Sunday, April 3, 2022

Euthanasia (MAiD): Nothing about this felt OK.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Ferrukh Faruqui is a Ottawa physician and freelance writer who wrote an essay examining how expanding eligibility for medical assistance in dying (MAiD) to those with non-terminal conditions is throwing the medical community into civil war. Faruqui's article was published by the National Post on April 1, 2022.

Dr Faruqui begins her essay by writing about the death of Alan Nichols, who died by MAiD in July 2019. Faruqui interviews Alan's brother Gary and sister-in-law Trish who maintain that Alan was not of sound mind and not terminally ill, nonetheless he died by MAiD.

Faruqui writes:
Alan was once “a bloody great goalie,” says Gary. But he faced a lifetime of challenges after his first brain surgery for a benign tumour at age 12 left him with a weak right side and hearing loss. Step by step, he learned to grasp a pencil and write with his left hand before completing high school.

Alan gave up hockey and picked up a Pentax camera instead. He became a loner who shot film, including beautiful prints for his parents’ silver wedding anniversary. He worked for years as a janitor before things got bad.

As an adult, he depended on his family for emotional as well as practical support. Once, when he didn’t show up for dinner and refused to open his door, they called a locksmith. When they rushed inside, they found him waiting in bed. “I knew someone would show up,” he said.

He was suspicious of authorities, refusing to accept his disability cheques. The family tried unsuccessfully to obtain guardianship over his affairs. His brother, Wayne, picked him up weekly to buy groceries and do his banking.

In June, alerted by his neighbour, Sharon, RCMP officers found Alan dehydrated and delirious. They quickly transported him to the hospital, where he was admitted under the Mental Health Act. Gary flew out to Chilliwack immediately. He was concerned but figured things would play out as usual — it wasn’t the first time Alan’s baseline depression plummeted and landed him in hospital. But he always got better, returning to his small, sparsely furnished condo, where Sharon kept an eye on him.
Alan & Gary Nichols
Faruqui explains that after entering the hospital, Alan stayed in the psychiatric unit for 5 days and was then released to the regular ward but uncharacteristically, this time Alan refused to speak to his family.
After five days in the psychiatric unit, Alan was discharged to the regular ward. Uncharacteristically, he refused to see or speak with his family. When reached by phone, staff assured them he was improving. On July 22, a doctor called Gary to say that Alan was scheduled to die in four days by medical assistance in dying.

Gary started to cry. How could a suicidal man who’d been involuntarily admitted be eligible for MAiD? He wasn’t facing imminent death. Despite the family’s pleas, the hospital insisted this was Alan’s decision, that his medical records were confidential, and they were lucky that Alan had grudgingly agreed to let them know.

A few days later, Gary and Trish, who’d spent decades helping Alan live, watched him die.
Faruqui explains that the family were not provided with answers to the decision to approve Alan's death.
A year later, despite getting legal advice and pressing the hospital and coroner for answers, they’re no further ahead. The Fraser Valley Health Authority told them the law doesn’t require patients to be actively dying to be eligible for MAiD.

Gary’s not a rich man and lawyers are expensive. He says he’s haunted by how families are shut out of these crucial decisions. He says Alan could have lived longer, that the system erred terribly. When he called Wayne to tell him what happened, Wayne was stunned.

“They killed our brother.”
Faruqui writes:
Gary Nichols’ grief demonstrates the heartache medical assistance in dying can inflict on family members. For many doctors like myself who’ve sworn to uphold life, decriminalizing the deliberate act of ending a patient’s life is an ethical turning point that’s transformed the very nature of the profession.
Faruqui explains how Canada's euthanasia (MAiD) law came to be. How the Supreme Court struck down the prohibition on euthanasia and assisted suicide. How the government passed Bill C-14 in June 2016. How the Truchon case, challenging the "terminal illness" requirement in the law was heard and decided in Québec, and how the current government expanded euthanasia (MAiD) by passing Bill C-7 in March 2021, a bill that removed the "terminal illness" requirement, eliminated the 10-day waiting period for terminally ill people and approved euthanasia for mental illness alone. She continues:
For millennia, it’s been taboo for doctors to kill their patients. In many places it still is. As western societies hurled off the shackles of religious authoritarianism, an ethical void was created. This gap’s been filled by humanist creeds that teach that the greatest good flows from personal independence. This libertarian ideal posits the individual as the master of his universe, however lonely that universe may be.
Dr Sonu Gaind
Faruqui writes that many physicians who oppose MAiD are silent for fear of repercussions, but now the issue has moved to euthanasia for mental illness putting psychiatrists on the line. She interviews Dr Sonu Gaind, a psychiatrist who doesn't oppose euthanasia in general but opposes euthanasia for mental illness. She writes:
Dr. Sonu Gaind is troubled, too. A professor at the University of Toronto, he’s not a conscientious objector. In fact, at the Humber River Hospital where he’s head of psychiatry, he’s the physician chair of the MAiD committee. He emphasizes that he’s speaking on his own behalf as an individual psychiatrist.

Pretending there’s no difference between physical as opposed to mental illness for the purposes of MAiD borders on “delusional,” he says. He can’t fathom why the statement of the Canadian Psychiatric Association, which declares that excluding access to MAiD for mental illness is discriminatory, makes no mention of the troubling suicidality that characterizes untreated psychiatric illness.
Language crystallizes key concepts of sweeping movements that reshape societies. But it can also mislead and flatten knotty issues such as euthanasia. Terms like discrimination and autonomy become missiles, annihilating debate. Offering death to the mentally ill, whose unique symptomatology includes pathological despair, is both illogical and unjust.
Faruqui further explains why Gaind opposes euthanasia for mental illness.
Gaind’s Senate testimony emphasized psychiatry’s essential incompatibility with the “irremediable” element of the MAiD framework. Society should recognize and address this contradiction, he insists. Doing otherwise is an exercise in obfuscation. Cardiologists know how heart disease works. But psychiatry hasn’t elucidated the pathophysiology of depression or schizophrenia. It’s impossible for clinicians to predict prognosis in individual cases, meaning that some who seek death would have gotten better.

He cites metrics that show a demographic divide. Those terminal patients who’ve lived a good life and have the privileged autonomy to choose a “good” death are overwhelmingly white and affluent. Unfortunately, their rights magnify the vulnerability of those who’ve never had a good shot at life. In the Netherlands, those marginalized by poverty and trauma are the ones seeking psychiatric euthanasia. Of these, 70 per cent are women. Gaind says these sad, lonely individuals need suicide prevention, which costs time and money and is mostly unavailable. Instead of the “right to die,” he wants to legislate the “right to live.” As for personal choice, he calls it a cruel fallacy. Guaranteed access to death in the setting of absent mental health treatment is no choice at all.

“You shift to MAiD to avoid a painful death — then you shift to MAiD to avoid a painful life. It’s like a Jenga tower — when you pull out one block, the tower comes tumbling down. It’s all connected.”
Faruqui writes that Gaind has now been suspended from the Canadian Psychiatric Association, a group the he is a past President, based on his opposition to their support for euthanasia for mental illness.

Faruqui then writes about the euthanasia death of Arthur Cole.
Jayde Curts’s long hair frames her sombre face. One November afternoon in 2020, she sat alone in her London, Ont., living room, cut off from the rest of her family. She heard the clock strike one. She remembers thinking, “I guess my grandpa’s dead now.”

She refused to attend his scheduled death by MAiD. She says her mother wouldn’t discuss it afterwards, while her grandmother isolated herself and refused to talk about it. Jayde says it didn’t feel right.

“Nothing about this felt OK,” she says. “It felt like putting a dog down.”

Her grandfather, Arthur Cole, was in his 80s. During surgery for thyroid cancer, doctors discovered it had spread. After being discharged home with a tracheostomy and without home care, his elderly wife had trouble managing the breathing tube. When the cancer spread to his brain, he requested home palliative care but was told it wasn’t available. Instead, a doctor offered to make a house call to administer MAiD.
Jayde says that her grand father did not receive the care that he needed and the decision has divided her family.
His granddaughter says Arthur worried aloud about burdening his family. Post-surgery, breathing through a tube, Jayde questions his psychological competence to make the critical decision to end his life.

“You read about this in the news. But it’s shocking when it happens to your family,” she says. She’s paid a heavy price for her outspokenness. She no longer speaks to her mother or her grandmother. She regrets the estrangement but stands by her conviction that the medical system blundered badly.

“They played on his emotions … He was vulnerable and it feels like they took advantage of him,” she says. She wonders why the health system offered death instead of help. She wants people to hear Arthur’s story so other families can speak up, too.
Faruqui then interviews Dr Balfour Mount the father of palliative care in Canada, who trained under Cicily Saunders, who developed modern palliative care. Faruqui writes:
Dr. Balfour Mount is the retired father of Canadian palliative care...

“Total pain” encompasses suffering across dimensions, especially the spiritual, where conventional medicine falters. Palliation supports patients through the arc of incurable conditions such as multiple sclerosis and heart failure. Mount believes the simple act of being present soothes existential pain and chases dread away, that once we slow down to appreciate each moment, the end of life holds infinite potential for joy. He once explained, “When pain and other symptoms are controlled, there really is limitless potential for quality of life at the end of life. … It’s not about ending things; it’s about the present moment. That’s all that any of us have — is just now. And, it turns out, that there’s endless potential in the present moment.”
Mount does not support (MAiD) euthanasia.
He calls MAiD a euphemism that confuses the public and muddies both the benefits of palliative care and the reality of euthanasia. He’s endorsed a joint statement by the Canadian Society of Palliative Care Physicians and the Canadian Hospice Palliative Care Association that rejects conflation of the respective practices, which are distinct in philosophy and intent. The latter exists purely to hasten death, while the former focuses on enhancing life.
Faruqui then speaks to Dr Leonie Herx, the past President of Canadian Society of Palliative Care Physicians, who lives in Kingston. Farququi writes:
“We’ve come so far in palliative care,” she says, adding that many patients either fear palliation will accelerate their deaths, don’t realize MAiD is a lethal injection, or both. She laments that even colleagues don’t appreciate how effective early palliation can be. Because of its absence from the conversation, too many patients opt for MAiD instead.
Herx has presented before parliamentary committee's and laments the quick expansion of MAiD. But not without a cost. Faruqui writes:
She’s withstood relentless attacks on her professional integrity by other physicians. She’s weary, despairing even as she wades into dangerous waters, citing hospital colleagues who complain they’re pressured, even bullied into going along with policies that trouble them. Doctors across the country call her to report that some MAiD providers refuse to assume transfer of care as the “most responsible physician,” thereby implicating them in a practice they are philosophically opposed to. Some institutions, perhaps lacking sufficient MAiD providers, even expect the MRP-conscientious objectors to conduct the initial MAiD assessment. All worry about professional ramifications. Some who’ve voiced doubts about MAiD in certain clinical scenarios have been called obstructionist, of trying to block access to a legal service. There’s no protection for whistleblowers. She knows of many doctors who’ve left the specialty or retired early. Her colleagues know of more. Some have left medicine for good. But they’re not talking. Few were willing to speak to me.
Herx is concerned that the pressure to participate in MAiD may cause her to leave medicine.
Herx warns that the implications of C-7, which expands MAiD from terminal to chronic conditions, will fan out to involve doctors across specialties. This tightening of the moral screw will likely precipitate more departures from the profession. With effective referral, mandated in only two provinces — Ontario and Nova Scotia — the pressure on these doctors to participate may become unbearable.

She describes the loss of moral integrity, “which is how we keep our resilience in medicine.” Dispensing with medical care to offer MAiD amps up moral distress. Herx speaks almost dispassionately about how she might have to quit medicine to avoid complicity.
Faruqui then interviews Dr. Karen Ethans who directs the Spinal Cord Unit at Winnipeg’s Health Sciences Centre, who says that she has seen patients being counselled to die by MAiD.
“My biggest concern,” she says, “is that people can’t initially see what their quality of life will be once they’ve adapted to their injury.”

It takes six months just to get out of the hospital, to go through denial and grief. Then comes vocational rehabilitation. Patients on ventilators within a week of injury are sometimes told their quality of life as quadriplegics will be poor, to turn off their breathing machines. One young man’s weeping mother followed Ethans outside the intensive care unit, looking for hope. Four months later, her son walked out of the hospital.

“Why does it have to be doctors involved in giving death serums?” she asks. Many of her colleagues are angry. They believe doctors should not be doing this work.
Faruqui continues her essay by speaking to the Nichols family again about the death of their brother Alan.
After the numbness wore off, the hurt set in, uneasy layers roiled by a gathering rage. Gary says that Alan wasn’t of sound mind, that his case warrants a thorough review. He’s bewildered by how patient confidentiality can trump common sense, bypassing grieving families in life-and-death scenarios such as MAiD.

Each institution they’ve appealed to for a review of Alan’s case denies jurisdiction. That includes the RCMP, the coroner’s office, the provincial and federal ministries of health and B.C.’s College of Physicians and Surgeons. Doors keep slamming shut. “They Ping-Pong you” back and forth, he says.
Faruqui then interviews Dr Stephanie Green, the President of the Canadian Association of MAiD Assessors and Providers (CAMAP) who clearly supports euthanasia and all the changes associated with the law.

Faruqui then tells the story of Elizabeth (71) a retired teacher in the United States who has lives with chronic pain for 30 years. Faruqui explains:
Elizabeth lays it out for me. She confesses that although she’s a devout Catholic, she plans to seek MAiD once her pain becomes unbearable, or she loses her independence. It’s not that she wants a doctor to put her to death. It’s that she has no other choice. She can’t move to the U.S. because, among other things, she’ll lose her pain specialist. And she can’t ask her son to upend his life for her. She says she’s a member of the growing ranks of the forgotten elderly, dismissed because they’re no longer productive.

“Rights don’t apply to us,” she says. “Our lives are cheap because we’re non-contributors.”

The inequalities in society scare her. She won’t use her real name because she hasn’t told her son yet. He’s an only child. She doesn’t want him to feel abandoned.
Faruqui then interviews Dr Sandy Buchman, a past President of the Canadian Medical Association, a palliative care physician and a (MAiD) provider. Buchman explains that with the passing of Bill C-7 he will limit his euthanasia practise to people who are terminally ill.

Faruqui continues her essay by speaking with Dr Natalia Novosedlik who opposes euthanasia but did refer a patient against her conscience. Faruqui writes:
“I oppose euthanasia in any case.” She says there’s a human need for contemplation, that this bill has been “rushed.”

She pauses. “Sometimes a picture is painted of MAiD being beautiful. The cases I saw — one involved pronounced social isolation — these deaths were not beautiful.”

She felt cornered by a patient who refused symptom management and insisted on a MAiD referral. Although he ultimately died naturally, she was terrified that every new patient would request MAiD. The anxiety was unrelenting.
“I knew I couldn’t do this again, it was so emotionally draining,” she says, so after the birth of her second child, she didn’t return to work.
When care coordination came up, many doctors asked to be taken off the list of providers and assessors. She feels guilty about pulling back, leaving patients to suffer. She hopes to eventually resume practice in a different field.
Faruqui then interviews Dr Mark D'Souza, who stopped being a palliative care doctor after euthanasia was legalized because of the pressure to participate in MAiD.
He couldn’t square his conscience with MAiD, a term he pronounces “Orwellian,” a form of “doublespeak” that’s critical to what he describes as the marketing of death. He calls such terms euphemisms for what’s really going on, which is “killing our patients,” so he settles for euthanasia, a less inflammatory term. He’s convinced that doctors have lost their way, that the radical left has taken over the profession. There’s an embargo on debating, much less opposing MAiD. He’s not sanguine about the profession, saying we “aren’t leaders anymore.
Dr. Viren Naik, the medical lead for Ottawa's Hospital's MAiD team admitted that only 5 of the 30 euthanasia providers are willing to participate in MAiD for people who are not terminally ill.
He describes how medically and ethically complex these patients are, and how emotionally taxing for clinicians, who question whether their MAiD requests are driven by underlying illness or vulnerability. He predicts that this exquisite challenge, what he terms “a grey area of practice,” will become more fraught once psychiatric MAiD is factored into the mix.
One MAiD providing doctor, who wished to remain anonymous, told Faruqui that research needs to be done on the effect of MAiD on the providers.

As Faruqui is closing her essay she states:
The doctors I spoke to are driven by altruism. Their compassion is compelling. But a number of MAiD providers refuse to offer death to those who aren’t dying. Personal autonomy as the overriding principle in this discourse overlooks the reality that state-sanctioned MAiD is not an autonomous act; involving doctors sanitizes it, makes it more palatable for everyone: lawmakers, patients, and society.
Faruqui quotes from Dr Herx who sees the changes in law as causing a schism in healthcare.
In the headlong rush to satisfy the individualistic need for control, we’ve glossed over MAiD’s practical, philosophical and moral harms. We’re on the cusp of sanctioning the deaths of the most helpless members of society — the mentally ill, children and the elderly — instead of caring for them. That existential nadir, when we’ve outlived our usefulness, is exactly when we should not, cannot abandon each other.
Faruqui ends her essay as she began it, with the Nichols family. Gary Nichols, Alan's brother states:
His family’s faced roadblock after roadblock. But they’re pushing on. The RCMP have opened a new case file. The Nichols family is angry at the way Alan — in equal measures volatile and vulnerable — was dispatched to death. They’re furious at the doctors who approved MAiD and the politicians who enacted the legislation that permits it. He says a lot of people care about this issue, but “so far, there’s been no accountability.” They’re fighting for safeguards to prevent the abuse of patient confidentiality by the profession.

If all else fails, Gary’s considering posting a YouTube video to warn complacent Canadians what can happen to them or their families under Bill C-7.

“We can’t save Alan now, Alan’s gone,” he concedes. “We’re trying to make some noise here to prevent other families going through this.”
Thank you Dr Ferrukh Faruqui.


Chuck said...

This is a sobering and valuable article, all the more remarkable because it was published at all. Too often mainstream stories about euthanasia amount to little more than predictable encomia to the 'beauty' and 'compassion' of medicalized killing. We need far more to be written about the real state of the euthanasia regime in this country, principally because I think most people are completely unaware of what's really going on. How much actual abuse of the system is taking place already? How much worse is it going to get? How much familial and social conflict and breakdown is happening because of euthanasia? What kind of society are we creating with these radical definitions of "autonomy"?

What this article highlights is the utter corruption of the medical profession in Canada as a result of euthanasia. While I understand any physician's choice to leave the profession under the pressure that the euthanasia enthusiasts are exerting (a choice I would likely make myself if I were a physician), it is frightening for society at large to be left in the hands of a system dominated by people who are at best indifferent to killing and at worst passionate proponents of it. No physician should feel bullied into silence for noncompliance with system that was illegal until a few years ago.

This paragraph jumped out at me:

"[Dr. Stefanie Green] believes doctors should leave their personal ethics at home. 'If you can’t practise medicine because you can’t do an effective referral, then you shouldn’t be in medicine.'"

We've heard this sort of thing before. What's notable about it is the stark, absolutist intolerance of it as well as its moral obtuseness. Surely she cannot be unaware that until ten minutes ago the idea of killing an innocent person would have been considered morally repellent by society at large and in many/most quarters still is. Most physicians practising today entered the field before the Supreme Court legalized euthanasia. It's absurd to suggest that they should simply jettison their values because we've changed the law. Killing is not a trivial moral issue. Indeed, we should all be terrified to live in a society where people violate some of our most long-standing and honoured moral values because they're just following orders. There are precedents for this that have ended catastrophically.

Much can be said about the revelations in this article but I'll finish by pointing out that the simplistic claim by some that the choice to die is a personal one and no one else's business essentially requires death on demand without any restrictions. It simply becomes a matter of entering into an agreement with a willing, or at least compliant, physician. If it's no one else's business then effectively all suicide prevention efforts are intrusive and invalid. The arguments in favour of euthanasia always start with suffering and end with the absolutist claim to personal autonomy. When you get to that point all conditions and reservations are nullified.

Chuck said...

By the way, the link to the article is wrong.

Alex Schadenberg said...

The link is fixed Chuck.