On May 10, 2017, Dr. Yves Robert, Secretary of the Collège des médecins du Québec, asked the following question in a thoughtful article published on the CMQ website:
“If the goal is euthanasia on demand based on a “right”, are we still talking about Medical Aid in Dying? Or simply Aid in Dying? And what, then, would the medical profession have to do with it?”
Considering the past positions espoused by the College and by Dr. Robert personally – “The debate is only beginning…” (words of Dr. Robert at 18m24) , such a quote is reminiscent of the classic novel Frankenstein, where that high-minded scientific genius, having created a humanoid monster threatening to the human race, is forced to confront the reality of his acts and of his responsibility for them. Tragically, but also heroically, he feels obligated, in the end, to hunt and destroy that creature – loved by him as a son – which his imprudent skill had set loose upon the world.
This reading of the text may be well beyond the Secretary’s intention. However, he has raised a clear statement of principle: if there are no criteria for euthanasia other than client demand, then medical wisdom, medical art and medical science have no role to play.
Once we allow any person to choose state-assisted suicide, and any doctor to perform it, we are legitimizing a purely subjective choice of death. There remains no logical reason why the right to exercise such choices should be restricted to this or that medical condition, or to medical conditions at all. Whatever limits are set, someone will feel constrained by them; and the state will continually be called upon to justify a discriminatory regime (where group “a” is allowed subjective decision, but group “b” is not).
Dr Robert apparently believes (or at least did believe) that protection of the common good can perform a limited retreat before the pressure of unfettered individual liberty, and that stable compromise can be established between these two visions. But the legal and moral change, from euthanasia-as-criminal-homicide to “medical aid in dying”, is not a difference in degree; it is a difference in kind. No compromise is possible. There is only a clearly perceptible earth-moving shift towards a radically different medical paradigm based, solely, upon personal subjective choice – a shift which the Physicians’ Alliance, palliative care providers and many others have opposed from the beginning.
The politicians who promoted Bill 52 insisted it was “an evolution, not a revolution”. But, as we observe the public opinion shift that alarms Dr. Robert – “the paradoxical discourse that calls for safeguards to avoid abuse, while asking the doctor to act as if there were none” – it becomes obvious that it is indeed a revolution, planned as such by its authors, wilfully ignoring the opposition of those who care for the dying. The ink is barely dry on Bill 52 and euthanasia enthusiasts are already demanding further concessions. The interim demands were never an acceptable final destination, only legal waystations on the path to complete liberty of personal choice. As Dr. Robert calls it, death à la carte.
And so it is, that even Dr. Robert has begun to speculate publicly upon the medical significance of such an extreme outcome. And these are the logical implications which he has now had the honesty and rigour to bring forward: The medical profession has no duty (or competence) to define, staff or take any responsibility for a public regime of death on demand. Whatever form such fundamental social change might take, it is NOT a medical problem. And (we would add) the sooner we realise this fact, and act upon its wisdom, the better things will be for all concerned.
Indeed, simple prudence would suggest that we show restraint right now in the administrative implementation of the euthanasia regime. Decontamination is always easier in proportion as the contaminated area is smaller. Hubris-driven attempts to impose MAID upon all corners of the health care system should be abandoned. Refusal of individuals and institutions to collaborate in this practice should be scrupulously respected.
Dr. Robert ends his article with a simple and sober admonition:
“Let us take the time to reflect carefully before going any further… Death is not that urgent.”
It is a sentiment with which we entirely agree.
Towards death à la carte?
Just over a year after the adoption of the Act Respecting End-of-Life Care (hereafter the Act) in Quebec, the Minister of Health and Social Services recently announced his plan for a reflection on expanding the scope of Medical Aid in Dying (MAID). It would seem that we already want to relax the access criteria.
It should be noted that the debate in Quebec was launched in November 2009 following the publication of the Collège des médecins du Québec’s reflection on the subject. The logic of care based on seeking the most appropriate care for each patient was the primary motivation for the approach that led to the law authorizing MAID, which came into force on December 10, 2015. With this logic of care, the Quebec legislator sought to recognize a logic of rights, confirming that the patient had a say in how he wished to live his last moments. Thus, the law grants the patient the right to quality end-of-life care: palliative care, including palliative sedation and, exceptionally, if it is not relieved by usual care, medical aid in dying. The Act also established a system of Advance Medical Directives (AMD), through which the physician is bound to respect the wishes expressed therein by a patient, regarding five specific treatments required by his or her state of health if, having become incapable, the patient is in one of two particular clinical situations. MAID is excluded by law from the AMD.
In just over a year, more than 400 patients have received MAID in Quebec. This period was a learning process for all of Quebec society, during which we collectively understood that there were criteria for access to MAID and that, when these criteria were not met, requests were refused. This observation, although obvious, was brutal for many.
Thus, patients suffering from progressive diseases but at an early or intermediate stage were denied MAID. Patients with disabilities, who were not at the end of their lives, were reduced to choosing to die through fasting. Finally, more recently, a patient suffering from dementia, incapable of consenting to care, was allegedly killed out of compassion by her spouse.
Since the coming into force of the Act, and particularly since the debate on the federal bill following the Carter decision of the Supreme Court of Canada, some people have invoked a “new constitutional right”: that of obtaining MAID on demand or even to claim it “pre-emptively” shortly after being diagnosed with severe or terminal illness, even before suffering from the dreaded incapacities or limitations. For many, it is about having control over their death and the right to choose its moment and manner. While MAID was reserved for the suffering patient, we see the emergence of pressure demanding a form of death à la carte. But is this really what our society wants?
We all know that at least three questions remain unanswered after the coming into force of the current laws: what happens to incapable persons, to minors, and to those with mental illness? These issues are not simple; we may have to accept that there is no answer. The question of incapable persons, which will be discussed by an expert committee formed by the minister in the coming year, is probably the most complex. It is envisaged to allow persons who are still capable to issue advance directives to request MAID in case of incapacity. In particular, it should be ensured that, where appropriate, the person clearly determine the medical condition for which he or she would want MAID. It’s not easy when one is still in good health. For obvious reasons, this possibility could not have the same binding power as an AMD. What then would be the decision-making process to be followed, and by whom, in the name and in the interest of the incapable person? Who would ultimately make the decision? Who would choose the moment? Medically, other conditions foreseen in the law for those who are capable should also be present, including suffering, which is not always present in dementia depending on the stage of the disease. It is also important to determine who would be suffering the most: the patient or his or her entourage? What if, at the time of the intervention, the patient, unaware of their purpose, resisted the injections? Finally, what would one do with all those patients currently suffering from dementia, who have not had the opportunity to express their wishes beforehand? What would be the response to those who would undoubtedly invoke a concern for fairness and claim a need for compassionate death in the name of a subjective “quality of life” that is so difficult to evaluate?
As can be clearly seen with the situation of incapable persons, broadening access to the MAID raises many issues that should be discussed collectively, and which go well beyond the current legal framework and even the Carter decision. Why and to what extent should new safeguards be introduced when, no matter what the access criteria, there will always be some people excluded by definition? If anything has become apparent over the past year, it is this paradoxical discourse that calls for safeguards to avoid abuse, while asking the doctor to act as if there were none. Many are ill at ease with exclusion and paradoxes, especially opinion leaders and media columnists who denounce refusals of MAID and promote death à la carte “to respect the choices of each individual.”
For them, what about the logic of care and of a “continuum of care” that preceded the Act Respecting End-of-Life Care? If the goal is euthanasia on demand based on a right, are we still talking about Medical Aid in Dying, or simply Aid in Dying? What would the medical profession have to do with it?
We should recall that, without the logic of care, physician intervention is not required. If the will of the people is limited to respecting the wishes expressed directly or indirectly by the person, society will have to lucidly consider other options than those which require the participation of the doctor, and transform Medical Aid in Dying into simply a legally authorized aid in dying. This could take the form of assisted suicide services provided by a private company that would deal directly with the person, as in Switzerland… But is it really in this direction that Quebec society wants to go?
What is striking after the first year of operation of this law, recognized as being the source of a “major opening”, is the rapidity with which public opinion seems to have judged this opening insufficient. Have we really gone that far? Even before having fully appreciated the application of the current provisions or their consequences?
Let us take the time to reflect carefully before going any further. Death is not that urgent.
Yves Robert, M.D.
Collège des médecins du Québec
 Cardiopulmonary resuscitation, respiratory assistance, dialysis, hydration and nutrition
 End of life and serious and incurable disease or severe and irreversible impairment of cognitive functionsShare