whether assisted death is in an individual's "best interests". Quebec's position is that suffering is the fundamental relating to the patient's perception. While Manitoba would like to institute a regimen whereby a psychiatric assessment would be mandatory of anyone seeking assisted death whose condition is not terminal.

Looming close on the horizon in Canada is the legalized assisted suicide and euthanasia law, and with doctors concerned at the impact this will have on their profession and their new and in many instances,  unwanted [some go so far as to claim unwarranted] obligations, the medical colleges have stepped in to provide guidelines. The result of which may be a mixed bag, depending on where anyone lives, with one province providing access at the patient's determination, others requiring specific affirming tests.

The Criminal Code ban on doctor-assisted death is set to expire in Canada on February 6, 2016. The provinces of Alberta, Saskatchewan and Manitoba have proposed policies relating to the issue, and are looking for useful responses. Ontario is in the preparation mode on interim advice to Ontario doctors. Quebec, on the other hand, has produced a precise euthanasia guide, a step-by-step instruction manual on administering life-ending injections reflecting the gravity of the end result.


Bringing this new ruling into law will not result in legislation favoured by most Canadian doctors who have no wish to be complicit in ending life when their profession gears them toward prolonging life. Even when they are guided toward a gently compassionate ethos reminding them of the links between life and death, the vitality and hope in the former, the inevitability of the latter. It is the suffering and pain and fear that people undergo and wish to terminate that leads society to this kind of intervention.

Where, according to the Quebec-sourced instructions, doctors are urged to perform euthanasia within a "peaceful and appropriate" setting, having turned off intrusively disturbing pagers and cellphones, informing colleagues they will be temporarily unavailable, their intention being to remain with the patient as a comfort and partner in the solemnity of life's end, until death do them part.

Brittany Maynard with her dog Charley in San Francisco. Maynard, a 29-year-old with terminal brain cancer, has died, advocacy group Compassion and Choices said in a Facebook post on Sunday -- CNN November 2014

Not Euthanasia On Demand : The Beginning of the End

"We don't want these recipes made too easily available to everyone."
"It is clearly not euthanasia on demand. It is clearly not that."
"The whole process, from beginning to death] would probably take something around fifteen minutes. [Some of the drugs are] thick [they cannot be administered by a] bolus [or] high-speed injection."
"If the vein is clotting, probably they have to remove the needle and find another route of entry. [The cost of medications] is something surely less than $100."
"We are talking about the administration of drugs, so the effect is almost immediate. In an oral route, it can take hours to have the effect."
"We think there should be as minimum time as possible between when the act is begun and the effect occurs, to limit the effect on the patient, and on the family and friends."
"This is why it's so important before beginning the three steps that the physician checks, or validates a last time, the will of the patient."
"Nobody feels prepared. We are exploring a new continent. But we have to learn how to do this as best as possible. There is a beginning for everything."
Dr. Yves Robert, college secretary, College des medicine du Quebec

Phil Carpenter / MONTREAL GAZETTE    Dr. Yves Robert, right, secretary for Quebec's College of Physicians, speaks during a press conference with Dr. Charles Bernard, president-director general of the College, in Montreal.

The urgent need for doctors to be trained in best practices protocol has led to the formulation in Quebec of standardized kits to enable doctors to end the lives of patients who wish to depart this mortal coil. A collaboration between the Order of Pharmacists of Quebec and the Order of Nurses of Quebec, a formal guideline to aid doctors in this process has been developed and appears on a secure area of the Quebec College of Physicians' website.

The kit is to contain drugs to calm the nerves and drugs which will halt breathing. Included in the kit will be instructions to guide doctors undertaking the procedure in preparation for the province to usher in legalized assistance in dying for patients whose condition is deemed to make them eligible for euthanasia. The guide is carefully explicit, meant to aid doctors before, during and after administering euthanasia to eligible patients.

Set out in a step-by-step process is the type of drugs to be used, the correct dosage, the injection site and how to respond should complications arise. Quebec is set to become the first jurisdiction in Canada permitting competent adults whose life is suffused with intolerable suffering as their end of life approaches to seek "medical aid in dying". And that permission is to be introduced in December.

Quebec's Bill 52, the first of its kind in Canada, permits doctors the administration of lethal injections to patients suffering an incurable illness, in unbearable physical or psychological pain, who are considered to be mentally fit to make such a decision for themselves. The individual must be seen to be approaching the end of life, in an advanced state of irreversible decline.

The Supreme Court of Canada discarded the century-old Criminal Code prohibitions against euthanasia in February, opening up to euthanasia and physician-assisted suicide, while abstaining from defining "physician-assisted death".  A broad interpretation of physician-assisted suicide would have a physician write a prescription for an overdose that the patient would themselves administer to end their life.

The Quebec guidelines will appear as a template for the entire country. It has its origins in a formula that has been used in the Netherlands. The protocol that Quebec has adopted is for a three-phase approach via lethal injection. A benzodiazepine [type of sedative] would be injected to ameliorate anxiety and "help calm the patient". Then a barbiturate drug would be injected, inducing coma. The final step would be a neuromuscular block that causes "cardiorespiratory arrest", acting on the respiratory muscles.

Doctors are instructed to be alert for reactions; allergic reactions or vomiting, and to have a care not to lose access to the vein. The euthanasia packages, prepared by pharmacists, are to contain two complete treatments, should a backup be required. Unused drugs are to be returned to the pharmacy from whence they came.

To ensure that doctors in Quebec comply with the guidelines, an special commission on end-of-life care will monitor compliance. The Quebec college of physicians had looked elsewhere for guidance, consulting with the first doctor in Oregon who had prescribed a legal dose of life-ending drugs, discovering that "bad side effects" sometimes can arise. Oregon law prescribes drugs to be taken orally, not injected.

The early experience in Oregon has been that some patients have regurgitated the drugs, alternately in some instances "reawakened" hours, occasionally days, after swallowing the lethal drugs. The journey to death has, as a result, taken far longer, and caused more anguish in these instances than anticipated.

People who opt for euthanasia can put a halt to the processes at any time up to the last moment before consciousness is lost. Euthanasia could be performed in a hospital, in a palliative care hospice, or alternately, the individual's home, surrounded by family.

Assisted dying in Canada; urgent need for doctors to be trained

Planned Procedure

• A sedative to calm the patient;
• A drug to induce a deep coma;
• A drug to induce cardiorespiratory arrest (two sets of each drug to provide a backup in case of complications);
• Syringes;
• Needles in different calibre sizes;
• IV tubing;
• IV solutions.

The Crowning Dilemma

"There's no moaning or groaning. The person might say a few goodbyes, or thank-you's, and then just falls asleep."
"[Under U.S. law overdose drugs must be oral, not by injection; a feeding tube could work] but the patient would need to do that. No other person could push it through. But that's much less likely, or common."
"People generally fall asleep within three to five minutes. It's a very quiet and gentle death. It's just a falling into a very gentle sleep and then, when the breathing stops, the heart stops a minute or two later because there's no oxygen in the blood. It's just very simple."
"I have seen technology keep people alive and suffering. I think  you have to think about it a long time for  yourself -- you have to realize we're no longer able to cure now; these are people who can't be healed. And we can't abandon them."
Dr. David Grube, Philomath, Oregon

"When I've done it, I've never felt like I was killing someone, that's why I don't like the word 'killed'. I always saw it, and most of my colleagues will see it, as terminating the suffering of a patient."
"We know from the scientific research that it can take up to 24 to 48 hours [process of dying with drugs administered]. That is considered to be inhumane for next of kin. That was not the (intention) for assisted suicide."
"Many times we ask ourselves why we have 100 percent positive treatment success with our euthanasia, and they have those failures in the United States."
Dr. Rob Jonquiere (former) chief executive officer, Dutch Right to Die Society, Amsterdam

"Doctors who are going to participate in this are going to want to know, 'What drugs do I use, at what doses? How do I administer'."
"We've seen recent examples in the U.S. of botched executions (of death row prisoners) and medications at the wrong dose, or in the wrong combination."
"What is the standard of care in the Netherlands? What is the standard of care in Belgium? Have you had any difficulty getting access to these substances? Have you had studies on efficacy and what works and what doesn't?"
"What we have now are many years of these procedures being done in other countries that we can learn from. That provides me with some comfort."
Dr. Jeff Blackmer, director of ethics and professional affairs, Canadian Medical Association

"The prohibition on assisted dying is overboard. It imposes unnecessary suffering on affected individuals, deprives them of the ability to determine what to do with their bodies and how those bodies will be treated and may cause those affected to take their own lives sooner than they would were they able to obtain a physician's assistance in dying."
Supreme Court of Canada, February 2015

Doctors in Oregon are permitted by law to prescribe a lethal dose of medication to terminally ill, mentally competent adults whose life expectancy has been diagnosed as less than six months. The state's Death with Dignity Act came into effect in 1997. From that date forward, 1,327 people had prescriptions written under that legislation. Of that number, 859 patients died from the effects of swallowing the drugs, and the numbers of those events have been steadily increasing.

The patient, according to rural practitioner Dr. Grube, is instructed to take a stomach-lining drug an hour before, to avoid vomiting the lethal drugs after administration. An overdose of a barbiturate is mixed as a powder with two or three ounces of water and people are required to swallow quickly, within minutes to avoid falling asleep before they've imbibed the full dose effectively. Most patients take less than an hour to die but there have been incidents (19%) where people took longer to die.

A Belgian “euthanasia kit.” What can Canada learn from other jurisdictions when it comes to what method is best for medically ending a life? ETIENNE ANSOTTE/AFP/Getty Images

A handful have, in fact, survived the event. One man asked his wife when he awoke, "Why am I not dead?" The prescribing doctor was present for only 14 percent of patients, at the time of death, in 2014. Dr. Grube explained that in each failed case full directions were not heeded; the drug wasn't taken, for example, on an empty stomach or the person fell asleep before taking the full dose. "The consequences were only that the patient awakened, which of course was not the patient's desire", pointed out Dr. Grube.

On the other hand, pointed out Dr. Jonquiere, with lethal injection, death is almost instantaneous. "That's something you have to prepare the family for, because it happens really fast." In the Netherlands, euthanasia accounts for 2.8 percent of all deaths, and 0.2 percent by assisted suicide. Dutch doctors first inject pentobarbital to induce coma. Then a powerful muscle relaxant is injected, paralyzing breathing muscles.

In studies of 515 cases of euthanasia performed by Dutch doctors from 1990 to 1996, physicians reported technical problems along with additional complications such as difficulty accessing a vein, spasms and nausea and vomiting. Assisted suicide was more frequently associated with complications than was death by lethal injection. Canadian doctors are now facing the necessity to confront these background concerns to better inform themselves of what they might expect of their enabling role.

A new law in Belgium would grant children, with the consent of their parents, to end their own lives, as well as dementia patients in the early stages of the disease. Fotolia

Canadian leaders in the field of public medicine, since the Supreme Court struck down legal proscription against assisted dying, are looking now at the experience of doctors abroad in coping with the need to assist some of their patients to end their lives rather than endure additional suffering in a life whose time has come to an end. Ironically, it seems that the safest, fastest and most efficiently successful method may be death by lethal injection, a prospect that most doctors find appalling to their medical ethics and personal philosophy.

Which has led leaders of the Canadian Medical Association to turn to American and European jurisdictions that have legalized doctor-assisted death to help them better understand the successes and failures of the paths they have chosen to take, in a field that still represents as experimental and one completely contrary to the medical oath of professional conduct; to 'do no harm'. It takes a philosophical leap to convince oneself that there are times when the greater harm may be to let a death proceed whose journey is cruelly painful.

While many doctors grapple with their consciences and their squeamish attitudes toward hastening death when all their training and the weight of long tradition in the healing arts inform them that they must never be involved in inviting death to enter when medical science and technology make it increasingly more possible to extend life, even a life of excruciating pain, others wonder why the careful administering of pain-relievers and the compassionate attendance of end-of-life care workers does not represent a more humane option.

Euthanasia and assisted suicide are highly controversial, but so too is the debate about which method is best. FRED DUFOUR/AFP/Getty Image