Euthanasia by Advanced Directive - A recipe for abuse.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Catherine Ferrier who is a Montreal physician who specializes in gerontology wrote an excellent article that was published in the Montreal Gazette titled: Advance Directives for assisted death a recipe for abuse.

Ferrier begins her article by outlining the challenges faced for people with dementia:

In my work in geriatric medicine, I have cared for thousands of people with dementia and their families. The challenge they face is not only the disease, but the stigma and neglect. The constantly fuelled perception that their life is undignified.

Ferrier then refers to advanced directives for Medical Aid in Dying (euthanasia), that is permitted by Québec's Bill 38 which is being debated. Ferrier refers to this as a quick fix to the concerns with dementia. Ferrier explains why it is a recipe for abuse.

I am regularly involved in legal disputes surrounding my patients. Is the will signed in the hospital three days before death valid? What about the protection mandate entrusting personal and financial decisions to an abuser?

The most public case in my career was chronicled in the Montreal Gazette: Veronika Piela, an elderly widow with no children, was forcibly removed from her home and had her bank account emptied, on the basis of a protection mandate later found to be forged. The crime would have been one of many that pass under the radar, had she not fled a nursing home without a coat in February.

Ferrier explains the differences between an advanced directive to refuse treatment versus an advanced directive requesting death:

Advance directives were invented to allow advance refusal of high-technology medical interventions expected to be futile or excessively burdensome. They are a request to be left alone, to not be touched. If one dies after treatment is refused or withdrawn, it is through the natural progression of the illness. An advance request for MAiD, on the other hand, is asking for an active intervention to end life. The important ethical distinction between these acts is often blurred in the current debate.

Ferrier shows how advanced directives are often inadequate in determining treatment decisions:

On the one hand, informed consent requires full knowledge of the condition for which an intervention is being considered, which is not possible in advance. On the other, research shows that people change their minds as an illness progresses, and later choices are very different from those they would have made when they were well or in the early stages of the disease. That is true also with dementia. 

The 2018 Council of Canadian Academies Expert Panel on Advance Requests for Medical Assistance in Dying studied in detail the literature on advance care planning. They found very few studies looking at written directives alone, and no evidence that they affected meaningful outcomes. In one Canadian study the documented preferences did not match the expressed wishes of the patient 70 per cent of the time.

Ferrier is concerned that advanced directives that are limited in their effectiveness for treatment decisions will now be used to end life.

Legalizing MAiD by advance request means, in stark simple terms, that doctors will kill people who are not asking to be killed. Some will resist and will have to be sedated without their knowledge or held down to inject the poison. That is what happens in the Netherlands now, and it has led to grave concern and decreasing support for the practice, even among those in favour of euthanasia for consenting adults.

Far from being the ultimate act of autonomy, MAiD by advance directive is a recipe for elder abuse.

Québec's Bill 38 would permit (MAiD) euthanasia by advanced directive and it will force palliative care institutions to participate in MAiD, even when the institution has determined that it is opposed to killing.