March 31st, 2014

Health & Ed | February 3rd, 2014
The great divide
The right to die debate and Quebec’s Bill 52
Written by | Visual by Eleanor Milman | The McGill Daily

Though the Hippocratic Oath forbade physicians from administering lethal drugs in any context, euthanasia in the context of painful and incurable illness has been debated since the times of ancient Greece and Rome.

Today, all forms of doctor-aided death are illegal in most parts of the world; however, with an aging population and advances in medical technology that allow the prolonging of life even with terminal illnesses, physician-aided death is coming to the forefront of discussion in both medicine and law. Society is trying to reconcile the difficult problem of preventing suffering while preserving the sanctity of life. Physician-assisted suicide has been legalized in Belgium, the Netherlands, Switzerland, Luxembourg, as well as a few U.S. states (Oregon, Washington state, and Vermont). The conversation has recently gained fuel in Canada, and Quebec may become the first province in Canada to legalize physician-assisted death.

Physician-aided death in Canada

In Canada, physicians who aid a person in committing suicide are held criminally liable under the Criminal Code. This law has been challenged a number of times over the years – one of the most recent cases being Carter v. Canada (Attorney General), which involved Gloria Taylor, a woman who had amyotrophic lateral sclerosis (ALS), a neurodegenerative disease that involves muscle paralysis, and chronic pain while maintaining cognitive function, and leads to a slow, but eventual death. Taylor sought out physician-assisted suicide, and the British Columbia (BC) Supreme Court ruled in favour of providing an exception in her case; however, the BC Court of Appeal held the ban on assisted suicide. Though Taylor eventually died of an infection, the case is now being brought to the Supreme Court of Canada.

“I’d like to stress that ‘medical aid in dying’ is an expression that is well-chosen.”

The various definitions surrounding “end-of-life” interventions are poorly understood by the general public. Under the current law, discontinuing life-sustaining treatment (‘pulling the plug’) at a patient’s request is legal. All individuals have the right to refuse treatment, even if it means accelerating death. Potentially life-shortening symptom relief – such as palliative sedation, which involves using medications such as morphine to decrease a patient’s level of consciousness to relieve severe pain – is also considered legal, as long as the intent is not infliction of death. This is not to be confused with terminal palliative sedation, the practice of administering a lethal dose of sedative in order to accelerate the patient’s death. Euthanasia (the deliberate act of ending someone’s life in order to relieve suffering) and assisted suicide (providing the means or knowledge needed for an individual to commit suicide), and any act carried out with the intent of killing a patient are illegal under federal law.

Quebec’s Bill 52

A game changer in Canada may be Bill 52, termed “An Act respecting end-of-life care.” This bill was first introduced in 2013, and is currently being discussed at the National Assembly of Quebec. The bill defines “end-of-life” care as palliative care for individuals at the end of their lives, and includes the options of “terminal palliative sedation” and “medical aid in dying.”

The specific criteria for access to medical aid in dying are also outlined in the bill. Individuals must be of full age, be capable of giving consent, and the possession of an incurable serious illness with irreversible decline in capability and constant and unbearable physical or psychological pain.

A double-edged sword

Bill 52 has sparked heated debates, with strong supporters both for and against; however, both sides advocate for what they believe is the solution in the best interest of patients and society, and raise important considerations, making it difficult to define an easy solution.

This particular legislature uses the terms “medical aid in dying” and “terminal palliative sedation.” This has become one major area of contention – proponents of the bill see this as a necessary step in avoiding the negative connotation that comes with the terms “euthanasia” and “suicide,” while the opposing side has argued that this lack of clarity hides the reality of what it really is.

“I’d like to stress that ‘medical aid in dying’ is an expression that is well-chosen,” Veronique Hivon, the Quebec Minister for Social Services and Youth Protection, told The Daily. According to Hivon, the main differences are that euthanasia does not imply that all requests come directly from the person suffering, and assisted suicide does not make it necessary for a physician to be present when an individual carries out the act. “Here, the focus is on the ‘continuum of care,’ and the comforting and supporting aspect is very important,” Hivon added.

“In palliative sedation, people are made unconscious with the assumption that they will die. The problem is that we don’t know when it will happen – it could be days, hours, [or] weeks. The problem won’t be for the patient who is unconscious, but for the family that will have no end.”

Some opponents argue that because patients can be asked to be taken off life support – and palliative sedation provides the means to alleviate suffering – other options are not required, and should remain closed to prevent the risk of abuse.

To this, supporters of physician-assisted death argue that keeping people sedated without life support is inhumane and the length of time before a person passes away is often uncertain. “In palliative sedation, people are made unconscious with the assumption that they will die. The problem is that we don’t know when it will happen – it could be days, hours, [or] weeks. The problem won’t be for the patient who is unconscious, but for the family that will have no end,” asserted Dr. Yves Robert of the Quebec College of Physicians.

The slippery slope

One of the most commonly heard arguments against these death-inducing interventions is the “slippery slope” argument. Recently, a number of controversial cases have been arising in Belgium, where euthanasia has been legal since 2002. In September 2013 Nathan Verheist, a trans man, was given legal euthanasia for “unbearable psychological pain” after several unsuccessful surgeries. Earlier that year, Marc and Eddy Verbessem, two deaf twins who were going blind, were given legal euthanasia on similar grounds by the same doctor. These cases sparked the legal euthanasia debate in Belgium, raising the question of whether assisting death for “mental suffering” without terminal illness was pushing ethical boundaries. Additionally, Belgium’s recent moves to attempt legalizing euthanasia for patients with dementia and for terminally-ill minors have added fuel to this debate.

Arguing for the need to protect vulnerable populations from misuse of euthanasia, opponents of Bill 52 suggest that these issues could arise if Quebec legalized medically-assisted death. “I think everybody should object to euthanasia and physician-assisted suicide even if they don’t think it’s inherently wrong, because of the possibility of abuse and what it means for the values of our institutions and society,” said Margaret Somerville, a law professor at McGill.

“Whatever happens, there needs to be clear guidelines about how the process happens – and we need very good data. The slippery slope argument makes sense, but we don’t have very good baseline data.”

Policymakers and proponents, on the other hand, assure that the stringent requirements in Quebec’s bill make it impossible for these types of cases to occur legally. Unlike the laws in Belgium, which state that individuals suffering unbearable psychological or physical distress as a result of incurable medical conditions are eligible for euthanasia, Quebec’s laws additionally require the individual to be at the end of life. “For Quebec, it’s a combination of criteria similar to Oregon or Washington state that are based on the “end of life,” whereas in Belgium and the Netherlands it is based on suffering,” Hivon explained.

Yet, with little data regarding the state of physician-aided death currently occurring in Quebec, it is very difficult to know whether this slippery slope might materialize. “Whatever happens, there needs to be clear guidelines about how the process happens – and we need very good data. The slippery slope argument makes sense, but we don’t have very good baseline data,” says Emmanuelle Belanger, a researcher in palliative care at McGill.

Access to palliative care

Currently, not all individuals who need palliative care receive it. According to the Canadian Institute for Health Information, only 16 to 30 per cent of individuals who need palliative care actually receive it. Palliative care physicians are one of the groups that have been vocally against the adoption of Bill 52. One of their concerns is that the knowledge of the option to receive “medical aid in dying” may act as a barrier for patients seeking alleviation from suffering. Additionally, they argue that most individuals don’t fully understand all the options available and the various terminologies surrounding physician-assisted death.

Hivon assures that the bill takes measures to improve palliative care, describing the bill as being based on the idea of a “continuum of care,” with medically-assisted death being reserved for exceptional cases at the very end of the spectrum. The PQ government publicly acknowledged the need to improve palliative care services, announcing last May that it would invest $15 million into palliative care.

Not all physicians will be willing to carry out the act. A survey by the Quebec Medical Association revealed that only 41 per cent of doctors surveyed would be willing to grant the requests for medical aid in dying. “I’ve tried to get specialists to understand that if they referred me to a patient who did not want palliative care, I’d refer them back to them, because I can’t help them. They aren’t aware of the fact of who would be willing to do it. It’s one thing to support the idea in principle, and another to implement it,” Manuel Borod, a palliative care physician at the McGill University Health Centre, told The Daily.

End of the debate?

Though questions still surround the long term effects of passing a bill that will allow medical aid in dying, Bill 52 has aimed to address most of these issues, and is likely to move forward in the National Assembly. Physician-assisted death is a deeply divisive issue with individuals on both sides ready to fight for what they believe. Emotions run high. There is one point on which both groups agree: people deserve compassion and respect at the end of life. Even if Bill 52 is adopted in Quebec, it won’t be the end of the issue. All forms of physician-assisted death are illegal at the federal level, and the federal government has expressed that they will keep it this way, meaning that adoption of this bill could lead to a constitutional challenge. The debate will, seemingly, continue on indefinitely.

Euthanasia and assisted suicide laws around the world

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