Bill C-7 will sacrifice the medical profession's Standard of Care.

This article was published by Policy Options on February 11, 2021

By Trudo Lemmens, Mary Shariff and Leonie Herx

Trudo Lemmens

As Parliament discusses Bill C-7’s expansion of the Medical Assistance in Dying (MAiD) Act, one issue has been conspicuously absent from public debate, even though it has major implications for medicine and for patients: the impact of the bill on the role of the medical profession in determining the standard of care, as it applies to MAiD.

The government introduced Bill C-7 in response to the decision of Quebec Superior Court Justice Christine Beaudouin (in the Truchon case), who ruled unconstitutional the current law’s limiting of MAiD to those whose natural death is “reasonably foreseeable”.

Bill C-7 addresses Justice Beaudouin’s finding — which in our opinion should have been appealed instead — by introducing a second track of access to MAiD for people with chronic illness or disability whose death is not reasonably foreseeable.

For the second track, Bill C-7 imposes a 90-day assessment period, which can be shortened when deemed appropriate; a second eligibility assessment by a medical practitioner with expertise in the condition that is causing the person’s suffering; and two strengthened “informed consent” provisions, including an obligation for physicians to ensure that their patients have given “serious consideration” to other options.

The ableist assumptions behind C7

Dr Leonie Herx

The most often-voiced serious criticism, which we endorse, is that the bill’s second-track access system violates the right to life of people with disabilities and chronic illness, and discriminates against them. If implemented as written, Bill C-7 will expose only people who have a chronic illness or disability to a higher risk of premature death as a result of medical system-organized MAiD, even when they are not approaching death.

The current “reasonably foreseeable” death criterion functions as a safeguard to protect the right to life. Under C-7, this is now removed for people with chronic illness and disability, while others will not have access to a medically-hastened death and instead will normally receive suicide-prevention interventions if they express a desire to die.

As two UN rapporteurs and one independent expert on human rights warned in a recent official communication to Canada, Bill C-7 thereby appears to violate several provisions of UN conventions on human rights related to the right to equality and the right to life. While reflecting understandable empathy for often-severe suffering, the bill thereby conforms, in our opinion and that of the UN special rapporteurs, to an ableist presumption that a life with disability or chronic illness has less quality or is less worth living. Only for them, MAiD is transformed from a procedure to facilitate dying into a terminal therapy for life’s suffering.

Mary Shariff

It is understandable, therefore, that this has been the main focus of the debate. But there is another key issue that so far has received scant attention: how the bill undermines the crucial role of the standard of care, and what this will mean for medicine and for patients.

Displacing the Standard of Care rule

If implemented as written, Bill C-7 will allow physicians to end the life of people with disabilities or chronic illnesses at their request and will require the system to ensure it happens even when physicians are convinced, based on their expert knowledge, that medicine offers options and even when the patient may have years or decades to live with a good quality of life if other options are explored and tried first. In short, Bill C-7 displaces the long-standing professional rule of the “standard of care” — which obligates physicians to apply their skills and intricate knowledge to a patient’s particular clinical circumstances — and replaces it with patient choice.

The profession’s silence about Bill C-7’s impact on the standard of care is surprising. It is, in fact, an issue that already raises concerns in the context of Canada’s current MAiD law, since some people are already receiving MAiD as a result of a flexible interpretation of the “reasonably foreseeable” death criterion, while they may have had years to live if adequate treatment had been provided. We would have expected that also health professional organisations or scholars who endorse in principle the bill’s expansion, would have raised questions about this component of Bill C-7, since the concern will be so much more magnified.

Granted, there are other qualifying conditions in Bill C-7 than informed consent for access to MAiD. Patients must be capable of decision-making; must have a grievous and irremediable medical condition, which is defined as a serious illness or disability, which causes “enduring and intolerable suffering” resulting in an “advanced state of irreversible decline in capability.”

But there is no definition of what counts as “serious” illness, or of what is an “advanced state of irreversible decline”. Many, if not most, disabilities would fall under it. Severe hearing loss, significant loss of vision or of mobility, for example, are disabilities that can be associated with an irreversible decline of specific capabilities and would qualify. Such conditions, and even chronic tinnitus, have been the basis for MAiD in the few jurisdictions that allow MAiD outside the end-of-life context. The criteria of “suffering” is already interpreted entirely subjectively — completely determined by the patient in current MAiD practice.

 Standard of Care and consent

That physicians need to obtain “informed” consent from the patient before engaging in MAiD is obviously key. But they must also generally act according to the “standard of care” which is based on evidence-informed standards, shared among professionals and in line with their acquired clinical expertise.

The fact that a patient ultimately consents to a treatment proposed by a physician does not dislodge this a priori standard. It is part of medical practice that physicians can present only those medical treatment options that are reasonably and objectively indicated based on the “standard of care”.

While shared-decision making and patient-centred care are rightly emphasised as vital to decision-making, these important concepts do not mean that patients can insist on procedures that violate the standard of care, including how the standard of care stages different procedures as first, second or subsequent lines of treatment.

The application of the standard of care to a particular patient’s situation is determined by a complex process involving medical research, evidence-informed experience, and standards and rules set by regulatory agencies and professional organisations. Less-invasive options are usually required to be tried first, with higher-risk procedures as last resort. The integrity of the “standard of care” is what keeps physicians accountable and holds them to the highest level of medical practice. It is key to keeping patients safe in the hands of their physicians. It is from within the standard of care exercised by physicians that patients exercise their consent to treatment proposed. Not the other way around.

For example, hip or knee replacements for arthritis require that non-surgical interventions be tried first, such as lifestyle modifications (diet, exercise) and pain medications. Surgery is the last resort, and clearly not only because of cost considerations. Similarly, a neurologist who would offer deep brain stimulation to a person with epileptic seizures without trying less invasive treatments first would violate the standard of care — even if the patient insists and “consents” to it.

In our view, since physicians cannot offer treatments that run counter to the standard of care, then surely they cannot, pursuant to the standard of care, offer and provide to the patient the ending of their life — an ultimate and irreversible harm — if they are convinced that other medical procedures or support measures will provide relief. The importance of this is, for example, particularly clear in the mental health context, if mental health is accepted as a basis for requesting MAiD. Imagine what it will mean for the standard of care in mental-health care practice and suicide prevention if a severely depressed person, who is assessed as capable of decision-making, refuses all available treatment and support measures and insists on obtaining MAiD instead.

Misapplication of the doctrine of ‘informed consent’

To understand how we got to the point where “informed consent” is replacing the standard of care in the MAiD context, we must look at the Supreme Court’s 2015 Carter decision. The court ruled that patients suffering unbearably from a medical condition should be able to have some form of access to MAiD and invited Parliament to create an exemption to the remaining criminal law prohibition to allow this. It also reiterated, in passing, a patient’s right to refuse treatment, even in the context of a request for MAiD.

But it is important to keep in mind that the court’s decision was in the context of the case of Gloria Taylor, a person with ALS, who was approaching her natural death. In Carter, the court emphasised (and it bears repeating): “The scope of this declaration is intended to respond to the factual circumstances in this case. We make no pronouncement on other situations where physician-assisted dying may be sought.”

The court thus reaffirmed the “right to refuse treatment” within the factual context of an approaching death. Recognition and protection of the right to refuse an intervention in a general context is entirely different from the connections and analogies that can be made in the end-of-life context between treatment refusals and obtaining active assistance in dying. Even if the death of a patient with diabetes, for example, can become “reasonably foreseeable” in the event the patient refuses treatment, the “ethical distinction” is exceptionally clear when viewed from the standard of care perspective, since the physician is obligated to comprehensively explore with the patient the treatment options that will indeed save their life. In the non-end-of-life context, combining treatment refusal with a request to active ending of life raises the stakes.

Yet, the Supreme Court’s reiteration of the right to refuse treatment appears to be translated in the context of Bill C-7 as a confirmation that MAiD should always be the standard of care when MAiD is what a patient wants.

We believe this is a misapplication of the doctrine of “informed consent.” To accept this constitutes a wholesale abandonment of the idea that the medical profession has a responsibility to make considered medical determinations based on evidence, unique knowledge and expertise.

This is a stunning reversal of the central role of the medical and legal concept of the standard of care. It lifts “informed consent” up to the status of the sole arbiter of what constitutes proper medical practice. This development is also internationally unprecedented. Even the three most permissive MAiD regimes in the world — Belgium, the Netherlands, Luxembourg, the only ones that currently permit physician-provided ending of life outside the end-of-life context — treat MAiD rightly as the last resort, available when no other options are seen to remain.

It is thus astonishing that the Canadian Medical Association and some other medical organisations expressed support for C-7. If regulatory colleges follow the CMA’s lead, the medical profession is undermining the very reason why our society has provided it with self-regulatory powers. Physician self-regulation is based on the premise that physicians possess special knowledge and expertise, and that determining what constitutes proper health care is therefore best left to them, even if external scrutiny and oversight are appropriate.

By supporting Bill C-7, medical organisations are handing over to patients the determination of professional standards. They are thereby also abandoning their commitment to patients to provide the best evidence-informed care, based on the concept of “informed consent” that we also know is rarely if ever fully realised in practice.

We cannot believe that this is what our Supreme Court intended. While we believe that the very foundation of Bill C-7 is already discriminatory, the failure to properly respect and uphold the interaction between informed consent and the standard of care makes the potential impact of an expansion outside the end-of-life context so much more problematic.

The least we would expect is that the new bill explicitly confirms that MAiD is an irreversible last-resort option when all other reasonable options available according to the standard of care have failed.

There is no other country in the world that has elevated MAiD as a first-line medical treatment on demand, as an unmodified Bill C-7 would do.

Andrew Coyne: Canada is accelerating toward death-on-demand.

Andrew Coyne wrote the following opinion column, that was published in the Globe and Mail on December 11, 2020. Coyne, who has been writing about issues related to euthanasia and assisted suicide for many years examines Canada's move from cautiously considering euthanasia to Bill C-7 which nearly permits death on demand. Coyne writes:

Six years ago, before the Supreme Court discovered a right to die in the constitution’s guarantee of the right to life, what most people understood as the case for assisted suicide was something like the following: a mentally competent adult, suffering acute pain from a terminal illness and facing more of the same to the end, comes to a firm and unwavering decision to kill herself – but is physically unable, by virtue of the same illness, to do so unaided, or fears she will be unable to when the time comes.

That was the condition of Sue Rodriguez, whose 1993 Supreme Court appeal challenging the constitutionality of the Criminal Code prohibition on assisting in a suicide, though unsuccessful, first brought the issue to public attention. It was also the condition of Gloria Taylor, the woman on whose case the Court based its 2015 decision legalizing the practice (Lee Carter, whose name is attached to the decision’s short-form title, was merely a co-appellant).

Had you predicted then that the right to an assisted suicide would soon come to apply, not only in cases of physical pain but psychological, and not only to patients in the last agonizing stages of death but those who were nowhere near it – had you predicted, indeed, that a patient’s request to be killed would not even have to be repeated and persistent for a doctor to act on it, that the whole process could be telescoped into a single day – you would have been accused of “slippery slope” thinking.

Had you predicted that, by 2019, just the third full year after it was legalized, nearly one in 50 deaths in the country would be by assisted suicide, even on the (almost certainly underreported) official numbers; and that, this having been accomplished, talk would turn to extending the procedure – not just to competent adults, but the mentally ill and even children – you would have been carted off.

Yet that, incredibly, is where we are. The cautious, limited exceptions that people understood the issue to involve at the start – what most people understand it to involve even now – have been overtaken by an accelerating drive toward death-on-demand. Had the public known this was where we were headed, they might have objected. Instead it has been done in stages, a series of bait-and-switch routines in which the courts and legislatures have taken equal part.

The irony is that the very foundation of the Supreme Court’s decision in Carter was that there was no such slippery slope. Perhaps assisted suicide, once legalized, might have spread and metastasized in other countries, barbaric places such as Belgium and the Netherlands, to include children, people suffering depression, prisoners serving life sentences, and so on – but that, the Court was certain, could not happen here. The evidence was “anecdotal.” The “medico-legal culture” was altogether different.

And yet the Court immediately undermined its own premise. Though the decision ostensibly applied only “in the factual circumstances of this case,” i.e. to “people like Ms. Taylor” or “persons in her situation,” i.e. “wracked with pain” and near the “end of life,” by the time the Court got around to working out the general principle to be applied in such cases it had ditched any requirement that a patient’s condition be either terminal or physical; rather just “grievous and irremediable.”

Still, the decision did not preclude governments from imposing such a rule, even if the court declined to do so – if not that death be at hand, then at least “reasonably foreseeable,” in the language the Trudeau government adopted in subsequent legislation. So when a Quebec Superior Court judge ruled that provision unconstitutional in September, 2019, she was essentially freelancing.

The government had ample grounds to appeal the decision to the Supreme Court. Instead, it drafted legislation – Bill C-7, which it is now attempting to rush through the House of Commons in time for Christmas – that obediently accepted the Quebec court’s opinion as its own. Worse, it went further.

No longer would there be a mandatory 10-day waiting period between a request for assisted suicide and its execution, to allow for a change of heart. (According to Health Canada, 263 such requests were withdrawn in 2019.) Neither would two witnesses be required: henceforth, one would suffice.

Previous articles by Andrew Coyne:

• Andrew Coyne: "extending assisted suicide to children and the mentally incompetent, once derided as “slippery slope” alarmism, is now the next item on the agenda" (Link).
• Andrew Coyne: Assisted suicide makes us complicit in another's death (Link).
• Andrew Coyne: The absurd logic of assisted suicide (Link).
• Andrew Coyne: Crossing the Rubicon, Supreme Court seems eerily complacent about ramifications of assisted suicide ruling (Link).
• Andrew Coyne: Assisted Suicide, What begins in compassion seems to end in eugenics (Link).

Will Johnston: The case against physician-assisted dying

This article was published by the CanadianHealthcareNetwork.ca on June 1, 2016

Discussed: The 'wedge' cases, the language of the debate, the moral culpability of the doctor, and the question of pure autonomy

Dr Will Johnston

By Tristan Bronca.

The Euthanasia Prevention Coalition was officially founded in 1998 in response to rising public support for physician-assisted dying. It’s made up of about 2,000 donors—both members and organizations—who began to come together in about 1993 during the Sue Rodriguez case. One of those members is Dr. Will Johnston.

Now the chair of the B.C. chapter of the coalition, the family physician took a strong stance against euthanasia about 22 years ago, when he began writing about it and speaking to high school students and church groups. He also testified opposite euthanasia advocates in the Carter case, which led to the legalization of medically assisted death in Canada. Dr. Johnston spoke with the Medical Post about his concerns with the legislation recently passed through the house of commons, the laws around the world, and why he feels Canada is about to make a dangerous mistake.

Q: Explain the impetus for a coalition of bodies who are opposed to physician-assisted dying.

The bodies that are involved in the Euthanasia Prevention Coalition might not agree on any other issue but they share in common a sense of the huge societal mistake that is being made in euthanasia and assisted suicide. We realize that there is some strength in numbers. Obviously not enough strength to stop the freight train that ended with the Supreme Court being unanimous in its decision—which I think is a troubling sign of the shallowness of the Supreme Court’s reasoning—but nonetheless more power than we would have as individual activists.

Q: Which elements of the proposed federal legislation do you personally find most troubling?

The legislation doesn’t yet allow the euthanasia of children, psychiatric patients, or mentally incapable patients long after they consent, but the preamble to the legislation promises to explore those areas further, which is deeply troubling.

The activists who won in the Supreme Court won in part because they assured Canadians that they weren’t talking about those three groups. They were only talking about competent adults at the end of their lives who were able to give consent at the time they were killed.

Q: So you see the expansion of the legislation to include these other groups as problematic?

Absolutely. It seems clear that this no longer has anything to do with dying. This legislation has left open the door for assistance for people who want to commit suicide but don’t want to do it themselves, while it was originally marketed as helping terminally ill people in terrible pain to die sooner than they would have otherwise died. The latter was used as the cloak to wrap the agenda inside.

When the real agenda is to allow anyone who is dissatisfied with their life to be killed with the endorsement and assistance of the national medical system, it makes sense to hide those intentions behind the story of a person about to die who was having difficulty controlling physical symptoms.

Q: My understanding is that the reason why this legislation may be extended to psychiatric patients and to mature minors is because the legal experts didn’t feel that exempting those two groups would stand up to a charter challenge. It would be discriminatory to bar them from access to the service that is now being talked about as a universal human right.

You’re absolutely right and, in fact, I was making that point exactly as you have just made it back in the days when we were in court with Gloria Taylor and the Carters. You could never contain it to just these terminally ill patients but in court that’s all they claimed they were asking for: Terminally ill, capable adults who were suffering intolerably at the end of their lives and who consented and were capable of consent to be killed. That was the story on which the Carter case was won. . . .

These judicial activists were happy to pass the Carter case through on the narrow grounds knowing that it would be expanded later. They were happy to make an incremental change that they knew could not withstand a further charter challenge because of section 15 equality rights and so-forth.

Margaret Somerville - What the top court left out in assisted suicide decision.

By Alex Schadenberg

Executive Director - Euthanasia Prevention Coalition

M

Margaret Somerville

argaret Somerville, the founding director of the Centre for Medicine, Ethics and Law at McGill University, wrote an insightful article titled - What the top court left out in judgement on assisted suicide - that was published in the Globe and Mail on October 27.

In her article, Somerville comments on the Supreme Court of Canada assisted suicide decision:

A central question in legalizing physician-assisted suicide is where the balance between respecting individual rights to autonomy and protection of the “common good” (protection of others and society, including its important values) should be struck. In this case, there was almost no such balancing. 

Rather, both the trial court and the Supreme Court focused almost exclusively on the rights of individual persons, so that the factual findings and legal reasoning were intensely individualistically based. 

Both courts adopted a narrow definition of Parliament’s purpose in prohibiting assisted suicide (namely, that it was to protect a vulnerable person in moments of weakness from acting on suicidal ideation) and concluded that an absolute prohibition was not needed to achieve this. Indeed, the courts accepted the evidence of plaintiff Gloria Taylor, who suffered from Lou Gehrig’s disease, that she did not need this protection as showing that she and people like her did not – that is, they were “not vulnerable.”

Then Somerville asks - But was the court correct in its assessment of vulnerability? She explains:

Prof. Henk ten Have, a physician-ethicist at Duquesne University in Pittsburgh, recently published a paper proposing that vulnerability is an innate human characteristic that we all experience throughout our lives, because it “comes from the social dimension of human existence.” In short, we are not free-floating autonomous atoms.

Somerville explains:

Vulnerability is linked to dependence on others. We are all interdependent, which means we are all vulnerable. This is not necessarily bad, as we might at first assume when we hear the word “vulnerable.” 

Somerville then concludes that Supreme Court missed the common good or the importance of people caring for one another. She concludes:

The Supreme Court saw the antidote to suffering as recognizing individuals’ right to autonomy and its use to consent to the infliction of death. An alternative is a communal response of providing fully adequate palliative care, which affirms our bonds with those who are in need and are especially vulnerable. 

In balancing autonomy with conflicting values, the Supreme Court failed to consider what is necessary to protect the “common good,” to protect all of us as vulnerable people by upholding “respect for life” (a preferable term to “sanctity of life”) in society as a whole. 

I suggest it requires, as it always has until now, the prohibition of intentionally killing an innocent human being or helping them to kill themselves.

Margaret Somerville will be speaking on October 31 at the Euthanasia Symposium in Montreal.

• Euthanasia and assisted suicide: A physician's and Ethicists perspective.
• Assisted suicide: The issue we can't afford to get facts wrong.
• Margaret Somerville: Should Canada permit assisted suicide.

Protecting the vulnerable still the goal, says government lawyer in B.C. assisted suicide case.

The Toronto Star reported on the first day of the BC Court of Appeal hearing of the Carter case, the case that seeks to legalize assisted suicide and a limited form of euthanasia in Canada.

The article was written by Petti Fong and published in the Toronto Star on March 18, 2013.

Protecting the vulnerable still the goal, says government lawyer.


Petti Fong - March 18, Toronto Star, Vancouver

Audrey Laferriere doesn’t understand all the legal arguments being heard in B.C.’s highest court over Canada’s assisted suicide laws but she said Monday she’s worried enough that she wanted to come and listen.

“I’m interested in the court case because it’s about security of persons and security of life,” said Laferriere. “I’m not religious but we have the right as Canadian citizens that we have security of persons and no one can come and just end your life.”

Laferriere, 70, has a spouse with depression whom, she fears, might one day find a physician to help him have an assisted suicide. She said she’s against any changes to Canadian laws that will allow that.

The federal government is arguing in the B.C. Court of Appeal that a lower court decision last summer, which found Canadian assisted suicide laws unconstitutional, should remain as law.

Averting all harmful deaths was the objective of the last Supreme Court of Canada ruling on the matter, according to Donnaree Nygard, the lead counsel for the Attorney General of Canada.

“Minimizing the risk of vulnerable individuals to being induced to commit suicide,” was the goal of the Supreme Court of Canada decision in 1993, said Nygard. “The goal was avoiding the harm caused that some lives are less worthy of protection.”

In the 1990s, Sue Rodriguez, of Victoria, fought all the way to the Supreme Court of Canada to have an assisted suicide, but it ruled in 1993 by a vote of 5-4 that the law should remain.

A year later, Rodriguez, who had ALS, died after getting help committing suicide from an unknown physician.

A B.C. Supreme Court ruling last June found section 241 of the Criminal Code, which makes it illegal for anyone to counsel a person to commit suicide, violated the Charter rights of people with disabilities.

The lead plaintiff in the challenge to the current laws, Gloria Taylor, a woman who, like Rodriguez, was diagnosed with ALS, was given the first constitutional exemption to have a physician-assisted suicide. Taylor, however, died last October in hospital without the help of a physician after getting an unexpected infection.

Her case, brought on her behalf by the B.C. Civil Liberties Association, is being appealed by the federal and provincial government in the Court of Appeal.

Nygard told the judges Monday the issue has been debated and considered by Parliament and the Supreme Court of Canada, and the decision has always been that the rights of vulnerable people outweigh the rights of those wanting physician-assisted suicide.

The case will be heard this week with the B.C. Civil Liberties expected to make their arguments on Wednesday. Groups including the Farewell Foundation, which is for assisted-suicide and the Alliance of People with Disabilities, which is for maintaining the current laws, will also be making submissions.

Previous articles.
* Legalizing assisted suicide creates a double standard.
* EPC wants BC Court of Appeal to reverse errors in assisted suicide court decision.
* Suicide Prevention for All. No Assisted Suicide.
* Euthanasia at the water cooler.

Media Release: EPC wants BC Court of Appeal to reverse errors in assisted court decision.

Media Release - March 17, 2013

EPC wants BC Court of Appeal to reverse errors in assisted court decision.

Norman Kunc

The Euthanasia Prevention Coalition (EPC), an intervener in the assisted suicide case at the BC Court of Appeal, is asking the BC Court of Appeal to reverse the errors in the Carter decision concerning assisted suicide and euthanasia.

Norman Kunc, a long-time disability rights activist will be speaking out against assisted suicide at the Monday morning courthouse demonstration. 

Kunc who has cerebral palsy will share his story and his perspective on behalf of the Euthanasia Prevention Coalition, and explain why 2012's Carter case will harm citizens with disabilities.

EPC Vice President, Dr Margaret Cottle, who specializes in palliative care stated: 

“Legalizing euthanasia or assisted suicide would give doctors the power over life and death. I am concerned about patient safety.” "Elder abuse is already difficult to detect and would be no easier to combat when a suicide offer is part of the culture of care for a vulnerable older person. Giving legal immunity to those who would provide suicide does not make our loved ones safer."

EPC legal counsel, Hugh Scher stated: 

“EPC is concerned about the safety, security and equality of people with disabilities and seniors which is central to the protections set out under our Charter of Rights and Freedoms and our Criminal Code.”

 EPC Executive Director, Alex Schadenberg, stated: 

“the Carter decision erred in several significant areas … the judge came to her decision by falsely assuming that there is a ‘right to suicide’ in Canada.” 

Schadenberg further explained: “the Carter decision misinterpreted the data from other jurisdictions that legalized assisted death when it suggested that there is no significant risk to vulnerable patient groups. A recent study found that 32% of all assisted deaths in Belgium were done without request. The study revealed that incompetent people who are over the age of 80 are vulnerable to dying by an assisted death without request.”

For more information, contact:
Norman Kunc, disability leader: (604) 366-6263, ndkunc@gmail.com

Dr Margaret Cottle, EPC Vice President (604) 813-8665, mmcottle@mac.com

Hugh Scher, EPC Legal Counsel: (416) 816-6115, hugh@sdlaw.ca

Alex Schadenberg, EPC Executive Director: (519) 851-1434, info@epcc.ca

Ruth Goodman died by suicide, not assisted suicide.

The Victoria Times Colonist has reported on the story of Ruth Goodman (91) who decided to die by suicide.  Goodman had her son, Dean, send her "goodbye" letter to the Globe and Mail with the hope of creating greater support for legalizing assisted suicide.


The article in the Victoria Times Colonist titled: Healthy Vancouver Senior takes own life in bid to change assisted suicide law interviews Grace Pastine, the litigation director for the BC Civil Liberties Association, the group that is steering the Carter case, the case in British Columbia that seeks to legalize assisted suicide and a limited form of euthanasia.

Grace Pastine

Pastine told the Times Colonist:

Ruth Goodman was not terminally ill or assisted in any way, the association would not have a legal position or opinion on her case.

Since Goodman was not aided, encouraged or counseled to commit suicide therefore the law has not been broken.

Goodman died on February 2, 2013; the same day that Ginette Leblanc died of natural causes. Leblanc was the litigant in the Quebec case to strike down Canada's assisted suicide act. Leblanc, who was living with ALS, died of natural causes after experiencing a stroke a few days before her death.

Gloria Taylor, the main litigant in the Carter case in British Columbia, the case that Pastine  is directing, also died of natural causes on October 5, 2012. Taylor, who was living with ALS, died from an infection.

The deaths of Ruth Goodman, Ginette Leblanc and Gloria Taylor did not require a change in the law. Each of these ladies died on their own terms, without experiencing traumatic deaths and without requiring someone else to assist their suicide or actually lethally inject them.

There is no need to legalize euthanasia or assisted suicide in Canada.

Rasouli case: 'End of life' often really means 'ending life.'

While going through my emails I came across this excellent article that was written by Tom Koch, a bio-ethicist and gerontologist in Toronto. This article was published in the Toronto Star on December 15, 2012 under the title: 'End of life' often really means 'ending life.'

Koch examines the Rasouli case based on its similarities to the issues within the Carter case in BC and the Leblanc case in Quebec. The Carter case and the Leblanc case seek to legalize assisted suicide and euthanasia in Canada.

The Euthanasia Prevention Coalition (EPC) had intervenor standing in the Rasouli case at the Supreme Court of Canada and has intervenor standing in the Carter case at the BC Court of Appeal and the Leblanc case at the lower court in Quebec.

'End of life' often really means 'ending life'

Tom Koch

Tom Koch, Toronto Star - December 15, 2012

Hassan Rasouli lies in a bed, his family by his side, as machines assure his bodily functions and the Canadian Supreme Court decides his future. Should Sunnybrook Hospital physicians be given the right to discontinue his respirator or should his family’s wishes for his continued care take priority?

The Rasouli case is the flip side of one heard last summer in B.C. Supreme Court where Gloria Taylor, a woman with Lou Gehrig’s disease (ALS), successfully sued for the right to physician-assisted termination at a moment of her choosing. Taylor later died of an infection while her case was on appeal. Taylor wanted to control her death while the Rasouli family wants to control their father and husband’s continued life.

What the court decides in Rasouli’s case will give us insight into its thinking when the case of Ginette LeBlanc — another woman with ALS seeking physician-assisted termination — is heard in the Quebec Supreme Court next March.

There are two very different positions in all these cases, each defined by the language used by proponents. In thinking about what these cases mean, and how we should address them, it’s the language that tells the tale. Here is a sample of the oppositions that stand for either continued life or termination at a moment of either a person or a doctor’s choosing.

The 2012 Royal Society Expert Panel Report on End of Life Decision Making, for example, talked about “physician-assisted death” while I talk about “physician-assisted or directed termination.” The first describes a passive, morally neutral role by physicians who accept death’s inevitability and take as their mission helping persons to meet it without fuss.

The second is a bare, active description. In providing drugs that stop the heart, in discontinuing life support we do not “assist” but wilfully terminate a life that is ongoing. Maybe we are right to do this, maybe not.

At the very least, we need to know the difference.

The Royal Society’s experts also talked about “end of life decision-making.” So, too, do most popular writers. But none of these cases are about “end of life” and its final choices. The issue is ending a life that is ongoing.

Hassan Rasouli

With continued support, Hassan Rasouli, 61, could continue for years. So, too, would LeBlanc, whose ALS is not “terminal” in any short-term sense of the word. So we are talking about people at the “end of life” only to the degree they are terminated prematurely.

The physicians who seek the court’s permission to terminate Rasouli’s care over the objection of his family insist his condition is “futile.” By this they mean they cannot do anything to improve his condition. And there they are correct. But the family insists the effort it takes to keep him alive is not “futile” because his life has value and care buys him time to recover on his own. “The treatment is 100-per-cent effective,” a family spokesman reported. “It permits him to breathe.”

In arguing for discontinuing life support, the physicians imply that where respiration is mechanized and brain function is at best minimal, there is no life.

But as Rasouli’s advocates said in court — and as others have insisted in other cases — we are unclear about the science of these things. Studies in the 1990s of patients diagnosed as being in a “persistent vegetative state” found many to be, in fact, at least minimally conscious. A few were “locked in,” unable to communicate but very much aware. And we also have “coma miracles” in which persons long believed dead to the world awoke for reasons nobody understands.

That is why some people use “persistently unconscious” rather than “vegetative” in describing such cases The former suggests the potential for an improvement the latter denies.

Beneath this discussion runs the bottom line, not of care and caring, of life and how we value it, but money. Some reporters — and physicians — have suggested the issue is one of triage, of the best use of health-care dollars and equipment in a period of scarcity. But what is right, what we should do in medicine and as a society, is not about cost efficiencies. If we believe it is important, we find the monies for what we need.

We can afford to maintain the occasional citizen whose family insists — even if only on the basis of faith — a restricted life is still a worthy life. The question isn’t money, in other words, but our willingness to spend on the fragile life.

Finally, there is the irksome issue of “autonomy” and choice. For 40 years or more, medical ethics has focused upon the idea of patient autonomy and the right to patient choice. Where the patient is unable it is the “surrogate,” usually a family member, who gets to make the call on care or its cessation.

In this case, that idea is challenged by physicians who seek to trump the choice of the patient’s surrogates who include, by the way, a physician. So do we advocate patient autonomy and choice only when it is cost efficient and convenient? Or is the patient’s right of choice inviolate, even when the attending doctors disagree?

There is a problem of consistency here. If we are to grant people like Gloria Taylor or Ginette LeBlanc a right to termination, doesn’t that mean we must grant to the Rasoulis the right to choose continuance?

The heart of the issue is this: Is there ever an “unworthy life”? Or, as the Rasouli family insists, is life worth preserving even in a fragile, limited state? Here members of the so-called disability community weigh in on the potential of life in restricted states. “We know,” they say, “what you do not. The life you see as insupportable is to us our life and worthy after all.”

Tom Koch is a bioethicist and gerontologist. His latest book is Thieves of Virtue: When Bioethics Stole Medicine.

Council of Canadians with Disabilities: Help To Live Not Die

CACL

CCD

The Council of Canadians with Disabilities (CCD) and the Canadian Association for Community Living (CACL) were granted joint intervenor standing by the BC Court of Appeal, yesterday, in the Carter case. 

The Euthanasia Prevention Coalition (EPC) and EPC-BC were also granted intervenor standing, by the BC Court of Appeal in the Carter case, that will be heard by the BC Court of Appeal from March 4 - 8, 2013. 

On June 15, 2012, Justice Lynn Smith decided, in the Carter case, that the law protecting Canadians from assisted suicide was unconstitutional because it deprived some people with disabilities equal access to suicide. Justice Smith also ordered parliament to legalize a limited form of euthanasia and she gave Gloria Taylor, one of the plaintiffs, a constitutional exemption to die by euthanasia or assisted suicide. 

Gloria Taylor died from natural causes on October 5, 2012.

On July 13, 2012, the Hon Rob Nicholson, Attorney General of Canada, appealed the decision by Justice Smith, in the Carter case, to the BC Court of Appeal. It is expected that the Carter case will ultimately be decided by the Supreme Court of Canada.

To raise money for the legal costs to intervene at the BC Court of Appeal, CCD has established a website entitled: Help To Live Not Die. The Help To Live Not Die website explains the position of CCD on assisted suicide and encourages people to donate money for the legal costs for their intervention at the BC Court of Appeal in the Carter Case.

CCD is a national human rights organization of people with disabilities working for an inclusive and accessible Canada. CCD is the leading national organization of people with disabilities in Canada.

CCD/CACL oppose assisted suicide and have been granted the right to make the following arguments before the BC Court of Appeal in the Carter case:

1. they will provide insight into the interpretation of "death with dignity" in the disabled community;2. the impugned provisions are consistent with discouraging people from choosing death over life, while the trial judgement makes death more palatable for people with disabilities, a result incompatible with the values underlying (s. 7) and (s. 15);3. decisions allowing physician-assisted suicide of persons with disabilities is based on and fosters stereotypical thinking that is inherently discriminatory, and deepens the disadvantages and inequalities suffered by people with disabilities;4. financial and social conditions place increased stress on those who provide support to the disabled, creating greater potential for abuse. The autonomy of vulnerable people cannot be separated from the perilous and dependent circumstances in which they live, and the choices that flow from this;5. No reliable half-way measure exists for achieving the purposes of the impugned provisions. The trial judge erred in failing to properly consider and balance competing interests in her (s. 7) and (s. 1) analysis; and6. the Charter value of life underlies the impugned provisions and the exemption for the disabled created by the trial judgment cannot be justified.

In granting intervenor standing to CCD/CACL Madam Justice Neilson recognized that some of the arguments are already being made by the Attorney General of Canada, but she stated:

"I am persuaded an important distinction lies in the fact these applicants present these arguments from the point of view of the disabled community, a segment of society that will be profoundly affected by the outcome of the appeal and whose perspective should be before the court."

The Euthanasia Prevention Coalition (EPC) requires your financial support to enable us to intervene in the appeal of the Carter case. Donations to EPC can be made online here. 

We also encourage people to support the fundraising efforts of the Council of Canadians with Disabilities (CCD) that is presented on the Help To Live Not Die website. EPC is very pleased that the CCD/CACL were granted intervenor standing in the appeal of the decision by Justice Smith in the Carter case.

Assisted suicide opens the door to grave abuses of elderly people.

The following article was written by Derek Miedema and published on November 15 in the Toronto Star under the title: Assisted suicide opens the door to grave abuses of elderly.

Derek Miedema, Toronto Star - November 15, 2012

Canadians can watch disturbing videos on a government website warning about elder abuse — an elderly man is pushed to move faster, an adult child steals money from a grandmother’s wallet.

However, just as some still turn a blind eye to the fact that elder abuse is happening, proponents of assisted suicide refuse to connect the dots between legalized assisted suicide and the potential for serious abuse.

Pressure is mounting from assisted suicide advocates. In British Columbia, a judge struck down existing Canadian laws against assisted suicide, giving the federal government one year to rewrite them. In the meantime, that same judge granted Gloria Taylor a personal exemption under the law, although she died of natural causes before using it. This case is expected to reach the Supreme Court of Canada. The Quebec provincial government is poised to introduce a bill in 2013 to legalize assisted suicide without waiting on the courts. On Nov. 6, the state of Massachusetts voted down a ballot initiative that would have made it legal for a doctor to help someone commit suicide. While it is fantastic that this initiative failed, more are bound to come up.

We need to understand that legalizing assisted suicide is not about choice, empowerment or the right to choose a time and place of death, particularly for those suffering from severe illness. In reality, it looks quite different. Far from increasing choices at the end of life, assisted suicide opens the door to grave abuses that are particularly heinous when forced upon vulnerable seniors.

The nature of elder abuse is changing. Laura Tamblyn Watts, lawyer and senior fellow at the Canadian Centre for Elder Law, describes the financial side: “People used to wait until their parents died until they went after the money. Today, with longevity being what it is and with increased financial pressures, what we’re seeing is boomers going after the assets of their parents while they’re alive.” While she didn’t mention assisted suicide, it would be naive not to be concerned about the implications of legalizing assisted suicide where such abuse happens.

Will Johnston, family physician and chair of the Euthanasia Prevention Coalition of B.C., sees elder abuse first-hand in his practice. “Under current law, abusers take their victims to the bank and to the lawyer for a new will. With legal assisted suicide, the next stop would be the doctor’s office for a lethal prescription,” he writes.

It is not a big stretch to see children orchestrating the death of their family member to access their finances. Statistics Canada finds seniors are at higher risk of abuse by a family member than a stranger.

In Britain, bitter accusations are swirling around a program called the Liverpool Care Pathway, which was established to extend quality of care practices from hospice homes to other areas of health care dealing with the end of life. Many families are raising questions because they believe medical staff hastened the death of their loved ones, down to mere hours or days, when they weren’t actually dying. The result is a public inquiry into the purported abuse. If these allegations hold true, this would mean abuse at its worst: medical practitioners choosing to speed up the death of patients.

There is evidence this has happened before. A study in Belgium showed that doctors killed just under 1,000 patients without their express request in 2007.

The spectre of elder abuse is real. It is so real, in fact, that the government of Canada has taken the initiative to highlight what it is and to address it in law by making “vulnerability due to age” a factor in sentencing. Their public service announcements challenge us to notice elder abuse where it occurs all around us. Great. But we need to challenge others to notice that legalizing assisted suicide could simply be a death sentence for our already abused elders. Why would we legalize suicide for the very few when experience shows the very many will be affected to the point of death?

Derek Miedema is a researcher at the Institute of Marriage and Family Canada.

Elder abuse: It’s happening all around us: And it’s one more reason not to legalize assisted suicide

The following article was written by Derek Meidema and published by IMF Canada on November 8, 2012 under the title: Elder abuse: It’s happening all around us: And it’s one more reason not to legalize assisted suicide.

Derek Meidema, researcher, IMFC Canada, November 8, 2012

Canadians can visit a government web site to learn about elder abuse. Short commercials warn us to be vigilant about the problem—by showing an elderly man who is pushed to move faster, an adult child stealing money from a grandmother’s wallet.

However, just as many still turn a blind eye to the fact that elder abuse is happening, proponents of assisted suicide refuse to connect the dots to see how legalized assisted suicide opens the door to more—and more serious—elder abuse.

In Québec, the provincial government is poised to introduce a bill in 2013 to legalize assisted suicide. Gloria Taylor made a successful plea for an assisted suicide exemption from the British Columbia courts (she died October 4, 2012 of natural causes before using it).¹ On November 6, the state of Massachusetts voted no on a ballot that would have made it legal for a doctor to help someone commit suicide. While it is fortunate that this initiative failed, more are bound to come up.

Legalizing assisted suicide is not about choice, empowerment or the right to choose the time and place of death, particularly for those suffering from severe illness.

The reality on the ground is much different.

For one, the nature of elder abuse is changing. Laura Tamblyn Watts, a lawyer and senior fellow at the Canadian Centre for Elder Law, among others, addresses the financial side of elder abuse: “People used to wait until their parents died until they went after the money. Today, with longevity being what it is and with increased financial pressures, what we’re seeing is boomers going after the assets of their parents while they’re alive.”² While she wasn’t making a link to assisted suicide with this comment, it would be naïve not to be concerned about the implications of legalized assisted suicide.

Dr Will Johnston

BC family physician Will Johnston, who is also chair of the Euthanasia Prevention Coalition of BC is not shy about connecting the dots. He sees elder abuse firsthand in his practice. “Under current law, abusers take their victims to the bank and to the lawyer for a new will. With legal assisted suicide, the next stop would be the doctor’s office for a lethal prescription,” he writes.³ Coercion, not choice, will play a role in legalized assisted suicide.

Statistics Canada finds seniors are at higher risk of abuse by a family member than a stranger reporting that “grown children were most often identified as the perpetrator of family violence against seniors.”⁴ In fact, “over the past decade, half (50%) of all family homicides against seniors were committed by grown children.”⁵ It is not a big stretch to say children would orchestrate the death of family members to access their finances.

Across the pond in Britain, a parliamentary inquiry has been established because a program intended to help people may have been causing their premature death. The Liverpool Care Pathway was established to extend the quality of care practiced in hospice homes to other areas of health care dealing with the end of life.⁶ Instead, today, families are raising questions because they believe medical staff hastened the death of their loved ones when they weren’t actually dying. The result is an official inquiry into the purported abuse.⁷

It wouldn’t be the first time doctors killed patients. A study of Belgium, where assisted suicide is legal, showed that they killed just under 1000 patients without their request in 2007.⁸

The specter of elder abuse is real. Government public service announcements challenge us to notice elder abuse and they’ve gone further too, with a current attempt to make “vulnerability due to age” a factor in sentencing.⁹ That’s great, but we need to connect the dots. Legalized assisted suicide would simply be a death wish for some of the most vulnerable among us. Why would we give the very few the right to suicide when experience shows the very many will be affected to the point of death if we do?