Wednesday, October 3, 2018

WMJ - Euthanasia in Canada: a Cautionary Tale

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

On the eve of the World Medical Association (WMA) conference in Iceland, where the Canadian and Dutch Medical Associations are pressuring the WMA to change its opposition to euthanasia and assisted suicide, the Journal of the World Medical Association (WMJ)  published an article titled: Euthanasia in Canada: a Cautionary Tale (pages 17 - 23).

Link to the Spanish and French translations of the article.

This in-depth article was written by seven leading Canadian physicians and endorsed by another 57 Canadian physicians including Dr Balfour Mount, the father of palliative care in Canada.

It's important to state that the current WMA Declaration on Euthanasia states:

‘Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical’.
The current WMA Statement on Physician Assisted Suicide declares:
‘Physician assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically’.
The article begins with the physicians stating that they are considering leaving Canada or withdrawing from Medicine based on their concern with practice of euthanasia and issues related to their personal integrity and professional conscience. They state:
All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide.
After explaining how the euthanasia laws works in Canada they outline how the law is already expanding. They wrote:
Within a year of the ruling, the pressure for “Carter Plus” had become so great that the federal government legally committed itself to consider allowing euthanasia and assisted suicide for adolescents and children, for indications caused by mental illness alone, and by advance directive (for those who lack capacity, like patients with dementia). In ... Canada we have observed that even the prospect of legalization whets the appetite for it, and the appetite is not satisfied by legalization alone.
The writers explain that the Vulnerable Persons Standard was developed to establish effective oversight of the law, but the "safeguards" are now beingconsidered a barrier to access rather than a protection for people at a vulnerable time of their life. They wrote:
Even supplemented by provincial and professional guidelines, current criteria are so broad as to have permitted lethal injection of an elderly couple who preferred to die together by euthanasia rather than at different times by natural causes.
The article then explains why physicians are being pressured to collaborate in killing by euthanasia. They wrote:
EAS practitioners also claimed that there was “a crisis” because so few physicians were willing to provide euthanasia or assisted suicide. Their alarm seems to have been triggered by a 46.8% increase in EAS deaths in the second half of the first year of legalization.
They then explain how their conscience rights are being trampled upon:
It is true that nothing in the Criminal Code requires physicians to personally kill patients or help them commit suicide. However, nothing in the Criminal Code prevents compulsion by other laws or policies. Thus, for example, Canada’s largest medical regulator demands that physicians who are unwilling to personally provide euthanasia or assisted suicide must collaborate in homicide and suicide by referring patients to colleagues who are willing to do so. 
We categorically refuse. Such collaboration would make us morally responsible for killing our patients; if not for the Carter decision, it would make us criminally responsible and liable to conviction for murder, just as it still does in most parts of the world. For refusing to collaborate in killing our patients, many of us now risk discipline and expulsion from the medical profession.
The pressure to force physicians to participate in killing is based on two principles. Access to euthanasia is viewed as an entitlement and access to euthanasia is being re-defined, as a "human right"
Part of the explanation is that Canada’s state-run health insurance system pays for “medically necessary hospital and physician services” from public funds. ... many Canadians now believe we are state employees, and we face an entrenched attitude of entitlement. Since taxpayers pay for “medically necessary” health services, many people think it is unacceptable for physicians to refuse to provide those. 
Quebec law allows hospices to opt out of providing euthanasia, but when Quebec hospices opted out, the Minister of Health denounced them for “administrative fundamentalism,” declaring their refusal “incomprehensible.” Notwithstanding the law, a prominent Quebec lawyer urged that their public subsidies be withdrawn, accused them of compromising the right of access to care, and warned that allowing refusal was a slippery slope. A similar situation is also being faced by the hospices in other provinces such as British Columbia.

Quebec physicians and health care practitioners now work in environments characterized by an emphasis on a purported ‘right’ to euthanasia. The notion that access to euthanasia and assisted suicide is a fundamental human right has spread across Canada since the Supreme Court of Canada ruling in Carter. We are accused of violating human rights – even called bigots – because we refuse to kill or collaborate in killing our patients.
Pressures have led to providing euthanasia as being a professional and "ethical" obligation. They wrote:
By redefining euthanasia and assisted suicide as therapeutic medical services, the (Canadian Medical Association) CMA made physician participation normative for the medical profession; refusing to provide them in the circumstances set out by law became an exception requiring justification or excuse. That is why public discourse in Canada has since centred largely on whether or under what circumstances physicians and institutions should be allowed to refuse to provide or collaborate in homicide and suicide: hence the “long debate” about conscientious objection at the CMA’s 2015 annual meeting.
The CMA does uphold conscience rights, even though the Ontario Medical Association does not, but medical students require support when they are told not to apply to medical school if they oppose euthanasia. They wrote:
To be fair, our pleading has not been in vain. The CMA does support physicians who refuse to provide or refer for euthanasia and assisted suicide, asserts that the state should develop mechanisms to allow patients direct access to the services without violating physicians’ moral commitments, and rejects discrimination against objecting practitioners. But this advice can be ignored and, when it is, Hippocratic practitioners face the state in court and foot the bill for expensive constitutional challenges. Further, public calls from influential voices have been heard for those medical students who are personally opposed to the euthanasia imperative, to either abandon, or refrain from applying for, medical training.
Why has euthanasia grown so quickly in Canada?
In Canada, however, access to euthanasia and assisted suicide is seen as a tax-paid entitlement, is described as a “constitutionally protected civil and human right,” and homicide and suicide are legally and professionally defined to be therapeutic medical services. Moreover, a physician’s conviction that there are other reasonable and efficacious alternatives is irrelevant; patients can insist upon lethal injection. Finally, the criterion of intolerable suffering is entirely subjective, established unilaterally by the patient.  
Small wonder, then, that the onus seems increasingly to lie on physicians to show why euthanasia should be refused, and that health care administrators may be more anxious about being accused of “obstructing access” than about “killing people who really ought not to be killed.”
Even the Secretary of the Québec Medical Association (CMQ) was concerned when he stated:
“If anything has become apparent over the past year, it is this paradoxical discourse that calls for safeguards to avoid abuse,” he wrote, “while asking the doctor to act as if there were none. … [W]e sees the emergence of pressure demanding a form of death à la carte,” he warned.
The writers then expressed their concern that the number of palliative care physicians has dropped after euthanasia was legalized:
We are disturbed that the number of Quebec practitioners entering palliative care dropped after legalization of euthanasia, and the CMQ and the Quebec Society for Palliative Care are concerned that patients are choosing euthanasia because adequate palliative care is unavailable.
They then shared three stories of patients who were pressured to die by euthanasia.
We are disturbed and grieved by the story of a 25-year-old disabled woman in acute crisis in an Emergency ward, pressured to consider assisted suicide by an attending physician, who called her mother “selfish” for protecting her. 
We are disturbed and angered to hear that hospital authorities denied a chronically ill, severely disabled patient the care he needed, suggesting euthanasia or assisted suicide instead. 
And we were astonished to hear that some emergency physicians in Quebec were, for a time, letting suicide victims die even though they could have saved their lives. The incidents came to light at about the time the Quebec euthanasia law came into force, and the president of the Association of Quebec Emergency Physicians speculated that the law and accompanying publicity may have ‘confused’ the physicians about their role.
Euthanasia is transforming the medical culture in Canada. They wrote:
However, when emergency physicians refuse to resuscitate patients who attempt suicide and urge disabled patients in crisis to request euthanasia, such “changes in the medical culture” are not, in our view, consistent with ensuring patient safety, nor with maintaining the trust essential to preserving the Hippocratic physician-patient relationship. 
And when physicians are told to write ‘natural death’ instead of ‘euthanasia’ on the death certificates – and, by extension, to misrepresent facts – “changes in the medical culture” may make physicians comfortable, but we do not believe that they will sustain trust in the medical profession. Even newly released federal guidelines for monitoring euthanasia lack any emphasis on prevention of EAS, in favour of merely regulating these practices. 
Finally, when a Jewish nursing home forbids euthanasia and assisted suicide on its premises out of respect for Jewish beliefs and concern for its residents (who include Holocaust survivors), “changes in the medical culture” may encourage applause for the EAS practitioner who crept in at night to lethally inject someone, but we do not applaud; we are aghast.
They concluded the article by stating:
As Canadians, we are saddened by this situation, but we hope that our experience and observations will serve as a warning for our colleagues in other countries, and their patients. Most important: The World Medical Association must recognize that accommodating the kind of radical change in medical culture underway in Canada is ill-advised. Mindful of the legacy of past WMA leaders, such as former Secretary General, Dr. Andre Wynen, who, based on his personal experience, stood courageously against any minimization of the dangers of euthanasia to patients and physicians, we advise against any compromising additions or modifications to existing WMA declarations, and strongly support a full defence of established policy against euthanasia and assisted suicide.
Links to other articles concerning the World Medical Association euthanasia debate:

1 comment:

gadfly said...

"Counsel and overcome resistance from family members..." From the academic article cited and linked. Um, why didn't the process come to a halt if the family members were resisting? Isn't the presence of that phrase equivalent to admitting that there is medical coercion happening?