Sunday, January 16, 2022

A duty to warn Americans after years of medicalized assisted death in Canada

Gordon Friesen
By Gordon Friesen, EPC board member

A proposition for legislative opposition to the medical justification of assisted suicide and euthanasia, based upon years of experience with hyper-medicalized assisted death in Canada

A unique Canadian experience, and a duty to forewarn

It is an unfortunate fact that Canada, since 2015, has had a much greater and more painful experience of assisted death than any other country in the English speaking world. It is therefore to be hoped that our experience may be of some use to those, of similar cultural affinity, who are currently faced with the legalization and expansion of such practices, and particularly, of some help to our immediate American neighbours.

From the Canadian experience, one may rapidly deduce that -- beyond the mere legalization of assisted death as such -- the most pernicious associated phenomenon has been the tendency to justify, to normalize, and to expand this practice as essential medical care.

The conceptual danger of accepting assisted dying as medical care.

Medical care is almost universally perceived as a desirable good. There is, in fact, an enormous volume of political opinion currently supporting the idea of medical care as a basic human right, on the same footing as food or shelter.

Therefore, from the moment that assisted dying (whether assisted suicide or euthanasia) is perceived as medical care, it becomes possible, for its promoters, to claim far-reaching rights of practice, and even, to claim assumed obligations -- of the State, of medical professionals, and of institutions -- to provide assisted dying services, and to actively disseminate information to that end; or at the very least (for individual professionals) to collaborate with, and to provide direct access to, other professionals who will.

Real consequences, as currently experienced North of the Canadian border

In Canada, we now have conclusive and dramatic experience to demonstrate exactly where such thinking logically leads: for of all nations, Canada stands alone in explicitly defining assisted suicide, and euthanasia, as medical care (via legislation in the Province of Quebec that has subsequently been accepted as a de facto national standard) Practical results include the following:

  1. Euthanasia is currently practiced in Canada, to the virtual exclusion of assisted suicide, and that, even though previous legal discussion always centered on assisted suicide, while euthanasia was presented only as an exceptional procedure (to overcome accessibility issues affecting a small number of patients). 
  2. Euthanasia (Medical Aid in Dying) is guaranteed as a "universal right" to all legally eligible patients regardless of doctor opinion (beyond the mere evaluation of eligibility). 
  3. It is mandated that euthanasia shall be practiced in all medical institutions, of any description whatsoever (including, notably, long term and palliative care facilities), with only a trivial number of faith-based exceptions (the total of which, throughout the entire nation, can be counted upon one's fingers). 
  4. It is assumed (although still disputed by some) that all medical professionals must either provide euthanasia themselves (with the narrowest of conscience based exceptions), or that (in any case) they must provide an effective referral to those who will. 
  5. It is decreed, in the ethical guidance provided to doctors by state established governing bodies, that all eligible patients be (proactively) informed of that eligibility. 
  6. For medical professionals in the next generation, it is assumed that the willingness to participate in assisted dying practices will become a requirement of professional certification, and has already become a requirement: for most institutional employment, and even for entrance to professional training. 
  7. Beyond obligation (for those professionals who actively support assisted dying as medical care), the freedom is now granted to proactively recommend (that is in medical terms: to prescribe) such treatment to any patient legally eligible for such (without first receiving a request from the patient themselves); which recommendation, considered from a classic perspective of suicide prevention, represents an unconscionable psychological aggression.

The case for maintaining that all such measures are not medically justied

Clearly, all of the above innovations (currently being normalized throughout the entire Canadian medical industry), are entirely dependent upon the definition of assisted dying (ie. euthanasia) as standard (even essential) medical care. And yet there is no reason why any such definition should be admitted.

On the contrary: there are not, and never have been, agreed, objectively verifiable medical indications for the prescription of assisted dying to any particular patient (which is the first requirement of clinical medicine); the fundamental justification for all assisted dying has always been the autonomous desire of the individual patient. Nothing in the possible permission granted to medical professionals, to practice assisted dying, could possibly be construed as justifying the professional rights and obligations associated with typical medical treatment.

The institutional support for such a position

At the present time, the Swiss medical association (in a country where access to assisted suicide is not only legal but has allowed the creation of a tourist-based industry) still considers assisted dying to be fundamentally at odds with the medical mission. The Dutch Medical Association (where euthanasia has been legal for 20 years) calls the practice medically "exceptional". The American Medical Association (where several States have legalized assisted suicide) flatly condemns assisted suicide and euthanasia. The British Medical Association has only lately amended their traditionally oppositional stance, to a merely "neutral" policy. Most tellingly of all: the World Medical Association recently (2019) felt it necessary, after a prolonged and extensive exercise of formal consultation on all the continents, explicitly reaffirmed their policy, to the effect that assisted dying is medically unethical. The Canadian Medical Association, to their shame, were notably isolated in resigning from the WMA subsequent to that decision.

The question must be asked: Why on earth should any credence be given to the interpretation of assisted dying as benign, standard, (even essential) medical care, which has been injected by judicial and legislative action, not in response to true medical opinion, but demonstrably in opposition thereto? And how can this fictitious definition of assisted suicide and euthanasia, as "medical aid in dying" be prevented from creating the pernicious professional rights and obligations observed above?

A suggested strategy of disallowing the medical justification for assisted dying

It the present situation nothing, other than opposing assisted death as such, can be considered as important as opposing the medical justification of such practice.

Even though the historical context of these debates has ensured that assisted death (where legalized) be restricted to the actions of medical professionals only; and even if medical criteria are invoked to determine who may or may not be legally permitted to seek such assistance: there is no reason to accept the assertion that assisted death is, in fact, medically justifiable.

Therefore, it is the duty of all those who oppose these practices, to see that this pernicious connection be snipped in the bud.

A proactive legislative agenda

One proposed method of attaining this goal is through deliberate, consistent, legislative action:

  1. Each time that legislation is introduced, for either the legalization or the expansion of assisted death, amendments should be introduced which expressly deny the medical justification of same. This is not the same as opposing adversarial bills as such. At the appropriate time, all of our allies must argue and vote against any such initiatives on principle. However, as a separate and equally important practical matter, even if such legislation should pass, it should also (ideally) contain language expressly disavowing any assumed medical legitimacy, or obligation. 
  2. To the extent that resources are available, proactive initiatives should also be undertaken to amend existing legislation to this effect.

A proposed model for future legislation

The following text is intended as a first draft in the elaboration of such a general case clause, to be inserted in all existing and future assisted death legislation:

"Because assisted suicide (and euthanasia) are purportedly justified, above all, by personal choice; because (in the general case) there is no agreement on the medical legitimacy of assisted suicide, or euthanasia; because (in the particular case) there is no agreement on the objective conditions which would indicate the use of assisted suicide, or euthanasia (not as a right of choice, but as a true, objectively justified medical treatment); because, therefore, the term "medical assistance in dying" signifies only a "death facilitated or caused by medical professionals", but not a "death facilitated or caused as an objectively indicated medical procedure"; and because of the public and personal interest in limiting the propagation of suicidal suggestion: be it resolved that,

1. Assisted suicide (and or euthanasia) be allowed (if allowed at all) by permission only, creating no obligation of any kind to provide (or to assist in the provision of) these services, whether such obligation be portrayed as public, private, or institutional. And in particular:
    a) i) the public powers of government, and administration, shall have no obligation, and no mandate (express or implied) to provide or to insure access to assisted suicide, or to euthanasia.
        ii) no public resources shall be directed towards the provision of such services, or of information facilitating same
    b) no institution, whether public or private, shall have any obligation to provide assisted suicide (or euthanasia), nor obligation to permit such practices in premises under their administration.
    c) no individual, whether doctor, medical professional, or other, shall have any obligation to provide assisted suicide, or euthanasia; nor to provide information pertaining thereto; nor to provide any referral for the provision of such service, or of such information.

2. Regardless of any permission for medical professionals to provide assisted suicide, or euthanasia, pursuant to a properly expressed patient choice: it shall remain a criminally culpable act for such professionals (or any other individual) to proactively prescribe assisted suicide (or euthanasia); to proactively counsel a recourse to assisted suicide (or euthanasia); or to proactively provide any information, whatsoever, concerning assisted suicide (or euthanasia).

Gordon Friesen, Montreal, January 15, 2022


Jeannette Furtak said...

This was well written. Thank you.

gordon friesen said...

Jeannette, Thank you for your kind words. It is my thesis that "choice" and "medicine" must be rigorously separated. The hybrid MAID construct must be broken down into its constituent parts. We must not allow choice, even if granted, to impose a situation of medical normalcy. The one must not be allowed to drag the other into areas where neither doctors nor patients (in their respective majorities) have any wish to go.
thank you again for taking the time to respond
Gordon Friesen