Zoom Event: Seeking Medicine's Moral Centre

Tom Koch

Don't miss our next EPC Zoom Event:

Join us on Wednesday July 16 at 10 am (Pacific Time) / 1 pm (Eastern Time) for an excellent discussion on how ethics have changed and how it led to our current euthanasia and assisted suicide laws.

Register in advance (Registration Link)

Join Professor Tom Koch and Alex Schadenberg as they discuss (MAiD) euthanasia in Canada as it relates to his new book: Seeking Medicine's Moral Centre, Ethics, Bioethics and Assisted Dying.

Tom has been a long time critic of the ethical assumptions related to euthanasia and assisted suicide.

Tom is a defender of the Hippocratic ethic of medical care. His new book marks the history of change in medical ethics over the past 30 years. It is important to understand how we got to where we are before we can effectively reverse the trend.

Tom an expert who I have respected for many years. His writing are based on indepth research and reality rather than ideology. He is always open to respectful discussion.

Tom is an intellectual who is capable of speaking with everyone. Tom is known for his research and his consistent ethical position.

Register in advance (Registration Link)

Five Years Experience with (MAiD) euthanasia in Canada - A skeptics point of view.

Tom Koch

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Related article: Ontario euthanasia deaths increase by more than 30% in 2021 (Link)

An excellent research article was written by Tom Koch and published on February 12, 2022 titled: A Sceptics Report: Canada’s Five Years Experience with Medical Termination (MAiD). 

Koch, who is an ethicist and long-time researcher on issues related to end of life care, examines Canada's experience with euthanasia in comparison to other jurisdictions that have legalized euthanasia and assisted suicide.

Koch thoroughly examines the history that led to the legalization of euthanasia (MAiD) in Canada and compares Canada to other jurisdictions, such as the Netherlands.

With reference to Canada Koch writes:

The Canadian experience since 2016 has evidenced a similar pattern of expansion. The annual number of cases increased annually as the class of potential recipients expanded. The Second Annual Report on Medical Assistance in Dying in Canada, 2020 reported that between 2016 and 2020 the number of reported cases of medical termination increased from 1018 to 7589. ... The result provincially and nationally has been the very definition of a slippery slope with an increasing number of cases whose individuals had a progressively broader set of medical conditions.

To illustrate his point Koch writes:

In 2018, Canadian newspapers reported favourably on the medically induced deaths of George and Shirley Brickendens. In their 90’s, both were in reasonably good health, pain-free, and comfortably situated in a retirement home. Their existing chronic conditions were well managed medically and posed no immediate threat of serious decline. They sought and received MAiD not because they were in pain or particular distress but because they feared a future disabling illness. In the medical assessment required by law one doctor wrote that Mr. Brickendens, “has a serious and incurable illness, which is age-related frailty. It is end stage”. This ageist diagnosis was the physician’s way of fitting a stable, reasonably healthy patient with some chronic conditions into the broad, legal standard of candidacy.

Koch then comments on circumstances where euthanasia might be considered for people who only fear future suffering. He continues by writing on an experience he had with a treatable patient who had requested euthanasia. Koch writes:

A similar fear was that MAiD would become a default clinical response in cases where treatment would otherwise be recommended. In 2020, for example, I was asked to consult for a 93-year-old woman in Toronto living independently with some home assistance whose bursitis prevented her from dressing and washing herself. She told an attending physician if she could not do those things she did not wish to live. She was then referred for assessment as a candidate for MAiD. Upon examination with a palliative care physician, however, we determined her bursitis could be easily treated thus permitting her to regain shoulder-arm function. With treatment her request was withdrawn and she died naturally several years later.

Koch examines euthanasia of people with a wrong diagnosis. He first comments on the fact that of 133 people who Jack Kevorkian helped to kill, there were 88 autopsies and 3 of those autopsies indicated that there was "no evidence of any chronic, progressive disease." Koch then refers to an Australian study which found that 10% of people who ask for MAiD will have a misdiagnosis.

Koch continues by referring to a Canadian study on lung cancer patients that found that people diagnosed with lung cancer will often forgo effective life-saving treatment and immediately seek euthanasia. Koch writes:

In a recent report at the World Conference on Lung Cancer, Canadian researchers reported that with the increased accessibility of MAID, “Patients are seeking this option despite the availability of more effective and more tolerable treatment options. … While biomarker-driven, targeted therapies and other immunotherapies can be effective, many patients undergo medial termination without “accessing—or, in some cases, without being assessed for—these treatment options"

Koch then examines the reason why Canadians are asking for euthanasia. Koch states:

The Health Canada report emphasizes the degree to which those seeking MAiD were concerned with the limiting effects of their conditions (84.9%) and a resulting loss of ability to perform daily activities (81.7%). That is, some say, while life might be lived it would not a life they wish to pursue. The suggestion that this is simply a logical and rational choice assumes that those limits are necessarily unmanageable.

Koch then states that some people are seeking euthanasia (MAiD) due to a lack of medical or community supports. He refers to a study by Gallagher et al. that argued, that a “hastened death” chosen because of disease burden and resulting distress is a medical error in the absence of “timely, quality palliative care.” 

Roger Foley

Koch continues by writing about the case of Roger Foley:

In the most recent case to gain notoriety, 42-year old Roger Foley’s battle with the Health Science Centre’s Victoria Hospital in London, Ontario, is instructive. Foley has a degenerative neurological condition requiring skilled home support. Health authorities contracted with a private, for-profit company to provide his at-home care. The result of untrained, unsupervised personnel was, Foley charged, repeated hospitalizations. “I have been given the wrong medications, I have been provided food where I got food poisoning, I’ve had workers fall asleep in my living room, burners and appliances constantly left on, a fire, and I have been injured during exercises and transfers,” Foley claimed. “When I report these things to the agency, I would not get a response” (CTV 2018). The case became a cause celebre among disability rights advocates when Foley refused to leave the relative safety of his hospital bed and sued for the right to chose his own home care providers (Foley and Victoria Hospital et al. 2018). He became a national figure after tape recording a hospital ethicist suggesting he might consider medical termination instead of seeking better home care.

Koch then seeks to open a wider discusion. He states:

Clearly, on the evidence, skeptics expectation of a slippery slope along with an increasing number of persons in an expanding class of eligible persons would seek and receive early medical termination was justified. The number of persons accessing medical aid in dying has expanded to include those who are simply afraid of future illnesses as well as those whose condition seems to them untenable in the absence of necessary services. And, too, there are those who might live with appropriate care and cognitive, physical, or sensory limits who simply refuse to accommodate the changes that would require. The critical concern of early skeptics that medical termination would become a substitute for the kind of palliative and other services the Senate Committee called for in 1995 has been fulfilled. MAiD is increasingly a default choice offered, and in some cases promoted, in areas where expert care and support are unavailable and sometimes even where they are available.

Koch then discusses conscience rights and the pressure within the health care system to provide euthanasia. He writes:

Undiscussed here but not unimportant has been the manner in which practitioners and institutions have been pressured to provide MAiD assessments and service. Much of the evidence is anecdotal... But the defunding of a Delta, British Columbia, hospice that refused to provide MAiD, available at a hospital literaly next door, is one indicator of the pressures brought on those concerned that medical termination may be inappropriate.

Koch argues that the lack of proper end-of-life care has made MAiD a choice for many people. He states that some people will suggest that what is done is done, but Koch argues the point. He states:

First, by introducing MAiD without attention to the necessities of care for those with chronically limiting, often painful progressive conditions the impetus to assure that care is diminished. The class of those who might otherwise protest their lack of care, and choice of alternatives, is diminished and a public demand for better care is diminished as well. The only question has become if a more or less cognitively able person asks for it. But if we wish to promote patient autonomy and freedom of choice the lack of alternatives to medical termination means the choices open to patients are limited. It is, as I argued in 1996, like asking the most vulnerable among us to play “Russian Roulette with a fully loaded revolver”

Koch then argues that MAiD is diminishing equality. He writes:

Finally, promoting MAiD without prior attention to the palliative, rehabilitative, psychological and social services implies that those so in need are somehow unworthy of supportive care that would make an assisted life worthwhile. Medical termination provides both an alternative to the limited care they receive but as well a quick and cost-efficient way to address what might otherwise be a complex and expensive care program. Thus from the perspective of disability the person him or herself is diminished in importance relative to others in the population at large.

Based on the lack of real options available to Canadians, Koch challenges the concept of choice. He writes:

The history of MAiD also raises the question of what is meant by autonomy and freedom of choice. That has been the clarion call of advocates from the start but, in the absence of adequate and sufficient clinical and social services what choice is there, really? Typically what is offered is not a balanced and reasonable choice between living and dying “with dignity” (Koch, 2000a) but simply medical termination. These are important issues that are hidden beneath clarion calls for patient choice, autonomy, and freedoms of choice in medical affairs.

Koch is stating that since Canada's healthcare system lacks the supports that are necessary to ensure "freedom of choice" as defined by those who support euthanasia. He continues by quoting from former euthanasia leaders in the Netherlands. He writes:

In 1994, Dr. Cornelisse-Claussen, then director of the Dutch Voluntary Euthanasia Society made this emphatically clear: “Everyone here is able to get good health care, and I think only in this context can a law like we have be passed. If the socio-economic circumstances in a country are different, and if there are lots of financial problems with getting good care, then people should be very, very, very careful about introducing these possibilities”. A similar caution was offered, cited in the same article, by Dutch physician Dr. Gerrit Kimsma, an enthusiastic proponent of physician assisted or directed death. "The Netherlands has an extensive primary care system, with universal access with a nursing support that covers 24-hour care for terminal patients.”

Koch explains that the US Supreme Court Gluckberg decision shared the same warnings concerning the lack of effective end-of-life care. 

Koch concludes that euthanasia proponents Jocelyn Downie and Udo Schuklenk are promoting Canada's euthanasia law as the model for other jurisdictions. This explains why several jurisdictions have debated legalizing Canadian style euthanasia laws. Koch states that if Canada's experience is to be a model for other countries, as Downie and Schuklenk hope, it serves better as a caution than recommendation.

A link to previous articles by ethicist Tom Koch (Link).

Bioethicists joust over Canada’s ‘Medical Aid in Dying’ euthanasia law

This article was published by Bioedge on August 29, 2021.

Michael Cook

By Michael Cook, Editor of Bioedge

The debate in Canada over euthanasia and assisted suicide – or, as it is called there, Medical Assistance in Dying (MAiD) – will have a huge impact upon developments elsewhere in the Anglosphere. As two of Canada’s stalwart defenders of MAiD, Jocelyn Downie and Udo Schuklenk, pointed out in a recent article in the Journal of Medical Ethics, “other countries will confront the same questions if they contemplate changing their assisted dying law”.

This makes their pushback against critics of MAiD even more interesting. (Schuklenk, by the way, is a trenchant opponent of conscientious objection over abortion and euthanasia. He has even proposed that medical schools screen out potential objectors.)

The two bioethicists home in on two weighty criticisms of Canada’s MAiD regime: “social determinants of health” and slippery slopes. “Social determinants of health” is a WHO term for the non-medical factors which influence health outcomes – which range from racism to disability and mental illness to unemployment.

They argue that it is discriminatory to deny people with mental illness and disability access to MAiD. Patient rights would be sacrificed on the altar of paternalism.

As for the slippery slope argument, they dismiss it as illusory.

The change from Carter to C-14 moved Canada in a more restrictive direction. The entire scene is that Canada has not become more permissive as between the Supreme Court of Canada decision in Carter and Bill C-7. Rather, there was a period during which Canada had an unconstitutional tightening of the eligibility criteria. Canada is simply back where the Supreme Court of Canada put it through Carter.

This sets the scene for a vigorous response in the JME from another Canadian academic, Tom Koch, of the University of British Columbia.

He says that the “social determinants of health” argument remains valid. “Inadequate control of pain and control of other symptoms was a rationale in over half of all MAID cases. This outcome reflects the limited number of palliative and rehabilitative physicians in Canada.” In his view, the availability of MAiD means that bioethicists and others no longer feel the moral urgency of clamouring for more and better palliative care.

As for the slippery slope argument, Koch simply points to the numbers.

An expanding class of persons eligible for MAID has resulted in an exponential increase in the number of reported cases. Total reported cases of MAID across Canada increased from 1018 in 2016 to 21,589 in 2020. This is by definition the slippery slope: a relaxation of requirements resulted in an expanding class of eligible persons and an ever increasing number of medically induced deaths.

Michael Cook is editor of BioEdge

Tom Koch: Euthanasia is legal in Canada but that doesn't make it ethical.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Delta Hospice Society in BC was recently told by Adrian dix, the BC Minister of Health, that they must start doing euthanasia by February 3 or loss provincial funding. In response to this dilemma Dr Tom Koch, a consulting medical ethicist and gerontologist and author of the book Ethics in Everyday Places, wrote an opinion article that was published in the Globe and Mail on January 6.

• Sign the petition: Hospice Organizations Must NOT be Forced to do Euthanasia (Link).

Koch begins:

Because something is legal doesn’t mean it is ethically acceptable or, in medicine, clinically appropriate. The debate swirling over the Delta Hospice Society’s refusal of medical termination, “medical aid in dying” (MAID), in its beds is an example.

Diagnosed with terminal cancer, Clint Gossard, 59, hoped for a bed at the society’s 10-bed Irene Thomas Hospice in Delta, B.C. But he also wanted what they refuse to permit: medical aid in dying. For that, he had to go to Delta Hospital where his life was ended last January.

His widow and MAID advocates found that unacceptable. As a result, B.C. Minister of Health Adrian Dix has threatened the society’s funding if they don’t permit medical termination on their premises. Hospices I know elsewhere are similarly under pressure.

Koch explains that assisted dying is not part of hospice or palliative care. He writes: 

Speaking for the Delta Hospice Society, its founder and former director, Nancy Macey, argued not only that MAID violates the hospice’s constitution but the goals of palliative and hospice care. The society’s position is shared by many including those, like me, who are at best agnostic. Instead, it follows the guidelines in this area.

In November, 2019, for example, the Canadian Hospice Palliative Care Association (CHPCA) and the Canadian Association of Palliative Care Physicians (CAPCP) issued a joint statement stating categorically that “National and international hospice palliative care organizations are unified in the position that MAID is not part of the practice of hospice palliative care."
Medical aid in dying, they argued, is not an “extension of palliative care” but a violation of hospice and palliative medical goals of care.

Koch goes on to explain that good palliative care is not a simple process:

In its focus on the best of life to the end of life, hospice practice requires an understanding not only of clinical but also psychological needs. I have several times been engaged in discussions with those who wanted to die because of problems, clinical, personal or social, that were then addressed by palliative caregivers. In these cases, “I want to die” was really “I need help with this.”

A simple "it's your choice" removes our opportunity to find and provide the necessities of an acceptable life to the end of a patient's days. It replaces complexity with a simple, “Well, they wanted it” even where the reasons for wanting could be palliated.

Koch concludes by stating that he believes that Mr. Dix’s threat seems to violate the spirit if not the letter of enabling federal legislation that assured the rights of practitioner conscience would be protected.

Tom Koch: Provide real alternatives rather than a fatal injection.

This article was published by the Huffington Post on November 30, 2015.

Tom Koch

By Tom Koch, who is an ethicist, author and gerontologist.

The first person who asked me to kill him was my then 72-year old father. If he couldn't work and couldn't drive, what was there left to live for, he asked. "Lots," I said in refusing his request. "I'll show you."

He died peacefully in his sleep five years later.

My oldest brother, seeing our father in decline, asked me to promise to kill him as "an act of brotherly love" if he ever became infirm. During a period of depression resulting from an adverse prescription drug reaction, he refused hospital-based treatment. Instead he put his affairs in order and killed himself, suicide by pistol.

There have been others who wanted my help in dying after amputations, cancer diagnoses, while struggling with multiple sclerosis, paralyzing strokes, and a range of other incapacities.

I told each my job was to help them live as fully as possible despite their limits. That meant fighting for the best possible counseling, palliative (pain control), rehabilitative, psychiatric and social services available. I told each of them that before they gave up, they should try a life that while different could still be worthwhile.

In striking down the section of the Criminal Code that makes "aid in dying" illegal, the Supreme Court justices argued last February for individual autonomy and choice. The courts "pro-choice" judgment made overly simple what is in fact complex. If choice is our goal, we first need to address the reasons people with limits think life has lost its meaning. That's the basis of current challenges to Quebec's law legalizing what the Dutch call physician-assisted or directed termination.

A 74-year-old woman told me she doesn't want to die in pain as others have. "If I get there, end me," she said recently. I told her (and have told others) palliative medicine has come a long way and promised her pain would be treated. And, yes, I can make that promise given the state of medications today if -- a big if -- they're administered by professionals expert in their use.

Some years ago following a stroke, a woman looked down at her body, paralyzed on one side, and said to me that she didn't want to live. I told her she would improve with therapy and time and if she wanted to die today she might not tomorrow, or next week.

She lives, ten years later, with some paralysis but without pain. She uses a cane and has other mechanical aides. She is a volunteer advising new stroke patients of the possibility of life with a body some of whose parts do not respond.

A young amputee lost his right leg in an accident and could not see a future without football, baseball or dancing at parties. It took weeks to get him to accept rehabilitation, and eventually prosthesis. He's alive and well today.

The point is two-fold. First, what we request today or this week, following a grievous injury or serious diagnosis, may not be what we'll want in a month or a year. All those paralyzed by spinal cord injuries go through a depressed period of suicidal thinking. Over two-thirds find, after two years of counseling and rehabilitation that life is at least equally good, if different.

It is not "paternalism" to insist the newly injured or diagnosed take the time to adjust. It is good care and a recognition born of experience that the depressed and fearful patients does not yet have.

The second point is there is no real choice when pain control is absent or inadequate; when rehabilitation is minimal or simply unavailable. Where counseling and support are absent depression is a constant and death seems an increasingly welcome alternative.

Canada has no national program to assure a balance between "aid in dying" and assistance in living despite restrictions. While most major hospitals provide at least some pain management the demand far exceeds the ability to provide relief. In rural areas expertise is limited or non-existent.

Similarly, we have no national rehabilitation program to assure every Canadian receives the best possible rehabilitative services to strengthen the limbs that have been weakened and accommodate to the new realities of a limited body.

Nor do we adequately support the families and friends who assist our fragile citizens on a daily basis. If the newly limited feel themselves a burden on family and friends then, like Willy Loman in A Death of a Salesman, they'll see a quick death as the honorable thing.

In law it's called a predicate act or cause. It's the context in which decisions are made. People usually seek aid in dying because we have not provided aid in living. And if we believe the Supreme Court's insistence on choice, before offering an easy death we need first to assure the support is there for a life with dignity despite restrictions.

In crafting law in this area, Parliamentarians need to insist that jurisdictions offering physician-assisted termination first assure adequate support for the fragile is in place. Where that is not in place, there will be no real choice at all.

Some will say this is simply unaffordable. It will take too long to assure the resources for all Canadians facing limiting conditions. But, if we believe in choice we have to afford it. We have no alternative if we accept the Supreme Court's call for real patient choice. Think of it as infrastructure spending, a predicate act permitting people real alternatives other than a medically delivered, fatal injection.

Without, there is no real choice at all.

If you -- or someone you know -- need help, please call 1-800-273-8255 for the National Suicide Prevention Lifeline. If you are outside of the U.S., please visit the International Association for Suicide Prevention for a database of international resources.

The Law and Physician Assisted Dying.

This article was written by Tom Koch and published by the CMAJ on October 13, 2014.

Tom Koch

By Professor Tom Koch

For most Canadians, the October 15 arguments at the Supreme Court in Ottawa will be about medical “aid in dying,” what the Dutch bluntly but accurately call physician assisted or directed termination. But what is really at stake in Carter et al. versus Attorney General et al is Canadian law itself, the meaning of its guarantees, promises, and injunctions. In effect, lawyers for and against “aid in dying” are asking the Supreme Court’s justices to interpret two sections of the Canadian Charter of Rights and Freedoms.

The result will define not simply issues of “assisted dying” but the future of Canadian law and society for years to come.

The Charter’s Section 15 guarantees that: 

“Everyone has the right to life, liberty and security of the person.” Section Seven promises that “every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination … based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.”