Chair, Canadian Virtual Hospice Virtual Hospice Executive Committee Virtual Hospice National Advisory Committee
Without C-14 on the books, Canada will have the most open death hastening culture in the world

Bill C-14 is not perfect. Given how diverse and polarized the opinions are, trying to land on a perfect Bill—or as some have opined, ‘getting it right’—is like trying to achieve unison when everyone is singing from a different score. Now more than ever, wisdom and restraint must guide Canada through this transformative change in our approach to suffering.

PUBLISHED in the Hill Times: Tuesday, June 7, 2016 11:07 AM

Within days of Bill C-14 being tabled, I knew the road ahead would be long. Responses to the draft legislation on Medical Aid In Dying (MAID) spanned from assertions that it was an affront to the Supreme Court’s Carter decision, to allegations it amounted to legalized murder. In the weeks that followed, some criticized the draft legislation for setting the bar too high, possibly excluding certain competent, suffering individuals from obtaining MAID. Others countered the bar was too low, placing vulnerable persons at risk of having their lives ended prematurely.

Until the government passes critical legislation to regulate the practice of physician-hastened death in Canada, the decision to use MAID will become a matter of a perception; shaped by values, assumptions and biases of those trying to practice in the shadow of a Supreme Court decision which was not written to provide these answers.

The critical question of the Senate remains: should MAID be defined on the basis of a reasonably foreseeable death? Phrased another way, should a Canadian only be able to access medically assisted death if they are imminently dying? In Oregon, physician-assisted suicide is limited to patients with less than six months to live. It is therefore exclusively for those who feel that the process of dying has become intolerable. Holland on the other hand, does not impose any prognostic limitations. Hence, for the Dutch, euthanasia and assisted suicide have become options, when living has become intolerable.

But as a physician, I know that life spares few of us what feels like intolerable suffering - the anguish of losing someone we love, the challenges of chronic illness, the reality of mounting disability, the torment of physical or psychological trauma. While Bill C-14 will provide one option to relieve the burden of dying, by confining it within a circle of reasonably foreseeable death, we can continue to respond to the burden of intolerable living with steadfast compassion, respect and support. Those are core Canadian values, whose violation will undermine our social fabric, changing how we perceive the sick, the weak and the vulnerable, and ultimately, how we see ourselves. 

An all party Parliamentary Committee suggested that ‘grievous and irremediable medical condition’ was an acceptable and clear eligibility criterion. The Canadian Medical Association warned, however, that physicians would struggle to interpret this vague benchmark. The same committee suggested that under Carter, patients with psychiatric illness are eligible for MAID. Conversely, the Canadian Psychiatric Association has stated there is no accepted standard of ‘irremediable’ within the context of mental illness. An Alberta Court of Appeal recently ruled a patient with a psychiatric condition (conversion disorder), whose death was not reasonably foreseeable, met Carter criteria. In the absence of Federal legislation, this ruling points the direction Canada is likely heading.  

Bill C-14 includes safeguards, such as death being reasonably foreseeable; and precludes eligibility for mental illness, advance directives or minors until further studies can be undertaken. The Bill does not require a palliative care consultation, which would have been an efficient way to ensure all manner of suffering has been identified and every therapeutic option offered.

And why not restrict MAID to physician-assisted suicide; unless someone is unable to take lethal medication independently, in which case a lethal injection could be permissible. Unlike euthanasia, physician-assisted suicide provides the opportunity for people to change their minds. About forty percent of prescribed lethal drugs in Oregon are never consumed. This amendment alone would reduce the number of hastened deaths in Canada from 10,000 per year (based on extrapolations from Dutch studies) to about 1,000 per year (based on data from Oregon).

Despite Bill C-14 being passed in the House of Commons, some Senators seem convinced that no legislation is better than legislation they deem too narrow an interpretation of Carter. Their broader reading would include a provision for MAID by advance directive. While a compelling idea, it must yield to compelling data. Dutch studies examining euthanasia by advance directive report profound and unequivocal findings. In the vast majority of instances, physicians are not able to comply with directives made by competent individuals, later rendered incompetent by dementia, given the patient is no longer psychologically the same person, they are unable to affirm that they are suffering, or that the person in fact still wants to die.  Most family members also declined to have their now demented loved ones euthanized.

The biggest risk, however, is if Bill C-14 does not pass. Without this essential legislation, Canada will have the most open death hastening culture in the world. Physician-assisted suicide and euthanasia will be available, without restrictions based on prognosis; without restrictions based on physical versus mental illness; and, if some Senators have their way, without restrictions for those rendered incompetent by way of dementia. Ours will be the only nation to wrap these death-hastening options into our constitution; a constitution that currently provides no assurances of compassionate, quality palliative care for all Canadians approaching death.

Bill C-14 is not perfect. Given how diverse and polarized the opinions are of MAID, trying to land on a perfect Bill, or as some have opined, ‘getting it right’, is like trying to achieve unison when everyone is singing from a different score. Now more than ever, wisdom and restraint must guide Canada through this transformative change in our approach to suffering.