What is the Good of Euthanasia? Part V: How different policies, from Quebec and Canada, have created a philosophical fork-in-the-road, for Canadian provinces.

Gordon Friesen

By Gordon Friesen
EPC board member

The legal justification for Medical Aid in Dying has two distinct parts. First, there is a purported "right" to "choose" death. Second, there is a claim that euthanasia be considered a legitimate medical "treatment".

Thus far, the acceptance of euthanasia, in Canada (and other places where the "medical aid in dying" vocabulary has been adopted) has depended on a slip-shod conflation of these two justifications, blithely ignoring the fundamental contradictions involved. It is my belief, however, that recent developments in the Province of Quebec are ultimately destined to bring this unstable MAID construct under increasing (and perhaps unsustainable) strain.

In fact, the first significant cracks have already appeared.

How medical provisions in Quebec are expected to differ from criminal immunity under federal law

Following the acceptance of federal law C-7 --extending euthanasia access to those not in imminent peril of death (and after March 2023, even to those suffering uniquely from psychological disorders)-- the provincial legislators of Quebec immediately undertook a review of their own law (QC Bill 52, "Act Respecting End-Of-Life Care").

The two most important recommendations of this review are 1) the acceptance of MAID by advance directive (on reception of a diagnosis of neurodegenerative disease), and 2) the refusal of MAID to those suffering from mental illness only. Both of these proposals are contrary to the federal dispositions of C-7: for Quebec wishes to enable advance directives (which the federal government has refused); and Quebec wishes to refuse MAID for mental illness (which the federal power has approved)!

The table is therefore (apparently) set for a major test of wills. However, this test is not to be based upon substantive disagreement only, but rather, on a true conflict of federal and provincial powers. Quebec, to be clear (as all other provinces) has exclusive jurisdiction in the domain of public health care. This means that Quebec will likely decree that euthanasia for mental illness is not medically justifiable, but that euthanasia by advance directive is. As a result, we will soon see (in all probability), people accessing Maid by advance directive (in the Province of Quebec) even though no criminal immunity has been created to that end in federal law. And similarly (assuming that the March 2023 deadline of C-7 is respected) we will also see people legally dying in Quebec, by euthanasia for reasons of mental illness, even though that province may have declined to define such deaths as legitimate instances of medical assistance in dying.

In other words, there will now be an open, and very significant, disagreement between that which is legally permitted (throughout Canada in virtue of the Criminal Code) and that which is offered as medical treatment (in Quebec, in virtue of provincial health powers). Nor is their any reason that such disagreement be definitely settled any time soon (one way or the other), because both province and federation would seem to be in the right from a constitutional point of view. And the ultimate meaning of these facts will be the realization (should honest clarity prevail), that we are not actually talking about one single thing (MAID), but of two very different things indeed: on the one hand, euthanasia decriminalized to support a purported "right to die"; and on the other, euthanasia justified as medical treatment.

A positive road forward

Throughout this present series of articles, I have attempted to show that the ethical path (and the logical implementation) of euthanasia-as-right-to-die and euthanasia-as-medical-treatment are entirely different and that great harm has already come of confounding the two. Happily then (in Canada at least), it would now appear that our political and legal landscape is actually divided (between the provinces and the federation) in such a way as to naturally force us towards precisely this desirable conclusion. And whether by the genius of our founders (or by the blind luck of historical compromise) we would now seem to be ideally placed to pursue these questions in a dynamic environment of honestly competing principles and policies.

For Quebec is not alone in possessing the real powers (and the potential motivations) required to adopt a distinct vision of medical euthanasia. There are, in fact, ten provinces, each representing populations of varying philosophical persuasions, and each of which benefits from the same constitutional powers described. Quebec has indeed furnished us with valuable precedents in this regard, but other provinces can soon be expected to respond in kind.

For instance, the original medical interpretation of euthanasia was strictly limited to patients who were actually dying. In the critically important Quebec Bill 52, the practice was explicitly defined as "end-of-life care". (And that, by the way, is the only instance in the world of euthanasia actually defined as medical care.) I personally had the honor of addressing the Quebec Special Commission (on the evolution of end-of-life care, 2021 -- french only, audition , memoire ) where I encouraged the deputies present to simply ignore C-7. "Why", I asked, "should Quebec accept a medical interpretation of euthanasia practiced upon people who were not dying?" For quite simply: a rapid study of the reasons proposed for adopting the original law 52 ("An Act Regarding End-of-life Care") reveals that these reasons could not possibly apply to the viable patient (a view with which several of the original architects of that law now concur). Moreover, the rejection of euthanasia, for the mentally ill, would imply that such arguments have not been entirely unfruitful.

Criminal law, and medical practice, therefore, are now on diverging paths. Euthanasia-by-choice and euthanasia-as-medical-treatment, are no longer interchangeable terms. There is no reason why other provinces should not define medical euthanasia in a narrower sense: to maintain the end-of-life provision, or indeed: to reject the notion of medical euthanasia entirely.

No such action would prevent deaths resulting from the legal immunity provided by federal bills C-14 and C-7, which now enable a de facto "right-to-die" (by decriminalizing assisted suicide and euthanasia under prescribed circumstances). However, provincial definitions of medical euthanasia will have a critical impact upon the medical professions, and upon the therapeutic experience of the typical non-suicidal patient.

It is time, I believe, that provincial representatives, everywhere, become aware of the power and the responsibility that they possess in this domain.

January 18, 2022

Gordon Friesen, Montreal

http://www.euthanasiediscussion.net/ (français)
http://euthanasiadiscussion.com/ (english site in development)
http://hopeandfree.com/ (personal philosophical musings)

The true scale of demand for euthanasia in Canada (Who really wants to die? : Part IV)

This is the fourth in a series of articles by Gordon Friesen.

• Who really wants to die? Part 1: A brief quantative analysis of the purported "need" for euthanasia (Link).
• Who really wants to die? Part 2: The popular impact of celebrity suicide (Link).
• Who really wants to die? Part 3: Life choices of the common person (Link). 

Gordon Friesen

By: Gordon Friesen
http://www.euthanasiediscussion.net/

 -- What is really at stake here ?

Faced with the complete up-ending of the Canadian medical industry which has been forced upon us by the unprecedented legislative redefinition of medicalized suicide, as benign “care” – and presented, in fact, as a universal right;

Faced with the resulting obligatory and omnipresent intrusion of this practice into every corner of our public healthcare system;

Faced with a duty imposed upon every doctor to inform each eligible patient of their “right” to die by euthanasia (whether said doctor believes the procedure to be appropriate in a particular case or no, and notwithstanding the negative burden of inflicting such informational aggression upon those typical patients who have demonstrated no autonomous desire to be euthanized);

Faced, moreover, with an actual obligation (duty) to perform the act of euthanasia (when requested by an eligible patient) which can only be avoided by the affirmation of an “objection of conscience” founded in “deeply held” (ie, religious) beliefs;

Considering, that this exemption explicitly excludes the invocation of professional, medical, or scientific motives of refusal (because the legislative definition of euthanasia, as benign care, automatically denies any such pretension);

Considering, also, that even in the event that a physician exercises this restrictive “privilege of conscience” (to refuse to perform a specific euthanasia contrary to his or her best professional judgement), that such doctor must STILL collaborate, to the extent of providing an “effective” referral to a more willing colleague;

Faced, then, with all of these extraordinary circumstances, and with the extraordinary burdens they place upon the typical non-homicidal doctor (and the typical non-suicidal patient): We would, I believe, be entitled to expect the demonstration of an overwhelming patient demand for this service; entitled to expect, that is, that the ill and the disabled would accept this proffered clinical death, in near-unanimous fashion.

But such is simply not the case.

As a matter of fact, the true figures which represent the real choices statistically embraced by actual patients facing the prospect of medical “aid” in dying, diverge to an astonishing degree from the officially sanctioned narrative to which we have become so accustomed in recent years. May the reader be the judge.

The instructive cases of Belgium and the Netherlands

Let us stipulate, to begin with, that it would be little enlightening to begin this analysis in the Canadian context, because the arrival of euthanasia practice, in this country, is still too recent to permit accurate forecasting of future trends. Luckily, however, we do dispose of a large body of data -- much more informative – originating from two countries (and immediate neighbors), Belgium and the Netherlands, which are fairly similar to Canada culturally and economically, and which have now encouraged the practice of legal euthanasia for nearly twenty years.

Without any doubt, as concerns Europe (and perhaps the world), it is the Dutch, along with their cultural-ethnic Flemish cousins (living just across the Belgian border), who have shown the greatest enthusiasm for euthanasia. And much more, to be precise, than even their immediate Franco-Belgian (Walloon) neighbors. In fact, prior to the arrival of Canada (and the deliberately radical “Canadian model”) the systematic insistence of the Netherlands, and Belgium, on true euthanasia (rather than mere assisted suicide) represented a sort of singularity among nations permitting different forms of assisted death. The least we can say, however, is that our policy and attitudes, in Canada, were strongly influenced by the Dutch experience and intended, even, as an extension thereof.

Nothing but the facts...

Naturally, in the reporting of statistics, there is a journalistic tendency to deliberately present figures under their most dramatic aspect. And in the present case, the desire for journalistic hyperbole was further aided by a perception, on the part of both adversaries and promoters of euthanasia in Canada, that their respective causes would be assisted by the most extreme possible interpretations of Belgian euthanasia growth rates.

And objectively, also, we must admit that both were correct. For those who believe that even one act of euthanasia is wrong (categorically or medically) will also consider ever greater numbers, of euthanasia deaths, to be ever that much more wrong. And therefore, reference to rising death counts is a certain way of generating increased and continued outrage among those of us who share the required ethical reference points.

But on the other side, for the promoters of euthanasia -- for those who would wish to espouse a contrary moral position: a rapid expansion of recently legalized euthanasia practice, in Belgium, would seem to indicate a strong and growing demand. And this, they believed, would support the pretension that legalized euthanasia is a necessary service -- desired and desirable -- rationally provided in response.

The growth and stabilization of euthanasia rates in Belgium and the Netherlands

To take a particularly egregious example, journalistic reports in 2018 still made generous reference to the fact that the yearly number of Belgian euthanasia deaths had increased tenfold in the first 15 years of legality (up to and including 2017). Certainly, that does seem like prodigious growth! However, a more prudent analysis would remind us that ten times nothing remains nothing still, or in this case: that ten times 0.2% (of all deaths in Belgium) became only 2.2% at the end of that 15 year period.

Now it is true, that 2.2% of all deaths in that country would make a lot of bodies were they all brought together in one place. But it is also the property of large numbers and proportional relations that 2.2% is only a marginal fraction of the whole. And while it should, quite naturally, dismay the unconditional defenders of life, it is not a number which, I submit, should bring any comfort to the apologists of assisted death.

“But wait a minute”, some might exclaim, “at that pace of growth, the euthanasia rate would be 22% in another fifteen years, and ALL deaths would be due to euthanasia approximately 25 years out.”

Yes, of course. If we were talking about a straight-ahead exponential curve, there can be no doubt, that would indeed be so... But we are not. The greatest proportion of growth was observed in the first years, and has steadily declined thereafter, such that the Belgian rate has now been stable at the 2% level for several years. Nor is there any reason to believe that this rate will grow (unless new presently excluded client groups are subsequently granted access).

In the Netherlands, the portrait is similar. The rate of growth was slower, but the final proportion was actually much larger because of a higher starting point. To make the relation between the two countries easy to understand : after the first five years, the Belgians showed about half the Dutch number, and the two grew in lockstep thereafter, so that, as the Belgians stabilized at approximately 2 % of all deaths being due to euthanasia, so the Dutch number plateaued at 4% or a little more.

“And that”, as they say, “is that !” : 96 % of all Dutch deaths are NOT euthanasia ; 98 % of Belgian deaths are the same ; and barring changes in euthanasia policy in those countries, these numbers may be expected to remain constant. 

I recognize that several studies have indicated a large number of un-reported euthanasia deaths in Belgium and the Netherlands, nonetheless, the same issue with under-reporting may exist in Canada.

A return to the Canadian experience

My point here, with regards to the Canadian experience, is the following: Our policy was formed in the initial years of Belgian legalization when the numbers were soaring. In the minds of Canadian euthanasia enthusiasts, at that time, it seemed giddily clear that we would be required to prepare for a veritable tidal wave of euthanasia demand, from the very moment that the floodgates of legislation were broached. In fact, Canadian policy was obviously designed to maximize euthanasia supply, as an “improvement” on the framework of our European cousins, and intended to remove certain “barriers” denounced by their most radical practitioners, in a progressive display of legislative “leap frog”.

However, as we have seen, all of this was based merely upon fanciful statistical interpretation, similar to that of the eager stock broker who is willing to blindly follow the projected rising curve of his holdings, all the way out of his 50th floor window. Moreover, the error is not blameless. Because euthanasia was legalized in Belgium in 2002, but the Quebec law (Bill 52) was only passed in 2014, Carter vs Canada was rendered 2015, and the Canadian law (c-14) passed as late as 2016. By the first of those dates the Dutch-Belgian growth curve was clearly “flattening”, and by the last, that curve already appeared stable. Unfortunately, however, it now appears that the Canadian judicial-legislative juggernaut was decisively in movement at that time, and impossible to stop, even if there were no underlying data (in 2016) to support the extreme implementation of euthanasia that was finally embraced.

Canada by the numbers

If we look now at the little we do know of Canadian trends, after three full years of legality, we see the following proportions of euthanasia as a fraction of all deaths in Canada: 2016, 0.38 %; 2017, 0.99 %; 2018, 1.49%; 2019, 2.0%

Clearly, even though the data is scant, we already seem to notice, here, the same pattern as that observed in the Netherlands and in Belgium. The rate of the second year is more than twice that of the first, but the third year is only half again that of the second. Apparently, the curve is flattening in Canada as well.

Belgium. we remember, began at 0.2% and stabilized at 2.2%. Netherlands began at 1.5% and stabilized at 4.2%. Canada began at 0.38% and has now arrived at 2% after four years. What could be more natural than to speculate on a final stabilization, somewhere between our two overseas companions, in the 2% to 4% range?

And if that is the case, what conclusion can we draw concerning current Canadian policy?

A sad portrait of quantitative over-reach

The opening paragraph of this piece consisted of what I believe to be a very substantial list of negative consequences stemming from the definition of euthanasia as basic medical care, and from the formal state promise of universal accessibility that accompanied it. This policy stands in stark contrast to that of a country like Switzerland which, by comparison, only permits assisted suicide and makes no formal declaration on the medical ethics of that practice. Our policy, obviously, is based on the projected satisfaction of a much greater patient demand than that imagined by the Swiss. But, once again: on what evidence is such a demand postulated?

It is simply not rational, I would submit, for our entire traditional practice of medicine to have been turned upside down in this way, on the basis of a maximum client demand evaluated only at something between 2 and 4 percent. Nor can that life-centered medical care, which is required, and desired, by 96% (to 98%) of patients, be rationally fragilized in such an uncompromising, obsessive resolve, to maximize the access and recourse to euthanasia. Clearly, as the expression goes: “Mistakes were made...”.

Terrible mistakes, in fact, that must now be rectified.

Gordon Friesen is a member of the Euthanasia Prevention Coalition board.

Canada: Recent History of Euthanasia Legalisation

By Richard Egan (with the Australian Care Alliance)

On 21 April 2010 the Canadian House of Commons defeated Bill C-384 An Act to amend the Criminal Code (right to die with dignity) by 228-59.

The Quebec National Assembly passed an “An Act respecting end-of-life care” by a vote of 94-22. It came into effect on 10 December 2015. This Act permits euthanasia on the request of an adult who is “at the end of life; with a serious and incurable illness; and in an advanced state of irreversible decline in capability”.

On 6 February 2015 the Supreme Court of Canada in Carter v Canada (Attorney General) declared that provisions in the Canadian Criminal Code making it an offence to aid or abet suicide “unjustifiably infringe” section 7 [“Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.”] of the Charter of Rights and Freedoms “and are of no force or effect to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” The declaration was suspended for a year, giving the opportunity for the Parliament to amend the offending laws by providing a scheme for physician assisted suicide.

The core paragraph in the judgement reads that: “The right to life is engaged where the law or state action imposes death or an increased risk of death on a person, either directly or indirectly. Here, the prohibition deprives some individuals of life, as it has the effect of forcing some individuals to take their own lives prematurely, for fear that they would be incapable of doing so when they reached the point where suffering was intolerable. The rights to liberty and security of the person, which deal with concerns about autonomy and quality of life, are also engaged. An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.”

The argument based on the right to life is specious as it takes no account of the inevitability that a law permitting euthanasia will result in wrongful deaths based on medical errors, coercion, discrimination against or differential treatment of the disabled and mentally ill and suicide contagion.

The argument from liberty, if pressed to its logical conclusion, would require a law permitting assisted suicide or euthanasia on request by any person, including a minor, with capacity.

The argument from security is based on a false claim that pain and other physical symptoms cannot be relieved by best practice palliative care.

In response to the Supreme Court judgment, the Canadian parliament passed Bill C-14 which came into effect on 17 June 2016 and legalised euthanasia and assisted suicide on request for any adult who has “a serious and incurable illness, disease or disability”; is in “an advanced state of irreversible decline in capability”; and whose “natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining”.

Increase in numbers

There have been three interim reports providing national data on euthanasia as well as reports on the data from Quebec, the most recent of which covers 1 July 2017 to 31 March 2018.

First report.

Comparing the data for the three six month periods covered by the national data reports - 17 June 2016-31 December 2016; 1 January 2017-30 June 2017 and 1 July 2017-31 December 2017 – the number of deaths by euthanasia almost doubled (189%) between the first and third six month periods from 805 to 1525 increasing from 0.6% of all deaths in Canada to 1.07% of all deaths.

Similarly the data for Quebec shows that official reports of euthanasia almost doubled from an average of 46 per month for the six month period 1 July 2016-31 December 2016 to an average of 90 per month for the three month period 1 January 2018-31 March 2018.

Reported acts of euthanasia in Quebec accounted for 1.18% of all deaths in 2017.

Unreported cases

There is a discrepancy of 171 cases of euthanasia between the number of official reports received (1493) and the number of cases reported by institutions (1664) in Quebec suggesting a failure by physicians to report in 10.3% of euthanasia cases.

Failure to comply with the legal processes

Quebec euthanasia

Six per cent of all forms reporting euthanasia in Quebec are received late and 42% off all forms received have insufficient information and require follow up requests.

Even after repeated requests for further information there is insufficient information to conclude whether or not the act of euthanasia complies with the law in 5% of cases.

In a further 5% of cases (62 cases out of 1374 for which a final assessment has been made) there was a failure to comply with the law, including:

• 29 cases in which the consulting physician was not independent from the physician who carried out euthanasia. However, this has been addressed by officially slackening the interpretation of the requirements for independence! 
• 9 cases in which the physician who performed euthanasia did not ensure that the request for euthanasia was voluntary, informed and persistent  
• 6 cases in which the consulting physician examined the person before a request for euthanasia was formally made
•  5 cases in which the approval was countersigned by an unqualified person  
• 5 cases in which the person did not have a serious and incurable illness  
• 4 cases in which the person did not have the required Quebec health insurance  
• 2 cases in which the person was not at the end of life  
• 2 cases in which the physician failed to verify that all the conditions for euthanasia were met.
  

In summary of these 62 cases at least 23 could be characterised as possible wrongful deaths.

Underlying conditions

Very limited data is provided on the underlying condition for which euthanasia is performed. In the last reporting period 9% of cases involved either an unreported condition or a condition other than cancer related, neurodegenerative or circulatory/respiratory system.

Some of the “other” conditions have included osteoarthritis, rheumatoid arthritis and “age-related frailty”.

The Canadian law only requires that “death be reasonably foreseeable”. The decision of the Ontario Superior Court of Justice in AB v Attorney General of Canada delivered on 19 June 2017, in paragraph 81, interpreted this requirement as not requiring any connection whatsoever between the underlying conditions for which euthanasia is sought and the reasonable foreseeability of death – which can be based simply on advanced age. The woman in this case was 79 years old.

Additionally there are the 5 cases from Quebec in which the person did not have a serious and incurable illness and the 2 cases from Quebec in which the person was not at the end of life.

Short time between initial request and euthanasia being performed

Section 29 (c) of the Quebec law requires that before performing euthanasia the physician must verify “the persistence of suffering and that the wish to obtain medical aid in dying remains unchanged, by talking with the patient at reasonably spaced intervals given the progress of the patient’s condition”.

Section 241.2 (3) (g) of the Canadian Criminal Code requires a physician to “ensure that there are at least 10 clear days between the day on which the request was signed by or on behalf of the person and the day on which the medical assistance in dying is provided or — if they and the other medical practitioner or nurse practitioner referred to in paragraph (e) are both of the opinion that the person’s death, or the loss of their capacity to provide informed consent, is imminent — any shorter period that the first medical practitioner or nurse practitioner considers appropriate in the circumstance”.

Nonetheless according to a recent study of euthanasia at three institutions in Quebec the median number of days between the request for euthanasia and the patient’s death was just 6 days.

This study also found that in 32% of cases a palliative care consultation only took place less than 7 days before euthanasia was requested and in a further 25% of cases it took place on the same day or AFTER euthanasia was requested. This suggests that euthanasia is being routinely provided to people before they have had a chance to experience the full effect of palliative care to relieve their suffering and concerns.

Reasons for requesting euthanasia

A study from an Ontario hospital reported that those who received euthanasia tended to be white and relatively affluent and 95% of them indicated that loss of autonomy was the primary reason for their request. Other common reasons included the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life. Few patients cited inadequate control of pain or other symptoms.

Disability – the story of Candice Lewis

Candice Lewis with her mother.

Candice Lewis is a 25 year old Canadian woman who happens to have been born with cerebral palsy.

In September 2016 Candice went to the emergency room at Charles S. Curtis Memorial Hospital in St. Anthony after having seizures.

Dr. Aaron Heroux told her she was very sick and likely to die soon. He offered her assisted suicide. The doctor also proposed assisted suicide for Candice to her mother Sheila Elson.

This offer was repeated despite both Candice and her mother making it clear that this was not an option Candice would consider. Dr Heroux told Sheila she was being selfish by not encouraging her daughter to choose assisted suicide.

Candice describes how bad it made her feel that a doctor was offering her assisted suicide.

More than twelve months later Candice has recovered well and her health was much improved. Candice hasn’t been having any seizures, is now able to feed herself, walk with assistance, use her iPad. She is more alert, energetic and communicative. She was able to "walk" down the aisle as a bridesmaid at her sister’s wedding in August 2017. She is doing what she loves most, painting and being with her family.

Candice and her mother Sheila have been interviewed by Kevin Dunn, who produced a film on euthanasia and assisted suicide called Fatal Flaws. The film of the interview can be viewed here.

There are several take home lessons from Candice’s experience:

• Doctors can get the prognosis wrong. Candice was told she was dying but was flourishing twelve months later. A wrong prognosis can lead to assisted suicide or euthanasia. A life can be thrown away needlessly;
• People with a disability already suffer discrimination in health care. When assisted suicide and euthanasia are legal, people with a disability are more at risk of being offered death as a solution because doctors and others consider that they would be better off dead; 
• Once doctors are authorised by the law to provide assisted suicide and euthanasia some of them will feel empowered to offer it to anyone they think would be better off dead. This undermines patients’ trust in doctors and can cause great distress.

Roger Foley

Financial issues: Denied assisted living but offered assisted suicide
Roger Foley, who has a crippling brain disease, has been seeking support to live at home. He is currently in an Ontario hospital that is threatening to start charging him $1,800 a day. The hospital has told Roger that his other option is euthanasia or assisted suicide under Canada’s medical assistance in dying law.

Euthanasia: when safeguards become barriers to access.

This article was published by Mercatornet on July 4, 2017

B

Aubert Martin

y Aubert Martin, Executive Director of Vivre dans la Dignité (Living with Dignity) Quebec

A month after the publication of a letter by the secretary of the College of Physicians of Quebec – in which he expressed his concern about a growing “pressure, demanding a form of death à la carte” and in which he denounced those who interpret refusals of euthanasia as a form of exclusion – lawyer Jean-Pierre Ménard is challenging before the courts the cases of two people living with disabilities who were refused the assistance of a physician to kill themselves.

The plaintiffs requested the removal of the “reasonably foreseeable death” clause of the federal law as well as the “end of life” requirement in the Quebec law.

More voices were added to the chorus of “rebels” decrying the cruelty of all criteria that dare make reference to the proximity of death.

Yet not so long ago, the elected Members of the National Assembly in Quebec (MNAs) were congratulating themselves on the wisdom of their law that made reference to… the end of life. This is another reversal of logic in the long list of changes of rhetoric we have already witnessed.

Indeed, at the time of the adoption of the Quebec bill, words like “safeguard” and “strict conditions” peppered the speech of those seeking to calm the fears of people wary of allowing homicide under certain circumstances.

Today, potential extensions of the law are justified by referring to “consensus” and “the will of the people,” while the “safeguards” have turned into “barriers to access”.

Meanwhile, the same promoters of euthanasia who claimed that it was only a matter of “exceptional requests for exceptional cases” have updated their rhetoric to justify the explosion of euthanasia requests: it has become “a response to a need.”

Yet, before the legalization of euthanasia and assisted suicide in Quebec and in Canada, warnings of the slippery slope were met with mockery and contempt from those who embraced medical suicide with open arms.

At best, this cautious warning, based on the experience of countries that legalized euthanasia before us, was treated as a scarecrow brandished by alarmists. “The slippery slope doesn’t exist!” responded those anti-skeptics and other merchants of death.

Today, slightly more than a year after the Quebec bill 52 that legalized euthanasia came into force, we see the first obvious signs of the slippery slope: we have gone from exception to promotion. Already the “end of life” criterion is presented as discrimination which prevents people with disabilities from committing suicide, implying that their living conditions justify their desire to die.

Secondly, the argument that euthanasia is about “capable and consenting people” is giving way to the idea of killing an incapable person (with Alzheimer’s or dementia) regardless of the person’s consent at the time of death.

Finally, according to a Canadian study published in May, the proverbial patient writhing in pain on his deathbed has morphed into a person in existential crisis over his loss of autonomy (read: disability).

So we won’t be surprised if tomorrow we are presented with other ludicrous propositions, such as the one currently gaining popularity in the Netherlands: opening “medical aid in dying” to elderly people who feel they have accomplished their lives.

A society does not accept overnight the idea that the state should endorse the suicide of an elderly and healthy person simply because she is tired of living. It must first live through the deep malaise that accompanies every new expansion of euthanasia access that is sold to us as progress.

In fact, when we think about it, the only thing that is “reasonably foreseeable” is the extension of medically assisted suicide to more and more groups of people. If death is sold as a solution to suffering, and if suicide is viewed favourably when a doctor is involved, the real question is not why some are opposed to it, but rather “why say yes to one and no to others?”

Aubert Martin is the Executive Director of Vivre dans la Dignité (Living with Dignity), a Quebec-based organisation.

Dr Yves Robert concerned about evolving euthanasia laws in Québec.

This article was published by the Physicians Alliance Against Euthanasia on June 12, 2017.

Dr Yves Robert Secretary of the
Collège des Médecins du Québec

On May 10, 2017, Dr. Yves Robert, Secretary of the Collège des médecins du Québec, asked the following question in a thoughtful article published on the CMQ website:

“If the goal is euthanasia on demand based on a “right”, are we still talking about Medical Aid in Dying? Or simply Aid in Dying? And what, then, would the medical profession have to do with it?”

Considering the past positions espoused by the College and by Dr. Robert personally – “The debate is only beginning…” (words of Dr. Robert at 18 minutes 24), such a quote is reminiscent of the classic novel Frankenstein, where that high-minded scientific genius, having created a humanoid monster threatening to the human race, is forced to confront the reality of his acts and of his responsibility for them. Tragically, but also heroically, he feels obligated, in the end, to hunt and destroy that creature – loved by him as a son – which his imprudent skill had set loose upon the world.

This reading of the text may be well beyond the Secretary’s intention. However, he has raised a clear statement of principle: if there are no criteria for euthanasia other than client demand, then medical wisdom, medical art and medical science have no role to play.

Once we allow any person to choose state-assisted suicide, and any doctor to perform it, we are legitimizing a purely subjective choice of death. There remains no logical reason why the right to exercise such choices should be restricted to this or that medical condition, or to medical conditions at all. Whatever limits are set, someone will feel constrained by them; and the state will continually be called upon to justify a discriminatory regime (where group “a” is allowed subjective decision, but group “b” is not).

Dr Robert apparently believes (or at least did believe) that protection of the common good can perform a limited retreat before the pressure of unfettered individual liberty, and that stable compromise can be established between these two visions. But the legal and moral change, from euthanasia-as-criminal-homicide to “medical aid in dying”, is not a difference in degree; it is a difference in kind. No compromise is possible. There is only a clearly perceptible earth-moving shift towards a radically different medical paradigm based, solely, upon personal subjective choice – a shift which the Physicians’ Alliance, palliative care providers and many others have opposed from the beginning.

The politicians who promoted Bill 52 insisted it was “an evolution, not a revolution”. But, as we observe the public opinion shift that alarms Dr. Robert – “the paradoxical discourse that calls for safeguards to avoid abuse, while asking the doctor to act as if there were none” – it becomes obvious that it is indeed a revolution, planned as such by its authors, wilfully ignoring the opposition of those who care for the dying. The ink is barely dry on Bill 52 and euthanasia enthusiasts are already demanding further concessions. The interim demands were never an acceptable final destination, only legal waystations on the path to complete liberty of personal choice. As Dr. Robert calls it, death à la carte.

And so it is, that even Dr. Robert has begun to speculate publicly upon the medical significance of such an extreme outcome. And these are the logical implications which he has now had the honesty and rigour to bring forward: The medical profession has no duty (or competence) to define, staff or take any responsibility for a public regime of death on demand. Whatever form such fundamental social change might take, it is NOT a medical problem. And (we would add) the sooner we realise this fact, and act upon its wisdom, the better things will be for all concerned.

Indeed, simple prudence would suggest that we show restraint right now in the administrative implementation of the euthanasia regime. Decontamination is always easier in proportion as the contaminated area is smaller. Hubris-driven attempts to impose MAID upon all corners of the health care system should be abandoned. Refusal of individuals and institutions to collaborate in this practice should be scrupulously respected.

Dr. Robert ends his article with a simple and sober admonition:

“Let us take the time to reflect carefully before going any further… Death is not that urgent.”

It is a sentiment with which we entirely agree.

Translated from the original article in French by the Physicians’ Alliance against Euthanasia.

Québec pushes the euthanasia boundaries again.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition
 

Québec pushed the boundaries by legalizing euthanasia, through Bill 52, before the criminal code was amended by defining lethal injection as medical treatment.

Gaétan Barrette, Québec's Health Minister, is now considering incrementally extending euthanasia to incompetent people with Alzheimer's or Dementia, even though the law states that "medical-assistance-in-dying" is limited to competent people.
 
The Federal government is also examining extending euthanasia to persons under 18, people who are incompetent with Alzheimer's or Dementia and people who are "psychologically suffering" but not dying.

Konrad Yakabuski expressed his concerns with permitting "MAID" for incompetent people in an opinion article published in the Globe and Mail yesterday. Yakabuski stated:

On March 24, Health Minister Gaétan Barrette announced a three-pronged approach aimed at potentially broadening the eligibility requirements for medical aid in dying. First, a provincial commission will examine the more than 250 requests for the procedure that have been either rejected or withdrawn since the practice was legalized. A group of experts will subsequently re-examine the question of allowing advance consent for MAID by people diagnosed with degenerative diseases such as Alzheimer’s and other forms of dementia. Quebec’s Justice Ministry, meanwhile, will ask the courts to clarify the federal MAID law’s limit of the practice to only those facing a “reasonably foreseeable” death, which health professionals have complained is too vague.

When the Québec government was debating euthanasia, they insisted that they would implement the law carefully. Now that euthanasia is legal, the Federal and Québec governments are making plans to expand the law, just as we had predicted.

Yakabuski states his concerns:

None of this will make the path we have embarked on any less fraught with ethical red flags than it should be. There can be nothing ethically clear-cut about deciding when to end the life of an Alzheimer’s sufferer who is no longer cogent enough to consent. The whole notion of “unbearable suffering” (one of the federal law requirements for MAID) is in itself inscrutable when it comes to Alzheimer’s and dementia. Unbearable for whom? Just whose suffering is being alleviated when loved ones ask God or the state for their dementia-stricken ward to die?

For what it’s worth, the Alzheimer Society of Canada argues that “MAID should only be possible when a person is deemed competent at the time of MAID. … [P]eople with dementia need to be safeguarded as they will be extremely vulnerable at the end of their life [and] do not have the capacity to make an informed decision and consent to end their life at the later stages of the disease.”

Personally, that’s enough guidance for me.

When the government permits the killing of its citizens by lethal injection, it crosses the clear line, that killing a human being is always wrong. Now that one person can kill another person in Canada, the only question that remains is for what reason will it be permitted to kill. Incremental extensions are inevitable. 

The answer is to Care for people and not kill people.

Québec euthanasia deaths higher than expected.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

The Québec euthanasia commission has reported that during the first 7 months of the euthanasia law there were 262 reported euthanasia deaths, a number that is much higher than expected. The annual report of the commission is based on euthanasia deaths from Dec 10 to June 30, 2016.

Caroline Plante reported in The Montreal Gazette that Québec's Health Minister, Gaétan Barrette, seemed surprised by the number of deaths:

He expressed surprise that since the law came into effect Dec. 10, 2015, 262 people have resorted to what the provincial government calls “end-of-life care” and what Ottawa refers to as voluntary euthanasia. 

“I mentioned many times that I was expecting about 100,” 

“It’s almost three times that. Actually, on a one-year period, it will be over 300 … that in itself is surprising to me.” 

The report says medical aid to die wasn’t administered for 87 requests: 36 of them did not meet the criteria set out in the law, 24 people changed their minds, 21 died before receiving the aid, one has asked for a delay and five requests are still being processed.

The Montreal Gazette article also reported that the health Minister may reduce the requirement that two independent physicians approve the death:

... the minister said he is considering making some adjustments to simplify the paperwork and ease the obligation of seeking a second opinion from an objective and independent doctor, who must agree that there is no hope of recovery. 

Barrette said in certain, more isolated towns, it is difficult to find a second doctor who is completely independent from the patient.

Barrette first extended the law last June when he stripped palliative doctors and institutions of their conscience rights by ordering them to participate in the euthanasia law. 

Ingrid Peritz reported in The Globe and Mail that of the 262 deaths, 21 failed to meet the legal requirements of the law: 

The report found that of the cases it examined, 21 failed to meet the legal restrictions. 

The vast majority of those – 18 – involved questions about the independence of the second doctor who is required to sign off on the assisted death. Mr. Barrette said the problem often arises in smaller communities where doctors know one another. 

Of the remaining three cases, two were instances in which assisted death was administered without proving the patient was at the end of life. In one case, it wasn’t proven that the patient was facing a serious and incurable illness, as required under the law. 

All 21 cases have been referred to Quebec’s College of Physicians, which will review them, a spokeswoman said.

There were 262 reported euthanasia deaths in the first 7 months of the euthanasia law. Since the Québec euthanasia law is based on the Belgian law and since nearly half of the assisted deaths in Belgium are not reported we wonder how many euthanasia deaths have actually occurred in Québec?

Important articles:

• Dutch euthanasia deaths continue to rise in 2015.
• Belgian 2015 euthanasia report: Deaths continue to rise.
• Study: More than 1000 Belgian deaths were hastened without request in 2013.

For the Sake of Families Please Do Not Go Down Canada’s Dark Road of Euthanasia and Physician Assisted Suicide

Open letter to Governor Hassan of New Hampshire – From Dr Paul Saba

Dr Paul Saba

March 28, 2016

As the state of New Hampshire considers establishing an end-of-life choices study commission, I strongly advise against this. This will only lead down the same dark road that Canada has travelled. Although in the United States euthanasia and physician assisted suicide falls under state jurisdiction, in Canada this falls under both Federal and Provincial jurisdictions.

Presently, Canada is proposing doctor assisted suicide and euthanasia of its most vulnerable citizens including children who are “mature minors” and the depressed.

Children possibly as young as 11 or 12 could see their lives ended prematurely without parental consent or prior notification. The serious consequences of enacting such a provision is illustrated by the case of Nadine (Video Link). At 14 years old, she was diagnosed with an aggressive form of leukemia. She underwent multiple chemotherapies and a failed bone marrow transplant. She was told that she had little chance to survive. She states that without the loving support of her family, she would have given up. Today at 19 she is well and happy to be alive.

History has taught us that killing the weak and vulnerable is a formula for disaster. The Romans encouraged the weak, sick and depressed to kill themselves. In 1938, Germany started euthanizing handicapped children. Today, Belgium and the Netherlands euthanize children, the depressed and those tired of life.

As a physician with dual USA and Canada citizenship, I have studied and practiced medicine in both countries. I presently live in Montreal. As President and Founder of the Coalition of Physicians for Social Justice my progressive ideas have included promoting quality medical care for the poor, incapacitated, the elderly and the young. However, I do not consider euthanasia and doctor assisted suicide as progressive. Presently in the province of Quebec many citizens have already been euthanized under a cloud of government controlled secrecy despite a requirement of an oversight committee.

Physicians have been mandated by our provincial medical board not to write on the death certificate that their patients have been euthanized with the threat of sanctions and possible loss of their license. Physicians in Quebec and across Canada are awaiting the passage of a new federal law which will set national standards of extending euthanasia to children and the depressed. As a physician, I refuse to inject or refer any patient to be injected with a lethal substance. As a dad with young children, I will never give the right to another person to lethally inject my children or my neighbor’s children. For these reasons I have launched court challenges in the province of Quebec to stop this law. Disobeying the euthanasia law risks the possible loss of my medical license. Why am I opposing this law?

First, and foremost, every life is valuable. 

Second, there are errors in medical diagnosis in up to 20% of cases. 

Third, prognosis may be incorrect, as in the case of Nadine. 

Fourth, “mature children’ do not have the psychological or cognitive ability to reason like adults—that is why they cannot drive, vote, enter into civil contracts or get married. 

Fifth, a depressed person cannot make a free and informed decision to end her/his life because of feelings of hopelessness. 

Sixth, people faced with a serious diagnosis are more likely to be depressed. 

Seventh, quality medical care includes providing palliative care -- which is different from euthanasia. Doctors can reduce the suffering of end-of-life patients’ with palliative care. However, unfortunately many Canadians and Americans do not have access to quality palliative care. 

Eighth, the few jurisdictions that practice euthanasia are unable to establish workable safeguards. For example: in Belgium, 32% of euthanasia deaths are performed without specific request or consent; and, 47% of cases go unreported. 

Ninth, many civilized societies (e.g. the United Kingdom. Scotland and France) have recently rejected such legislation because of the inherent dangers to its citizens.

Tenth, euthanasia and assisted suicide are denounced by the World Medical Association that represents 9 million doctors in over 100 countries.

Governments and healthcare providers should adequately fund and provide the best health care for all its citizens and especially the children. Euthanizing citizens may save money, but this goes against all decent civilized human values.

Will New Hampshire go down the same dark road of Canada and euthanize its citizens? What about the children, the depressed and those tired of life? What about those too sick and too poor to fight for their lives?

Therefore I ask you not to establish an end-of-life choices study commission. This will only lead New Hampshire down the same dark road that Canada has travelled. The evidence is overwhelming clear—euthanasia and assisted suicide is not the solution for suffering. Many wise people have stated that insanity is repeating the same thing over and over again and expecting a different result.

Our citizens need to be cared for and not killed. How we treat the most vulnerable in our society, is a measure of who we are as a society.

Dr. Paul Saba M.D.

Lachine Québec