We are heartened to see, for the second time, a more nuanced and critical view of euthanasia policy emerging from the Collège des Médecins du Québec.
In May 2017 Dr. Yves Robert, Secretary of the College, expressed concern about a loosening of the qualifying criteria leading to euthanasia no longer being a rare exception but rather “Death à la Carte”.
This time, in a letter to Health Minister Gaétan Barrette dated May 29, 2018, CMQ President Dr. Charles Bernard laments the fact that Palliative Care, ostensibly the first priority of end-of-life policy planning in Quebec, has been severely neglected as regards the investment of budgetary resources, in favour of supporting euthanasia, thus harming the development of Palliative Care in the province. The Collège has rendered a great service to doctors and patients alike, by confronting Minister Barrette with the glaring opposition between his stated end-of-life-policy and its implementation.
There is no doubt that the typical doctor and patient in Canada has a deeply rooted and perfectly natural preference in favor of non-lethal, Hippocratic, end-of-life care – supported by expert Palliative Care. Even those who consider euthanasia to be theoretically justified still see palliative care as the preferred option, which should be offered to everyone before any consideration of euthanasia.
Dr. Bernard refers to:
“Resignations and a lack of replacement in many palliative care facilities, compromising access to service.”
“Difficulty accessing palliative care even in those regions best served, due to inefficient coordination, inappropriate admission criteria, etc.”
“Well identified cases of patients, lacking access to such care, who may have had had no other choice than to ask for medical aid in dying” (our italics)
Moreover:
“Patients requesting medical aid in dying have been given priority access to available resources (such as medical evaluation, psychosocial and spiritual accompaniment, etc.) to the detriment of other end of life patients, having similar needs.”
And regarding the all-important functions of research and evaluation:
“This plan cannot achieve its objectives without research and evaluation… [which are] poorly funded… [and the subject of] timid investment.”
“The Commission for End-of-Life Care … will be unable to portray accurately the current state of palliative care, as it is overwhelmed by a single aspect of this task, that of assessing declarations of medical aid in dying…”
In other words, contrary to the stated goals of Minister Barrette in his signature end-of-life policy, Palliative Care is not in expansion. Professionals are leaving the field; patients have no better (perhaps worse) access than before; patients have chosen euthanasia because they could not get Palliative Care; and human resources of all kinds are allocated, in priority, to patients requesting euthanasia. And the evidence of these terrible facts is being largely swept under the rug because the oversight commission cannot, with the resources available to it, do more than collect data on euthanasia.
Much of the discussion revolves around the implementation – or lack thereof – of the Health Ministry’s 2015-2020 development plan for palliative and end-of-life care.
Several themes in this plan had a certain meaning before the Act respecting end of life care came into effect in 2015, but can be understood very differently now. Consider: the “patient as partner” who “while recognizing and respecting the expertise of team members, orients them around his own needs and life project.”; a “collaborative approach” between members of the team “around the patient’s [chosen, evolving] life project”; “continuity and fluidity” in a “continuum of care”… In the current context they could lead to the progressive destruction of Palliative Care, if the patient’s life project includes orchestrating his or her own death, and if the continuum of care includes euthanasia, as its proponents insist it should.
When euthanasia is practised in the same place as normal, Hippocratic medicine, how are patients to trust their doctors to not kill them? The associated crisis of trust will increase as patient sickness and vulnerability increases, reaching a crescendo in precisely those institutions where Palliative Care and euthanasia are supposed to “integrate” and “collaborate” in “continuity”.
How exactly are Hippocratic and non-Hippocratic physicians expected to collaborate? No one can deny that the “life project” adopted by a patient depends in part on the way information is imparted and on the advice given. Are they to cover each other’s patients as though their services were interchangeable? Will the patient’s first exposure to one school, or the other, be a matter of pure chance in the same way that an accident victim is arbitrarily assigned to a particular surgical team?
These are, we believe, irreconcilable absurdities. Euthanasia and Palliative Care are mutually exclusive therapeutic models: both require professionals who believe in them. People are not interchangeable robots. It has become increasingly clear that euthanasia and Palliative Care are not only different models, but models in competition, and that access to Palliative Care must be protected accordingly.
There are two major reasons why Quebec family doctors are leaving palliative care: Law 20, which requires them to sign up a certain number of primary care patients in a clinic or face economic sanctions; and unwillingness to accept the new “integrated continuity” between palliative care and euthanasia. If those leaving for the latter reason are replaced by more compliant colleagues, in a not too distant future we can expect the field to be full of doctors merely dabbling in palliative care, while waiting for patients to correctly adjust their “life project” and request euthanasia.
That is why, as we have said before, euthanasia and palliative care must be provided in separate institutions by separate professionals.
In the short term, at the very least, family physicians must not be penalized for caring for dying patients instead of –or alongside – practising primary care. This is a pressing need and has no ideological motive for refusal.
At the heart of Dr. Bernard’s recent letter to Minister Barrette, we find the following assertion:
“End of life care cannot be limited to medical assistance in dying. This final option makes no real sense, from a medical point of view, unless it is preceded by a complete range of effective palliative care services, available throughout Québec.”
At the very least.
Make euthanasia unimaginable.
Sincerely,
Catherine Ferrier
President