Wednesday, April 29, 2020

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues

This article was published in the World Medical Journal. (Link - page 28 - 39)

Written by: Dr Leonie Herx, Dr Margaret Cottle and Dr John Scott.

In June 2016, Canada legalized euthanasia and assisted suicide, which legislators referred to collectively as “Medical Assistance in Dying” (MAiD). In Sept 2018, an article was published in this journal summarizing the early impacts of legalized euthanasia on Canadian medicine [1]. In October 2019, the World Medical Association (WMA) reaffirmed its opposition to euthanasia and assisted suicide [2]. We propose in this article to update colleagues around the globe on consequences of the rapid expansion and cultural normalization of the practice of intentional termination of life in Canada. 

Dr Leonie Herx
This paper will balance recent portrayals in the popular and medical media that imply only a positive impact as a result of the introduction of euthanasia into Canada’s health system [3–4]. Evidence will be presented to demonstrate that there are significant negative and dangerous consequences of this radical shift for medicine, and particularly for palliative medicine. These include the widening and loosening of already ambiguous eligibility criteria, the lack of adequate and appropriate safeguards, the erosion of conscience protection for health care professionals, and the failure of adequate oversight, review and prosecution for non-compliance with the legislation. Indeed, what we have seen over the past four years is that “the slope has in fact proved every bit as slippery as the critics had warned” [5]. We also seek to reaffirm the vision of the physician’s role “to cure sometimes, to relieve often and to comfort always.” 

How Many People Undergo Euthanasia in Canada? 

Dr John Scott
In just under four years, the number of euthanasia deaths has rapidly increased in Canada. New statistics released by the federal government on February 24, 2020, show that 13,000 people have died by euthanasia since the legalization of the practice, which represents approximately 2% of all deaths in Canada. The government estimated that there were 5,444 deaths in 2019 and 4,438 deaths in 2018 from euthanasia [6]. In comparison, Statistics Canada reported 1,922 deaths in motor vehicle accidents for 2018, the latest year for which statistics are available [7]. Euthanasia proponents argue that the Canadian death rate should stabilize at a level comparable to other jurisdictions with equivalent legislation, such as the Netherlands where euthanasia now accounts for 4.9% of deaths [8]. However, it is troubling that Canada’s rate has increased more rapidly than other permissive jurisdictions over a similar initial time period, and that our rates are quickly approaching current rates in the Netherlands and Belgium, where euthanasia has been legal for almost 20 years. 

Expansion of Euthanasia Practice and Legislative Changes 

Dr Margaret Cottle
In addition to the increasing numbers of cases, there is also an expanding range of indications approved for euthanasia. In four years, Canada has moved from approving euthanasia for so-called “exceptional” cases to euthanasia being treated as a normalized, almost routine, option for death. 

Ongoing court challenges to legislative requirements for euthanasia have resulted in its approval for individuals with chronic illnesses such as osteoarthritis, dementia, and physical disability [9, 10, 11, 12]. Media reports point to less restrictive interpretations of eligibility criteria by assessors and providers of euthanasia without intervention from the courts [13, 14]. These precedent-setting cases have produced what euthanasia providers themselves call “not an expansion of our law” but “a maturing of the understanding of what we’re doing” [12]. This, in turn, has led providers to approve cases they would not have previously approved due to earlier fears of criminal prosecution [15]. Although reports of criminal code and regulatory body violations have been well documented [16, 17], no charges have ever been laid. 

In September 2019, a Quebec Superior Court ruling on the Truchon case [11] struck down a central euthanasia criterion for “reasonably foreseeable natural death” (RFND) which may soon open up euthanasia to those with chronic conditions, disabilities and mental health issues as a primary diagnosis. The Federal Government is committed to expanding the legislation and, on February 24, 2020, tabled a new bill in Parliament to respond to the Truchon case ruling to remove the requirement for RFND [18]. In the near future, euthanasia in Canada will almost certainly be open to any person who feels their suffering cannot be addressed except through intentional termination of life. As mandated by the 2016 legislation, the Canadian government is continuing to explore the additional inclusion of those with mental health issues as a primary diagnosis, “mature minors” (i.e. children), and euthanasia by advance directive (for those who may lose decisional capacity at some point in the future) as part of a parliamentary review expected to begin by June 2020 [19]. 

Even those who support euthanasia in some circumstances are voicing concerns over the rapid expansion of the procedure in Canada, and a problematic lack of proper, robust analysis of its utilization [20]. Many who care for citizens with mental health issues are extremely concerned, not only that psychiatric conditions may be considered “irremediable” by some, but also that if psychiatric indications are permitted as the sole reason for euthanasia, these patients could possibly have euthanasia performed almost immediately, whereas the wait time can be years for specialized, lifesaving psychiatric interventions and care [21]. The lack of access to psychiatric care in Canada is also putting patients who are facing an end of life diagnosis in an even more dire situation [22], given the high risk for suicide in this population [23, 24]. 

Euthanasia deaths are now serving as a growing source of organ and tissue donations in Canada [25]. Unlike other countries, Canada is the first jurisdiction to allow non-patient-initiated discussion of organ donation for those approved for euthanasia. In other jurisdictions where euthanasia is legalized, including the Netherlands and Belgium, only patient-initiated organ donation discussion is allowed, while in some jurisdictions, including Switzerland and some U.S. states, subsequent organ donation is not possible following assisted suicide. Having the potential to alleviate the suffering of another person in need or to leave a legacy appears to be a powerful motivator in the decision for organ donation as part of death by euthanasia [25]. One individual who donated her organs after euthanasia stated, “I thought the knowledge of having full autonomy by way of MAiD was comforting, but, when the possibility of organ donation was added to it, the sense of elation is the only appropriate word for me.” [25]. Given that most requests for euthanasia are due to existential suffering, in particular feeling a burden to others and loss of meaning and purpose in life [26], the potential “good” of organ donation may be a persuasive incentive for some who may otherwise not have chosen to hasten their death. 

Euthanasia providers are now making recommendations to add drugs (e.g., potassium chloride) to the existing regimen which will cause rapid cessation of cardiac activity and reduce the potential for ischemic damage to organs to be transplanted. The rationale for the change is that it “allows organs to be donated in the best condition possible” [27]. Questions are also being raised about starting organ procurement processes prior to death being determined which would also allow organs to be donated in “the best condition possible” [28]. There are a number of difficult issues that arise when considering organ donation in these circumstances, including conscientious objection of team members involved in transplantation, the “dead donor” rule, and informing potential recipients of the source of the organs to be transplanted. 

More evidence of the normalization of euthanasia can be seen in the recent set of tips published on how to prepare children for a euthanasia death of a loved one. The author, Co-Chair of the Ontario College of Family Physicians Palliative/End of Life Care and MAiD Collaborative Mentoring Network,  recommends, “if the adults surrounding them normalize MAID [sic], so will the children” [29]. Medical literature regarding children, death and grieving was used to extrapolate approaches to the euthanasia context. Tip #5 states that these conversations can easily be had with children as young as four years old. Tip #6 suggests that euthanasia providers should offer to show your equipment (syringes, stethoscope, IV  supplies). For example: “I have a tray with the things I will use to help your loved one die. These include medications and syringes. I am going to leave them on the table and if you would like to take a look you can. I will stand beside the table and you can ask me any questions” [29]. 

Euthanasia Due to Lack of Access to Care or Lack of Perceived Quality of Life 

Examples are mounting of Canadians requesting euthanasia because of lack of access to care, such as long-term care or disability supports [30, 31]. A significant number of reports have documented cases in which individuals have been told by health care professionals and others to consider euthanasia as an “answer” to a perceived poor quality of life or a lack of health care resources to meet their needs. Motivation for these decisions and suggestions appears to include the cost of care or specialized supports [32, 33]. 

Following the Quebec Superior Court ruling on the Truchon case [11], over seventy Canadian disability allied organizations came together out of concern for the equality rights of vulnerable Canadians, and signed an open letter asking the federal government to appeal the court ruling to the Supreme Court of Canada [34]. A similar open letter [35], urging an appeal in the same case, was signed by over 350 physicians from all specialties across Canada. No appeal was made. These disability experts and physicians argued that the removal of the end of life criterion (RFND) means that disability-related suffering, largely caused by lack of support and societal inequality, justifies the termination of a person’s life. When the legislation is amended, this will effectively enshrine in Canadian law the principle that a person’s life can be ended based on disability alone, further stigmatizing and devaluing the lives of those living with disabilities. 

Disability advocates continue to express alarm at the evolving situation in Canada, and Catherine Frazee (former Human Rights Commissioner in Ontario and retired professor in Disability Studies) points to the hidden message being conveyed by government, that expanding medically assisted death so that it is not only for those who are dying, but also, exclusively, for those who have some illness, disease or disability, makes us a ‘special case’ for ending a difficult life. This categorically sends one and only one message: we are not needed. Whatever gifts we bring to the world, gifts of mind and heart and body, are not of such value that Canada will fight for us to live [36]. 

International attention was garnered last year when the UN’s Special Rapporteur on the Rights of Persons with Disabilities traveled to Canada in the spring of 2019. In her end-of-mission statement, Ms. Devandas Aguilar stated that she is “extremely concerned about the implementation of the legislation on medical assistance in dying from a disability perspective…” and she urged Canada to do more to “…ensure that persons with disabilities do not request assistive [sic] dying simply because of the absence of community-based alternatives and palliative care” [37]. 

“Safeguards” for Euthanasia 

The Supreme Court of Canada, in the case of Carter v. Canada (2015), that originally led to the decriminalization and subsequent legalization of euthanasia, stated that a “carefully designed and monitored system of safeguards” would limit risks to vulnerable persons [38]. The safeguards in the subsequent 2016 legislation [39] include a mandatory ten-day reflection period between the request and the euthanasia procedure, the independent nature of the two eligibility assessors, the requirement for decisional capacity of the patient at the time of the request and at the time of the procedure, protection against coercion by requiring two independent witnesses, and a rigorous system of monitoring and review. 

Currently, the ten-day reflection period is often waived, and the newly proposed legislation would formally repeal this requirement [18]. In one cohort study of euthanasia deaths in Ontario, 26% of euthanasia deaths had the ten-day reflection period expedited [40]. In Quebec, it has been reported that 60% of euthanasia cases had the ten-day reflection period waived and, of these cases, 48% did not meet the criminal code criteria for removal (i.e., imminent risk of death or imminent loss of decisional capacity) and 26% had no documented reason for waiving the reflection period [41]. 

Compliance reports from Quebec have also documented concerns about the “independent nature” of assessors [17]. In our personal experience, the assessors are in reality not always independent. Assessors are often colleagues belonging to a small community of providers who practice euthanasia. The second assessor can see the first assessor’s report prior to seeing the patient or writing their own report. There are also no data about how often a second assessor disagrees with a first assessor, or how many different assessors an individual seeks out, since there is no limit to the number of assessments that can be obtained. An individual patient only needs two approved assessments. A study from Belgium, which deals with euthanasia for psychiatric reasons, suggested that 24% of cases involved disagreement amongst consultants, highlighting the challenge of discordant assessments [42]. Although the current and proposed initial amendments to the euthanasia legislation in Canada (response to the Truchon case) do not permit euthanasia for psychiatric reasons alone, this indication is under formal review [19] and there is considerable public pressure for its legalization from those who wish to see this expansion [43]. 

We also note that it is difficult, even in person, to determine decisional capacity or possible coercion, especially if a case is complicated. In Canada, both telemedicine (video) and telephone (voice) are allowed to be used for euthanasia assessments. Determination of a person’s decisional capacity is not straightforward and may require advanced skills and tools [44], but there are no formal requirements for training to assess decisional capacity and no requirement for psychiatric consultation in complex cases. Many physician colleagues, ourselves included, report personal experiences with patients who, in their opinion, lacked decisional capacity at the time of the euthanasia assessment and/or at the time of the procedure, and still received euthanasia even though formal documented concerns had been raised with the euthanasia providers. 

Monitoring requirements include only basic demographic information and are reviewed in retrospect [45]. Information about race, education, socioeconomic status, and language abilities is not collected, and there is no direct oversight or mechanism to stop the procedure if red flags are raised. 

A group representing euthanasia providers, the Canadian Association of MAiD Assessors and Providers (CAMAP) has been calling for the abandonment of the requirement for two independent witnesses (established to ensure protection against coercion). They contend that this requirement is a bureaucratic frustration that blocks patient access. New legislation proposes to reduce the number of witnesses to one and would make it legal for that witness to be the patient’s paid personal care worker or health care provider [18]. There is also a reasonable concern that the blanket misapplication of the so-called “duty to inform” may soon suggest to all physicians that they are required to offer euthanasia as an option in every serious illness. If this is the case, it will be impossible for physicians to avoid the appearance, if not the reality, of coercion for vulnerable patients who may already feel they are a burden to others. Even supporters of euthanasia have already acknowledged there is no reliable way to measure coercion [46]. 

Concerned Canadians continue to work together to address the issue of safety for vulnerable citizens. The Vulnerable Persons Standard (VPS), initially developed in response to the Carter v. Canada decision, is an internationally recognized evidence based framework “that provides clear and comprehensive guidance to law-makers by identifying the safeguards necessary to protect vulnerable persons within a regulatory environment that permits medical assistance in dying” [47]. The VPS was developed by a large body of advisors with expertise in medicine, ethics, law, public policy and the needs of vulnerable persons. Despite the fact that the VPS has received strong, broad-based, continuing support, it has been completely ignored by every level of government. 

It is also important to note that, during the legalization process, access to palliative care was positioned as a “safeguard” for euthanasia. However, in reality, less than 30% of Canadians have access to any form of palliative care and less than 15% have access to specialized palliative care [48]. Many, including Shariff and Gingerich, have questioned if euthanasia can truly be an informed choice if there is no meaningful access to palliative care [49]. 

Although economic considerations may not currently be driving the normalization and expansion of euthanasia in Canada, it cannot be denied that the procedure is significantly cheaper than rigorous, traditional palliative care. The financial savings of euthanasia for the health care system in Canada have already been reported [50] and with an aging demographic and diminishing fiscal resources, the option to save money in this way may become increasingly acceptable to health care decision makers. 

Confusion Between Palliative Care and Euthanasia 

Another ongoing issue is the confusion and conflation of euthanasia with palliative care. The use of the euphemistic terminology of Medical Assistance in Dying to refer to euthanasia in Canada has exacerbated this confusion in both the public and health care spheres. Canadian palliative care organizations have argued against the use of such language, affirming that palliative care provides support or “assistance» in dying to help people live as fully as possible until their natural death, but does not intentionally hasten death [51]. This assertion is also supported by the longstanding World Health Organization definition of palliative care [52]. 

In spite of clear and repeated distinctions made by national palliative care organizations and the Canadian Medical Association [53–56], there are ongoing efforts by some euthanasia providers to incorporate euthanasia within the scope of practice of palliative care, and to co-opt palliative care language to describe their euthanasia practice, “as one of the many items in the palliative care basket” [57, 58]. Linking the two practices in this way misleads other health care professionals and the public regarding palliative care. The 2019 Canadian Guideline for Parkinson Disease is a recent example [59]. Palliative care was commendably presented as one of the five key recommendations for the approach to care for persons with Parkinson Disease. However, euthanasia (as “MAiD“) was listed directly under the banner of palliative care support and was the only specific measure listed!

National Canadian palliative care organizations have expressed concern that this confusion and conflation of euthanasia and palliative care perpetuates the myth that palliative care hastens death and that misconception may prevent patients from seeking timely palliative care interventions which improve quality of life and, in some cases, enable people to live longer [60]. The Canadian Society of Palliative Care Physicians has stated that “patients and families must be able to trust that the principles of palliative care remain focused on effective symptom management and psychological, social, and spiritual interventions to help people live as well as they can until their natural death.” [53]. 

Dr. Balfour Mount, the “father” of palliative care in Canada, recently stated that 

Canadian legislation utilizes the euphemism ‘medical assistance in dying’ (MAiD) to define euthanasia/assisted suicide and that language has caused confusion concerning its distinction from Palliative Care. For over four decades, Palliative Care has been providing expert medical management to assist and support those who are dying without hastening death or administering a lethal dose of drugs to end life. The MAiD euphemism confuses and causes fear in our patients and the general public regarding the practice of Palliative Care and the nature of Palliative Medicine [61].

Impact on Palliative Care 

The 2016 Federal legislation positioned euthanasia (MAiD) as a health care right under the Canada Health Act, and so it must be publicly funded and accessible to all Canadians [39]. Palliative care, however, is not afforded such status and there is no similar requirement for it to be funded and accessible to Canadians. This is highly inequitable since almost 98% of deaths in Canada are not through euthanasia [6]. 

Euthanasia proponents continue to co-opt the vocabulary and tools of palliative care to create a new discipline of “end of life medicine” with a radically different philosophy, intention and approach that embraces hastened death as the “most beautiful death” [3]. Under this banner of “end of life care,” existing palliative care resources are being used in some jurisdictions to provide euthanasia, effectively reducing already limited resources for palliative care. This is the case in Ontario where, in some regions, the community Hospice Palliative Care Nurse Practitioners were given the additional role of providing euthanasia [62–63]. The assessment for and provision of euthanasia by physicians in Ontario are billed to the Ministry of Health using palliative care billing codes, despite the objections of palliative care physicians [64]. The very distinct and disparate goals and procedures followed by euthanasia teams and palliative care teams make it reasonable and advisable to separate the two practices. This separation should be accepted without acrimony or contention as it is in the best interests of patients, their families and the teams themselves. 

The impact of normalized euthanasia on our day-to-day clinical work in palliative care has been profound. When someone expresses a desire to die or a desire for hastened death (for example, “I just want this to be over…”), there can now be a knee-jerk reaction to consult the euthanasia team as a first response and neglect what palliative care has to offer. Until now, the standard of care has been to engage the patient in serious dialogue, to try to understand the nature of their suffering and grief expression more fully, and to determine what supports might be helpful. In palliative care, it is universally accepted that expressing a desire to die and talking about hastening death are most often normal expressions of grief, loss and coming to terms with one’s mortality in the face of a life-threatening condition. Such expressions of distress need to be explored and supported with skilled palliative care interventions to better understand the nature of the suffering and how to address this, and/or to accompany the person in their suffering. There are many holistic, dignity-conserving palliative care interventions such as Dignity Therapy [65], developed by renowned Canadian palliative care psychiatrist Dr. Harvey Chochinov, which are aimed at restoring purpose, meaning, and reframing hope in the face of the losses that accompany life threatening illnesses. Such therapies help a person and their loved ones to focus on living, even while dying, and provide support to accompany people on their journey, so they do not feel abandoned or alone. 

There is no mandatory palliative care consultation prior to euthanasia. The only requirement is that a patient is aware of all options for care (informed of all means to relieve suffering, including palliative care). Awareness is not the same thing as meaningful access, and what a person understands palliative care to be may influence the person’s understanding of what palliative care has to offer. The Chief Coroner of Ontario, who receives all reports of euthanasia cases in the province, has identified that it is very difficult to evaluate the quality/suitability of the palliative care being offered to patients who receive euthanasia [66]. Our own personal experience is that many patients and health care professionals, including some euthanasia providers, do not fully understand palliative care and its extensive array of therapeutic interventions. 

It is also our experience that, although palliative care teams offer to provide ongoing palliative care for patients who request a euthanasia death, a number of these patients reject palliative care involvement. These patients often refuse many of the medications offered for optimizing symptom management, citing fear that the medications will cause them to lose decisional capacity and therefore their eligibility to receive euthanasia. Tragically and paradoxically, this may result in the last days of life awaiting a euthanasia death being more highly symptomatic, and patients may have euthanasia without ever having a proper trial of excellent palliative care, even where it is available. A Quebec study found that in patients requesting euthanasia, 32% of those who received a palliative care consultation had it requested less than seven days before euthanasia provision and another 25% of palliative care consults were requested the day of or the day after the euthanasia request [41]. With the removal of the ten-day reflection period from euthanasia request to delivery of the procedure in the proposed revision for euthanasia legislation [18], the reality of a meaningful palliative care consultation seems even less likely. 

Downar et al (2020) state that 74% of euthanasia cases in Ontario had palliative care involved, however, the reporting measures used during the study period do not allow for a detailed evaluation of the quality of medical care provided, including palliative care, as it is not within the legislated requirements for oversight by the Office of the Chief Coroner to review or collect this information [66]. It is thus not possible to delineate or evaluate either the quality or quantity of palliative care involvement, when it occurred in relation to the request for euthanasia (the study only documented that there was involvement at the time of request), which palliative care team member provided it (e.g. physician, nurse, or social worker, etc.) or whether there was any meaningful involvement by a specialist palliative care team. A number of detailed responses outlining the significant problems with the conclusions made in this paper have already been published online [40]. 

Strong lobbies are pushing for euthanasia to be available in every palliative care unit and hospice in the country [67]. In many areas, euthanasia is required to be provided in all settings of care in order to avoid the withdrawal of public funding. Hospice societies who fundraise to build the buildings and co-support the day-to-day costs of specialized hospice care are also being mandated to provide euthanasia on site or face closure. Hospices and faith-based institutions are criticized for “blocking access” to euthanasia, even where access is documented to be excellent [68]. 

Protection of Conscience for Physicians 

Participation in euthanasia is also a great concern for physicians who are professionally and/or morally opposed to it. Some physician regulatory bodies require participation via a mandatory referral for euthanasia by physicians unwilling to provide the procedure themselves. For some physicians, such an obligation makes them complicit in an act they find not clinically indicated, unethical, or immoral. This happens in Ontario, Canada’s largest province, where the College of Physicians and Surgeons of Ontario has mandated such an “effective referral” requirement [69]. Physicians who decline to do this could face disciplinary action such as the loss of the license to practice medicine. The Ontario courts have agreed that the requirement for referral violates the conscience/religious rights of physicians (which are protected under the Canadian Charter of Rights and Freedoms) but justifies the referral requirement to “ensure access» to euthanasia for patients, despite no documented lack of access in Ontario [70]. This is the very first time in Canada that the burden of ensuring access to other parts of the health care system has rested on the individual physician. 

As previously discussed, euthanasia proponents are now suggesting that doctors must introduce euthanasia as an option to all potentially eligible patients as a so-called “duty to inform” [71]. However, in no other clinical situations are physicians required to discuss all potential options and procedures if they determine that those options are not medically indicated [72–74]. 

Some euthanasia providers are now refusing to become the “Most Responsible Physician” (MRP) via a transfer of care prior to or during the euthanasia procedure. One of the authors on this paper has directly experienced this at their local hospital. Personal written communications have also reported this practice happening at other hospitals across Canada. In addition, some euthanasia providers are refusing to accept patient transfers from palliative care units and hospices. These strategies profoundly damage collegiality and may force physicians unwilling to collaborate in euthanasia (professionally or morally) into an ethical crisis, compelling them either to remain the MRP, formally approving euthanasia and responsible for all aspects of care for the patient and family, or to refuse to approve it and face contrived accusations of having obstructed patient access. 

Palliative care clinicians have a high level of burnout [75–76], and the perceived lack of control over the scope of practice and forced participation in something that goes against their convictions about the very core of their vocation may be contributing to increasing moral distress and moral injury. This is reflected in colleagues who come to us on a daily basis to share experiences of repeated distress from euthanasia cases. Even colleagues who support euthanasia in some circumstances have reported experiencing this serious distress at times. Moral distress and moral injury manifest as early retirements, leaves of absence, and career changes by physicians who will no longer provide palliative care due to the expectation that euthanasia is included in the scope of practice. Additional moral distress is experienced by some palliative care leaders when health region administrators arbitrarily put euthanasia administration and oversight into the “end of life care” portfolio. The probable loss of palliative care physicians from the workforce at a time when even more clinicians are needed is in part a direct consequence of such stressful situations and heavy-handed measures. 

Proponents of euthanasia use the phrase “my life, my death, my choice,” which calls solely on the principle of autonomy as justification for euthanasia [77]. But, in Canada, the delivery of euthanasia is anything but an autonomous act. By design, it involves one or more other individuals. Many individuals and health care and community services commonly participate in each death, sometimes against their better judgment and possibly even against their will. 

While palliative care has so far been on the forefront of the euthanasia experience, the coming expansion of the legislation that will allow euthanasia for suffering due to any illness, condition or disability, will have a much broader impact on physicians from all medical disciplines, as well as on other health care professionals. There will be very few areas of medicine that euthanasia does not touch. 

In less than four years since the legalization of euthanasia in Canada we have witnessed:
  • rapid increase in rate of death by euthanasia (now estimated to be 2% of all deaths and expected to rise further) – a rate of growth over 3 years that has surpassed all other permissive jurisdictions 
  • the loosening of eligibility criteria by assessors and courts and the weakening of safeguard mechanisms in existing legislation 
  • the imminent expansion of euthanasia through legislative revision, despite strong opposition from citizens in the disability community, mental health professionals, palliative care clinicians and public policy leaders 
  • the failure of federal and provincial governments to designate palliative care as a right and to provide access to palliative care that is at least as robust as access to euthanasia 
  • the confusion and conflation of palliative care with euthanasia; and 
  • the erosion of conscience protection for physicians and other health care professionals leading to coerced participation and demoralization. 
These formidable challenges faced by physicians and patients in our difficult Canadian experience should not lead to discouragement but should instead inspire a reaffirmation of the commitment to traditional, whole-person medicine. Patients, loved ones, clinicians, and even society in general are all deeply enriched when palliative teams use our expertise to show compassion through excellent clinical care in an on-going, committed relationship with each patient, no matter how difficult the circumstances or how complicated the issues. Suffering — pain, fear, loss of control, sense of burden—is not solved by hastened death, but by this excellent care, delivered in a community and a society that honours and protects our most vulnerable citizens at the most difficult times in their lives. Euthanasia is not the panacea that proponents promise. Its legalization and subsequent rapid normalization have had serious negative effects on Canadian medicine and on Canadian society as a whole. We urge the WMA and our colleagues around the world to look beyond the simplistic media reports and to monitor developments in Canada carefully and wisely before making any changes in their own country’s legal framework for medical practice.

Authors’ Affiliations (Institutional affiliation are provided for identification purposes only and do not imply endorsement by the institution)

Leonie Herx MD PhD CCFP (PC) FCFP Chair, Division of Palliative Medicine Associate Professor, Department of Medicine Queen’s University Kingston, Ontario, Canada

Margaret Cottle MD CCFP (PC) Assistant Professor, Division of Palliative Care Faculty of Medicine, University of British Columbia Vancouver, British Columbia, Canada

John F. Scott MD MDiv Associate Professor, Division of Palliative Care, Department of Medicine, University of Ottawa Ottawa, Ontario, Canada

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23. Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide? South Med J. 2015 Oct;108(10):599-604. Kolva E, Hoffecker L, Cox-Martin E. Suicidal ideation in patients with cancer: a systematic review of prevalence, risk factors, intervention and assessment. Palliative Support Care. 2019 Sep 26:1-14. 
24. Deachman D. Medically assisted deaths prove a growing boon to organ donation in Ontario. Ottawa Citizen [Internet]. 2020 Jan 6 [cited 2020 Feb 29]. Available from: 
25. Rodríguez-Prat A, Balaguer A, Booth A, Monforte-Royo C. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open [Internet]. 2017 Sep 29 [cited 2020 Feb 29]; 7(9): e016659. Available from: e016659 doi: 10.1136/bmjopen-2017-016659 
26. Ball IM, Martin C, Sibbald R. Potassium chloride for medical assistance in dying followed by organ donation. Can J Anesth/J Can Anesth [Internet]. 2020 Feb 20 [cited 2020 Feb 29]. Available from: s12630-020-01603-w 
27. Ball IM, Sibbald R, Truog RD. Voluntary Euthanasia – implications for organ donation. N Engl J Med 2018 Sep 6;379(10):909-911. 
28. Woolhouse, S. This changed my practice: Preparing children for the medically assisted death of a loved one. University of British Columbia Continuing Professional Development (Internet). 2020 Feb 26 [cited 2020 Feb 29]. Available from: preparing-children-for-death-of-a-loved-one/ 
29. Canadian Broadcasting Corporation. B.C. man with ALS chooses medically assisted death after years of struggling to fund 24-hour care [Internet]. 2019 Aug 13 [cited 2020 Feb 29]. Available from: british-columbia/als-bc-man-medically-assisted-death-1.5244731 
30. Hamilton Spectator. Hamilton senior in unbearable pain wants assisted dying to save her from nursing home [Internet]. 2019 Jan 21 [cited 2020 Feb 29]. Available from: https://www. 
31. CTV News. Chronically ill man releases audio of hospital staff offering assisted death [Internet]. 2018 Aug 2 [cited 2020 Feb 29]. Available from: 
32. Canadian Broadcasting Company. Doctor suggests assisted suicide to mother of child with several medical conditions [Internet]. 2017 Jul 24 [cited 2020 Feb 29]. Available from: http:// 
33. Open Letter: Advocates Call for DisabilityRights Based Appeal of the Quebec Superior Court’s Decision in Truchon & Gladu [Internet]. 2019 Oct 4 [cited 2020 Feb 29]. Available from: 
34. Open Letter from Physicians Calling for an Appeal of the Quebec Superior Court Decision in Truchon & Gladu [Internet] 2019 Oct 9 [cited 2020 Feb 29]. Available from: en+Lettter+_+Updated+_+Re+_+Physicians+Cal l+for+Appeal+of+the+Quebec+Superior+Court’s +Decision+in+Truchon+%26+Gladu.pdf 
35. Frazee C. Opening Remarks. End of life, Equality and Disability: a National Forum on Medical Assistance in Dying [Internet]. Ottawa: The Canadian Association of Community Living and Council of Canadians with Disabilities; 2020 Jan 30 [cited 2020 Feb 29]. Available from: 
36. United Nations Human Rights Office of the High Commissioner. End of Mission Statement by the United Nations Special Rapporteur on the rights of persons with disabilities, Ms. Catalina Devandas-Aguilar, on her visit to Canada [Internet]. 2019 Apr 12 [cited 2020 Feb 29]. Available from: https://www.ohchr. org/EN/NewsEvents/Pages/DisplayNews. aspx?NewsID=24481&LangID=E 
37. The Supreme Court of Canada. Carter v. Canada (Attorney General), 2015 SCC 5, [Internet] 2015 Feb 6 [cited 2020 Feb 29]. Available from: item/14637/ 
38. Parliament of Canada. Bill C-14 [Internet]. 2016 Jun 17 [cited 2020 Feb 29]. Available from: 1/bill/C-14/royal-assent 
39. Downar J, Fowler RA, Halko R,  Davenport Huyer L,  Hill AD, Gibson JL. Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ [Internet]. 2020 Feb 24 [cited 2020 Feb 29]; 192 (8) E173- E181. Available from: DOI:https://doi. org/10.1503/cmaj.200016 
40. Seller L, Bouthillier M, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. Journal of Medical Ethics 2019; 45:106-111. 
41. Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients with Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362–368. 
42. Scully J. Why medical assistance in dying must treat mental and physical illness equally. Canadian Broadcasting Corporation (Internet). 2020 Feb 27 [cited 2020 Feb 29]. Available from: 
43. Kolva E, Rosenfeld B, Saracino R. Assessing the Decision-Making Capacity of Terminally Ill Patients with Cancer. Am J Geriatr Psychiatry. 2018 May;26(5):523-531. 
44. Government of Canada. Regulations for the Monitoring of Medical Assistance in Dying: SOR/2018-166 [Internet]. 2018 Jul 27 [cited 2020 Feb 29]. Available from: sor-dors166-eng.html 
45. Downar, D. Voluntary Assisted Dying: the Canadian Perspective [Internet]. Presented at: Voluntary Assisted Dying Implementation Conference; 2019 May 8-10; Melbourne, Australia [cited 2020 Feb 29]. Available at: F463-42D9-8039-A47E6AF0A788%7D 
46. Vulnerable Persons Standard [Internet]. 2017 Sep 28 [cited 2020 Feb 29]. Available from: 
47. Canadian Institute for Health Information. Access to Palliative Care in Canada [Internet]. Ottawa: CIHI; 2018 [cited 2020 Feb 29]. Available from: document/access-palliative-care-2018-en-web. pdf 
48. Shariff MJ, Gingerich M. Endgame: Philosophical, Clinical and Legal Distinctions between Palliative Care and Termination of Life. Second Series Supreme Court Law Review [Internet]. 2018 Jun 21 [cited 2020 Feb 29]; 85: 225-293. Available from: papers.cfm?abstract_id=3191962 
49. Trachtenberg AJ, Manns B. Cost analysis of medical assistance in dying in Canada. CMAJ 2017 Jan 23;189:E101-5. 
50. Canadian Hospice Palliative Care Association and Canadian Society of Palliative Care Physicians Joint Call to Action [Internet]. 2019 Nov [cited 2020 Feb 29]. Available from: https:// 
51. World Health Organization. WHO Definition of Palliative Care [Internet]. [cited 2020 Feb 29]. Available from: 
52. Canadian Society of Palliative Care Physicians Key Messages: Palliative Care and Medical Assistance in Dying [Internet]. 2019 May [cited 2020 Feb 29]. Available from: https:// CSPCP-Key-Messages-PC-and-MAiD-May2019-FINAL.pdf 
53. Canadian Society of Palliative Care Physicians. Key Messages: Physician-Hastened Death [Internet]. 2015, Oct [cited 2020 Feb 29]. Available from: uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf 
54. Canadian Hospice Palliative Care Association. Policy on Hospice Palliative Care and Medical Assistance in Dying [Internet]. 2019 Jun [cited 2020 Feb 29]. Available from: 
55. Canadian Medical Association. CMA Policy: Palliative Care [Internet]. 2016 [cited 2020 Feb 29]. Available from: default/files/2018-11/cma-policy-palliativecare-pd16-01-e.pdf 
56. Kutcher M. Navigating MAiD on PEI. Canadian Medical Association [Internet]. 2018 Nov 19 [cited 2020 Feb 29]. Available from: https:// 
57. Buchman S. Bringing Compassion to Medicine and to the CMA. Canadian Medical Association [Internet]. 2019 Oct 12 [cited 2020 Feb 29]. Available from: 
58. Grimes D, Fitzpatrick M, Gordon J, Miyasaki J, Fon EA, Schlossmacher M et al. Canadian guideline for Parkinson disease. CMAJ [Internet]. 2019 Sep 9 [cited 2020 Feb 29]; 191(36): E989-E1004. Available from: https://www. 
59. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363:733-742. 
60. Open letter Dr. Balfour Mount [Internet]. 2019 Dec [cited 2020 Feb 29]. Available from: https:// Letter-from-Dr.-Balfour-Mount.pdf 
61. Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018 Oct; 53(4):511-520. 
62. Nursing and Assisted Dying – Experiences from a Canadian Context [Internet]. Presented at: Voluntary Assisted Dying Implementation Conference; 2019 May 8-10; Melbourne, Australia [cited 2020 Feb 29]. Available from: Api/downloadmedia/%7B28620FDD-3485- 4292-98DC-52C08722D0E6%7D 
63. OHIP Payments for Medical Assistance in Dying [Internet]. 2018 Nov [cited 2020 Feb 29]. Available from: 
64. Dignity in Care [Internet]. 2016 [cited 2020 Feb 29]. Available from: 
65. Huyer D. Office of Chief Coroner of Ontario Oversight: Lessons from Ontario Medical Assistance in Dying [Internet]. May 2019 [cited 2020 Feb 29]. Available from: downloadmedia/%7B59E8A8AB-B84C-4047- 8B9E-E263E0500E50%7D 
66. DWDC, CAMAP issue joint statement on forced transfers for assisted dying [Internet]. 2018 Jan 8 [cited 2020 Feb 29]. Available from: 
67. Jones AM, Cousins B. Standoff between B.C. and hospice refusing to offer assisted dying [Internet]. January 20, 2020 [cited 2020 Feb 29]. Available from: standoff-between-b-c-and-hospice-refusing-tooffer-assisted-dying-1.4773755
68. Medical Assistance in Dying [Internet]. College of Physicians and Surgeon of Ontario. 2016 [cited 2020 Feb 29]. Available from: https:// Policies/Medical-Assistance-in-Dying#Policy 
69. Ontario Superior Court of Justice Divisional Court. The Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579 (CanLII) [Internet]. 2018 Jan 31 [cited 2020 Feb 29]. Available from: 2018/2018onsc579/2018onsc579.pdf 
70. The Canadian Association of MAiD Assessors and Providers. Key Messages: End of Life Care and Medical Assistance in Dying [Internet]. 2020 Feb [cited 2020 Feb 29]. Available from: 
71. Williams JR. Law catching up with ethics. CMAJ [Internet]. 2020 Feb 3 [cited 2020 Feb 29]; 192(5): E123. Available from: https://www. 
72. Downar J, Close E, Sibbald R. Do physicians require consent to withhold CPR that they determine to be nonbeneficial? CMAJ  [Internet]. 2019 Nov 25 [cited 2020 Feb 29]; 191(47): E1289-E1290. Available from: https:// 
73. Ontario Superior Court of Justice Wawrzyniak v. Livingstone, 2019 ONSC 4900 (CanLII) [Internet). 2019 Aug 20 [cited 2020 Feb 29]. Available from: doc/2019/2019onsc4900/2019onsc4900.html 
74. Kamal AH, Bull JH, Wolf SP, Swetz KM, Shanafelt TD, Ast K, et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. J Pain Symptom Manage. 2016 Apr; 51 (4): 690-696. 
75. Reddy S,  Yennu S,  Tanco KC,  Anderson AE, Guzman D, Williams JL, et al. Frequency of burn-out among palliative care physicians participating in continuing medical education. Journal of Clinical Oncology 2019; 37:31_suppl, 77. 
76. Wesley Smith. My Life, My Death, My Choice [Internet]. 2010 Aug 5 [cited 2020 Feb 29]. Available from: https://www.discovery. org/a/15141/

Sunday, April 26, 2020

Margaret Dore: New Jersey Motion for Reconsideration, on assisted suicide law.

This article was published by Choice is an Illusion on April 24, 2020.

Previous articles:
  1. New Jersey euthanasia act must be set-aside (Link).
  2. New Jersey appellate court lifts restraining order that stopped assisted suicide (Link).
  3. Court order temporarily stops assisted suicide in New Jersey (Link).
Margaret Dore
To view Dore's brief as submitted, click here.


Margaret Dore moves for reconsideration of the Court’s order dated April 1, 2020, which upheld the constitutionality of the Medical Aid in Dying for the Terminally Ill Act.[1]


The Court did not reach the Act’s violation of the object in title rule, which is dispositive to set the Act aside. The Court should reach this issue now to overturn the Act.

The Court’s order states that Dore asked the Court to declare the Act unconstitutional “on grounds not asserted by plaintiffs.”[2] The plaintiffs, did, however, ask the Court to rule on the issue, stating:

Ms. Dore’s brief should be considered by the Court since if the law is unconstitutional under the single object rule, it should be the Court’s responsibility to raise that issue sua sponte even if not raised by Ms. Dore or the Plaintiffs.[3]
The Legislature understood that it was enacting a strictly voluntary law limited to assisted suicide for dying patients.[4] The prior judge expressed a similar view. See, for example, the transcript from the hearing on August 14, 2019 (“This case is not about euthanasia”).[5]

This case, however, is about euthanasia. The Act is also not limited to dying people. Patient voluntariness is allowed, but not required. These are material facts not disclosed by the Act’s title and related findings. The Act is unconstitutional and must be set aside.


A. The Act Allows Physician-Assisted Suicide, Which It Terms Medical Aid in Dying
Dictionary definitions of “assisted suicide,” include “suicide committed by someone with assistance from another person especially: physician-assisted suicide.”[6] Dictionary definitions of physician-assisted suicide include the following:
[S]uicide by a patient facilitated by means (such as a drug prescription) or by information (such as an indication of a lethal dosage) provided by a physician aware of the patient's intent.[7]
Here, the Act allows this same practice, which it terms medical aid in dying. The Act, “Findings, Declarations Relative to Medical Aid in Dying for the Terminally Ill,” states:
[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[8]
The Act also specifically describes physician involvement to write the prescription for the lethal dose.[9] The bottom line, the Act allows physician-assisted suicide as traditionally defined, which it terms medical aid in dying.
B. The Act Legalizes Assisted Suicide as a “Right”
Again, the Act states:
[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[10]
If for the purpose of argument, this provision is limited to allowing voluntary assisted suicide (because it says that the patient may chose to self-administer the lethal medication), the Act will nonetheless also allow euthanasia due to assisted suicide being described as a “right.” This is true due to: (1) The New Mexico Supreme Court Decision, Morris v. Brandenburg, 376 P.3d 836 (2016); and (2) the Americans with Disability Act, both of which are discussed below.
1. Morris v. Brandenburg
The 5-0 decision states in part:
[W]e agree with the legitimate concern that recognizing a right to physician aid in dying will lead to voluntary or involuntary euthanasia because if it is a right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication. (Emphasis added).[11] 
2. The Americans With Disabilities Act (ADA)
The ADA is “a federal civil rights law that prohibits discrimination against individuals with disabilities in every day activities, including medical services.”[12] “Medical care providers are required to make their services available in an accessible manner.”[13]This includes:
Reasonable modifications to policies, practices, and procedures to make healthcare services fully available to individuals with disabilities, unless the modifications would fundamentally alter the nature of the services (i.e., alter the essential nature of the services). (Emphasis added).[14]
Here, the Act legalized “medical aid in dying” as part of New Jersey healthcare.[15] If for the purpose of argument, the Act does in fact require self-administration, the ADA will require a reasonable accommodation for individuals unable to self-administer. This will mean administration by another person. The Act will thereby require euthanasia as traditionally defined.


The Act has an application process to obtain the lethal dose.[16] Once the lethal dose is issued by the pharmacy, there is no oversight.[17] No witness, not even a doctor, is required to present at the death.[18]


The Act applies to “terminally ill” individuals. The Act states:

“Terminally ill” means that the patient is in the terminal stage of an irreversibly fatal illness, disease, or condition with a prognosis, based upon reasonable medical certainty, of a life expectancy of six months or less.[19]
Such persons may, in fact, have years or decades to live. This is true due to actual mistakes (the test results got switched), and because predicting life expectancy is not an exact science.[20] Also, sometimes doctors are wrong, as in way wrong.

Consider John Norton, diagnosed with ALS at age 18.[21] He was told that he would get progressively worse (be paralyzed) and die in three to five years.[22] Instead, the disease progression stopped on its own.[23] In a 2012 affidavit, at age 74, he states:

If assisted suicide or euthanasia had been available to me in the 1950's, I would have missed the bulk of my life and my life yet to come.[24]
A. Elder Abuse Is a Problem in New Jersey; Perpetrators Are Often Family Members
Elder abuse is a problem in New Jersey and throughout the United States.[25] Nationwide, prominent cases include actor Mickey Rooney and New York philanthropist, Brooke Astor.[26]

Perpetrators are often family members.[27] They typically start out with small crimes, such as stealing jewelry and blank checks, before moving on to larger items or to coercing victims to change their wills or to liquidate their assets.[28] Amy Mix, of the AARP Legal Counsel of the Elderly, states:

[Perpetrators] are family members, lots are friends, often people who befriend a senior through church .... We had a senior victim who had given her life savings away to some scammer who told her that she’d won the lottery and would have to pay the taxes ahead of time.... The scammer found the victim using information in her husband’s obituary.[29] 
B. Elder Abuse Is Rarely Reported, Victims Don’t Want to Report Their Children as Abusers
The vast majority of elder abuse cases are not reported to the authorities. Reasons include:
[F]ear of retaliation, lack of physical and/or cognitive ability to report, or because they don’t want to get the abuser (90% of whom are family members) in trouble. (Emphasis added).[30] 
C. Elder Abuse Is Sometimes Fatal
In some cases, elder abuse is fatal. More notorious cases include California’s “black widow” murders, in which two women took out life insurance policies on homeless men.[31] Their first victim was 73 year old Paul Vados, whose death was staged to look like a hit and run accident.[32] The women collected $589,124.93.[33]

Consider also, People v. Stuart in which an adult child killed her mother with a pillow, so as to inherit. The Court observed:

Financial considerations [are] an all too common motivation for killing someone.[34]

While elder abuse is a largely uncontrolled problem, there are penalties for doing it and when perpetrators are caught, they can be punished. The California black widows and the adult child who killed her mother with a pillow, discussed above, served prison time. With a risk of punishment, there is a deterrent to protect other potential victims from harm.

This is in contrast to the Act, in which purported protections are illusory, which renders potential victims sitting ducks to their adult children and other predators, without recourse. See below.


A. “Even If a Patient Struggled, Who Would Know?”
The Act has no oversight over administration of the lethal dose.[35] In addition, the drugs used are water and alcohol soluble, such that they can be injected into a sleeping or restrained person without consent.[36] Alex Schadenberg, Executive Director for the Euthanasia Prevention Coalition, puts it this way:
With assisted suicide laws in Washington and Oregon [and with the Act], perpetrators can . . . take a “legal” route, by getting an elder to sign a lethal dose request. Once the prescription is filled, there is no supervision over administration. Even if a patient struggled, “who would know?” (Emphasis added).[37] 
B. Someone Else Is Allowed to Communicate on the Patient’s Behalf
The Act uses the word, “capable,” which is specially defined to allow other people to communicate on the patient’s behalf, as long as they are “familiar with the patient’s manner of communicating.” The Act states:
“Capable” means having the capacity to make health care decisions and to communicate them to a health care provider, including communication through persons familiar with the patient’s manner of communicating if those persons are available. (Emphasis added).[38]
Being familiar with a patient’s manner of communicating is a very minimal standard. Consider, for example, a doctor’s assistant who is familiar with a patient’s “manner of communicating” in Spanish, but she herself does not understand Spanish. That, however, would be good enough for her to communicate on the patient’s behalf during the lethal dose request process. The patient would not necessarily be in control of his or her fate.
C. Purported Protections Are Illusory
The Act says that the attending physician is to ensure that all “appropriate” steps are carried out in “accordance” with the Act as necessary. The Act states:
The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] . . . including such actions as are necessary to: . . . 
(6) recommend that the patient participate in a consultation concerning concurrent or additional treatment opportunities . . . [and] 
(8) inform the patient of the patient’s opportunity to rescind the request . . . . (Emphasis added).[39]
The Act does not define "appropriate" or “accordance.”[40] Dictionary definitions of appropriate include "suitable or proper” in the circumstances.[41] Dictionary definitions of accordance include “in the spirit of,” meaning “in thought or intention.”[42]

With these definitions, the attending physician’s view of what is "suitable or proper" is enough for compliance with patient protections. The physician's "thought or intention" is similarly sufficient. The purported protections are neutralized to whatever an attending physician happens to feel is appropriate and/or had a thought or intention to do. The “protections” are unenforceable.

D. Deaths in Accordance With the Act Are “Natural” as a Matter of Law 
1. Action taken in accordance with the Act is not suicide or homicide
The Act states:
Any action taken in accordance with the provisions of [the Act] shall not constitute patient abuse or neglect, suicide, assisted suicide, mercy killing, euthanasia, or homicide under any law of this State. (Emphasis added).[43] 
2. The Act requires deaths to be reported as “natural”
In New Jersey, death certificates have five categories for reporting the manner of death, four of which are substantive: (1) natural; (2) accident; (3) suicide; and (4) homicide.[44] The fifth category is “undetermined.”[45]

As noted in the preceding section, a death occurring in accordance with the Act does not constitute suicide or homicide under any law of the State. The death is also not an accident due its having been an intended event. This leaves “natural.” Deaths occurring pursuant to the Act are natural as a matter of law.

E. Dr. Shipman and the Call for Death Certificate Reform
Per a 2005 article in the UK’s Guardian newspaper, there was a public inquiry regarding Dr. Harold Shipman, which determined that he had “killed at least 250 of his patients over 23 years.”[46] The inquiry also found:
that by issuing death certificates stating natural causes, the serial killer [Shipman] was able to evade investigation by coroners. (Emphasis added). [47]
Per a subsequent article in 2015, proposed reforms included having a medical examiner review death certificates, so as to improve patient safety.[48] The New Jersey Act has instead moved in the opposite direction to require that deaths be reported as natural. Doctors and other perpetrators have been enabled to kill under mandatory legal cover.
F. The Act Renders New Jersey Residents Sitting Ducks to Their Heirs and Other Predators
New Jersey’s slayer statute prevents a killer from inheriting from his or her victim. The statute states:
[A]n individual who is responsible for the intentional killing of the decedent forfeits [his or her inheritance].”[49]
The rational is that a criminal should not be allowed to benefit from his or her crime.[50]

Under the Act, however, a person who intentionally kills another person is allowed to inherit. This is due to the deaths being certified as natural. With the passage of the Act, New Jersey residents with money, meaning the middle class and above, have been rendered sitting ducks to their heirs and other predators.


A. My Clients Suffered Trauma in Oregon and Washington State
I have had two cases where my clients suffered trauma due to legal assisted suicide. In the first case, one side of my client’s family wanted her father to take the lethal dose, while the other side did not. The father spent the last months of his life caught in the middle and torn over whether he should kill himself. My client was severely traumatized. The father did not take the lethal dose and died a natural death.

In the other case, my client’s father died via the lethal dose at a suicide party. It’s not clear, however, that administration of the lethal dose was voluntary. A man who was present told my client that his father had refused to take the lethal dose when it was delivered, stating: "You're not killing me. I'm going to bed." The man also said that my client’s father took the lethal dose the next night when he (the father) was already intoxicated on alcohol. The man who told this to my client subsequently changed his story.

My client, although he was not present, was traumatized over the incident, and also by the sudden loss of his father.

B. In Oregon, Other Suicides Have Increased with Legalization of Physician-Assisted Suicide
Government reports from Oregon show a positive correlation between the legalization of physician-assisted suicide and an increase in other (conventional) suicides. This correlation is consistent with a suicide contagion in which legalizing physician-assisted suicide encouraged other suicides.[51]
C. The Felony for Undue Influence Is Illusory
The Act has a felony for “undue influence,” which is not defined and has no elements of proof. The Act merely states:
A person who . . . exerts undue influence on a patient to request medication pursuant to [the Act] or to destroy a rescission of a request is guilty of a crime of the third degree. (Emphasis added).[52]
The Act also specifically allows conduct normally used to prove undue influence. For example, the Act allows an infirm person with a terminal disease to request the lethal dose. Physical weakness is a factor generally used to PROVE undue influence.[53]

How do you prove that undue influence occurred when the Act does not define it, and the Act also allows conduct generally used to prove it? You can’t. The felony for undue influence is illusory and unenforceable.


As noted supra, the New Jersey Constitution governs permissible legislative conduct when enacting legislation. To that end, the Constitution sets forth the object in title rule, as follows:

To avoid improper influences which may result from intermixing in one and the same act such things as have no proper relation to each other, every law shall embrace but one object, and that [object] shall be expressed in the title. (Emphasis added).[54]
The rule is designed to protect against the misleading of the people. State v Guida, 119 N.J.L. 464, 465-466 (1938), states:
The sole requirement is that [the title] ‘shall express its object in a general way so as to be intelligible to the ordinary reader’; and it is the settled rule that a statute will not be judicially declared inoperative and unenforceable on this ground unless the deficiency plainly exists. (Emphasis added).
In the case at bar, the deficiency plainly exists. The Legislature, the Attorney General and the prior court were all mislead by the Act’s deceptive title, implying that the Act is limited to voluntary assisted suicide, when the Act also allows non-voluntary euthanasia. This Court has also been mislead. The Act must be set aside.

Respectfully submitted this 18th day of April 2020

Margaret Dore Esq., MBA, appearing pro se
Law Office of Margaret K. Dore, PS
1001 4th Avenue, Suite 4400
Seattle, WA 98154
206 697 1217


[1] The Act is attached in the brief's appendix, at pages A-1 to A-15.
[2] The Order, page 35, attached in the brief's appendix, at page A-20.
[3] Letter from E. David Smith, Esq., to Judge Lougy, dated March 20, 2020, in the brief's appendix at page A-23.
[4] See for example, the Order on Emergent Motion, Superior Court of New Jersey Appellate Division, August 27, 2019 (“the process is entirely voluntary on the part of all participants, including patients...”). Attached in the brief's appendix at page A-63.
[5] Transcript attached in the brief's appendix at page A-62.
[6] Merriam-Webster, attached in the brief's appendix at page A-27;
[7] Merriam-Webster, attached in the brief's appendix at page A-28.
[8] The Act, Section C.26:16-2, attached in the brief's appendix at page A-1.
[9] The Act, Section C.26:16-6, states:

The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] before writing a prescription for medication that a qualified terminally ill patient may choose to self-administer pursuant to [the Act]. (Attached in the brief's appendix at page A-4).
[10] The Act, page 1, attached in the brief's appendix at page A-1
[11] Morris v. Brandenburg, 376 P.3d 836, 848 (2016).
[12] U.S. Department of Justice, Civil Rights Division, and the U.S. Department of Health and Human Services, Office for Civil Rights, “Americans with Disabilities Act: Access to Medical Care for Individuals with Mobility Disabilities,” July 2010, available at
[13] Id.
[14] Id.
[15] The Act, Findings, attached in the brief's appendix at page A-1.
[16] See the Act, attached in the brief's appendix at pp. A-3 to A-7.
[17] See the Act in its entirety, in the brief's appendix at pp. A-1 to A-15.
[18] Id.
[19] The Act, C.26:16-3, attached in the brief's appendix at page A-3.
[20] Cf. Jessica Firger, "12 Million Americans Misdiagnosed Each Year," CBS NEWS, April 17, 2014, attached in the brief's appendix at page A-29; and Nina Shapiro, "Terminal Uncertainty — Washington's New 'Death with Dignity' Law Allows Doctors to Help People Commit Suicide — Once They've Determined That the Patient Has Only Six Months to Live. But What If They're Wrong?,” The Seattle Weekly, 01/14/09, attached in the brief's appendix at pages A-30 to A-33.
[21] Affidavit of John Norton, attached in the brief's appendix at pages A-34 to A-36.
[22] Id., ¶ 1.
[23] Id., ¶ 4.
[24] Id., ¶ 5.
[25] See e.g., Dansky Katz Ringold York, Attorneys at Law, Marlton New Jersey, “How to Spot and Prevent Elder Financial Abuse,” April 27, 2016, at; and Beth Fitzgerald, “New Jersey Considers Law to Prevent ‘Granny Snatching,’” New Jersey Spotlight, MAY 21, 2012,
[26] Tom Cohen, “Mickey Rooney tells [U.S.] Senate panel he was a victim of elder abuse,” CNN, March 2, 2011; Carole Fleck, “Brooke Astor’s Grandson Tells Senate Panel of Financial Abuse,” AARP Bulletin Today, 02/05/2015 (“The grandson of socialite Brooke Astor, who blew the whistle on his father for plundering millions from his grandmother’s estate, told the Senate panel Wednesday that his grandmother’s greatest legacy may be the national attention focused on elder financial abuse.”), and Matthew Talbot, “Issues of Prosecuting Elder Abuse: The Casey Kasem Case,” Talbot Law Group, PC, January 4, 2016, available at
[27] Id., MetLife Mature Market Institute, “Broken Trust: Elders, Familyand Finances, A Study on Elder Abuse Prevention,” March 2009, at
[28] Id.
[29] Kathryn Alfisi, “Breaking the Silence on Elder Abuse,” Washington Lawyer, February 2015.
[30] “Adult Protective Services: Facts and Fiction,” Division of Aging Services, NJ Department of Human Services, available at
[31] See People v. Rutterschmidt, 55 Cal.4th 650 (2012). See also
[32] Rutterschmidt, at 652-3.
[33] Id. at 652.
[34] 67 Cal.Rptr.3d 129, 143 (2007), available at
[35] See the Act in its entirety, attached in the brief's appendix at A-1 to A-15.
[36] The drugs used include Secobarbital, Pentobarbital and Phenobarbital, which are water and/or alcohol soluble. See excerpt from Oregon’s and Washington’s annual reports, attached hereto at A-41 & A-42 (listing these drugs). See also and
[37] Alex Schadenberg, Letter to the Editor, “Elder abuse a growing problem,” The Advocate, Official Publication of the Idaho State Bar, October 2010, page 14.
[38] The Act, C.26:16-3, attached in the brief's appendix at page A-2.
[39] Attached in the brief's appendix at page A-4.
[40] See the Act in its entirety, attached in the brief's appendix at pages A-1 through A-15.
[41] Attached in the brief's appendix at page A-43.
[42] Attached in the brief's appendix at pages 44 and A-45.
[43] The Act, C.26:16-17.a.(2), attached in the brief's appendix at page A-9.
[44] Andrew L. Falzon, MD, and Sindy M. Paul, MPH, “Death Investigation and Certification in New Jersey,” MD Advisor, a journal for the New Jersey medical community, 2016. (Attached in the brief's appendix at page A-46).
[45] Id.
[46] David Batty, “Q & A: Harold Shipman,” The Guardian, 08/25/05, at (Attached in the brief's appendix at pages A-47 to A-49).
[47] Id., attached in the brief's appendix at page A-49.
[48] Press Association, “Death Certificate Reform Delays ‘Incomprehensible,”
The Guardian, January 21, 2015, attached in the brief's appendix at pages A-50 to A-51.
[49] NJ Rev Stat § 3B:7-1.1, attached in the brief's appendix at pages A-52 and A-53.
[50] Cf. Ilene S. Cooper and Jaclene D'Agostino, "Forfeiture and New York's 'Slayer Rule', NYSBA Journal, March/April 2015, attached in the brief's appendix at page A-54.
[51] For a more information, see Margaret Dore, “In Oregon, Other Suicides Have Increased with Legalization of Assisted Suicide,” August 18, 2017, attached in the brief's appendix at pages A-55 to A-57. See also the Declaration of Williard Johnston, MD, attached in the brief's appendix at pages A-58 to A-60.
[52] Attached in the brief's appendix at page A-10.
[53] Cf. Neugebauer v. Neugebauer, 804 N.W.2d 450, ¶17 (2011)(“physical . . . weakness is always material upon the question of undue influence”).