By Gordon Friesen
President, Euthanasia Prevention Coalition
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Gordon Friesen
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It is a singularity of the British debate on assisted suicide, that considerable attention has been given to the possibility of creating a non-medical framework for this practice.[1] [2] In what follows we will briefly review the "why" and the "how" of such propositions.
Protecting majority patient interest
In most discussions of medically assisted death, very little concern has been shown for the quality of future care available to those who wish to go on living.
This is a truly extraordinary omission, because although there are some people who might surely wish to die, most of us will not. Nor is this last statement born of speculative opinion. It is an observed fact.
For example, the iconic terror of terminal cancer accounts for roughly 70% of euthanasia deaths in Canada, Belgium, and the Netherlands. And yet, as a share of all cancer deaths, that number is only 1 in 10.[3] Which is to say that only 1 cancer patient in 10 will consent to die by euthanasia (and far fewer in any other group).
In truth, the principal concern of typical dying patients is not suffering. Their main fear is of death itself. And their main comfort, faced with that mortal inevitability, lies not in the willingness of others to cut life short, but in the trust and confidence that family and professionals will value what life remains; and foster that life to the end, allowing them to die without precipitation, in their own time.
Traditionally, this patient confidence has been founded upon a multi-millennial promise affirmed by each individual physician: "I will do no harm or injustice... Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course."[4]
In the opinion of many, the removal of that positive certainty cannot possibly occur without a radical destabilization of doctor-patient relationships.
Assisted suicide and traditional care: mutually exclusive paradigms
Promoters of MAID, for their part, deny that the medically assisted death of willing individuals will have any effect upon the care provided to anyone else.
And yet it seems impossible to believe that physicians (or nurses) who participate in any form of medical homicide might still be considered appropriate caregivers for patients of the non-suicidal majority. One cannot be all things to all people. It would appear frankly inconceivable that the same doctor might pass from one patient to the next --presenting medically in precisely the same manner-- but to change so radically between times in his professional opinions, as to honestly favour the death of one but not the other.
In truth, euthanasia and traditional medicine are not only different, but mutually exclusive visions of patient care, and are practiced by individuals who are different also. Plainly stated: assisted death cannot be "added" to Hippocratic medicine any more than steak can be added to a vegetarian diet.
It is our most emphatic conclusion, therefore (and especially considering the one-sided quantitative division noted above) that any minority accommodation of assisted suicide should be provided apart from existing medical practice, in separate spaces and by separate professionals; that such accommodation must not be allowed to compromise --for others-- that precious clinical culture of trust and safety which physicians have so carefully cultivated over the past 2400 years.
What a non-medical regulating body might look like
In essence, a non-medical framework for assisted suicide would require the creation of a dedicated judicial authority like the Landlord and Tenant Board, or the Food Standards Agency: to evaluate requests, authorize procedures, license providers, regulate practice, and analyze reported data.
To explain the relative advantages of such a system, we will compare its projected operation with that of the most coherent system of medical euthanasia thus far established, that of Britain's close Commonwealth partner, the former Dominion of Canada.
The institutional "footprint" of medically assisted death
In Canada, "Medical Aid in Dying" (i.e. voluntary euthanasia) is defined as medical care whose goal is to relieve "enduring physical or psychological suffering" (2014,[5] 2016, 2021[6]).
In accordance with State duties to provide medical care as a human right,[7] euthanasia is practiced in all Canadian institutions, and by all Canadian professionals (subject only to minimal conscience exceptions). In particular, euthanasia is now an integral part of palliative care,[8] long-term care, and rehabilitation.[9] In all of these areas, professionals are theoretically expected to remain officially neutral regarding a patient's will to live; to "respect" whatever suicidal ideation might arise; and are empowered even to both initiate and channel that ideation themselves.[10] [11]
Finally, all meaningful limits to eligibility --including "reasonably foreseeable death",[12] "major age",[13] [14] [15]and "mental capacity"[16] [17]-- are being (and have been) successively abandoned, since suffering itself knows no such boundaries. Euthanasia for mental illness alone is authorized to begin in March, 2027,[18] euthanasia of demented patients by advance request has already begun in the Province of Quebec.[19]
It would be impossible to imagine a system better designed to maximize the practice of euthanasia. And indeed, that maximization is to the obvious benefit of systemic budgetary interest.[20]
It thus transpires that the vast non-suicidal majority of Canadian patients are left with nowhere to go; no place where they may confidently expect care from professionals who believe that they should be allowed (and even encouraged) to persevere in living. They are forced, instead, to navigate a clinical environment which has become objectively indifferent (if not openly hostile) to their continued survival.[21]
A minimally intrusive judicial authority
As envisaged under a non-medical authority, assisted suicide is completely severed from medical practice. The proposed regulatory body would arise from the Ministry of Justice, structurally distinct from that of Health.
Most importantly, when assisted suicide is not defined as medical care, it confers none of the special obligations associated with that status. The liberty granted is one of permission only. There is no public guarantee of provision. No mandates. No funding. No entitlement of any kind.
To the greatest extent possible, other patients would be undisturbed by required formalities. Actual assisted deaths would occur in designated locations outside of National Health Service (NHS) facilities. No patients --to insist on this crucial point-- would ever be importunately engaged in death-suggestive discussions initiated by doctors, or other staff.
Delivery and Financing: NHS obscurity versus independent transparency
If offered as a medical service by the NHS, all of the work required for assisted death --from information, to evaluation, to provision of service-- would come from doctors and nurses employed by that body. In the absence of new funding, therefore, the full cost of MAID would be carved out from existing programs, effectively cannibalizing thinly-stretched professional resources.[22]
A paradoxical dynamic is thus created whereby money is reputedly saved (by substituting death for care) but where physician availability for traditional medical purposes is nonetheless reduced.
If, on the other hand, assisted death is allowed by permission only, no public costs need be assumed beyond that of the regulatory body itself (and even those might be recuperated, just as fees are charged for motor vehicle registration).
The actual work of evaluation, preparation, accompaniment, and treatment of remains would be performed by non-profit charitable entities, licensed and regulated to that end, whose billing of clients would not be a public concern.
In conclusion
On the principal question, concerning the extraordinary social perils of establishing a legal precedent for the wilful taking of life, lawmakers are hereby earnestly entreated to reject any authorization of assisted suicide whatsoever.
If, however, we are eventually reduced to choosing between what is bad and what is worse: defining assisted suicide as medical care --and providing that service through public medical administration-- creates further grievous and unnecessary harms to the natural interests of the citizen/patient/taxpayer, which might be avoided through a non-medical regulatory framework, and non-governmental service provision.
Regardless, therefore, of any separate concession to death-as-choice, we emphatically demand that the introduction of death-as-medical-care be abandoned; that legislators preserve the integrity of our healing institutions, professions, and clinical practice, “To cure sometimes, to relieve often, to comfort always”.[23]
Gordon Friesen,
President, Euthanasia Prevention Coalition
www.epcc.ca
December 2, 2024 Footnotes:
[1] Preston, Nancy; Payne, Sheila; Ost, Suzanne, Breaching the stalemate on assisted dying: it’s time to move beyond a medicalised approach BMJ 2023;382:p1968 accessed July 22, 2024
[2] Twycross, Robert Assisted dying: principles, possibilities, and practicalities. An English physician’s perspective accessed July 22, 2024
[3] Note on Canadian and Dutch cancer euthanasia as a fraction of all cancer deaths: Terminal cancer is the category in which consent to euthanasia is most frequent (70% of all euthanasia deaths). However, in Canada and the Netherlands where all cancer patients are informed of their eligibility only 10-11% consent to die in that manner.
***
Canada total deaths: 330,380 statista.com accessed Nov.30. 2024
Canada euthanasia deaths: 15280 epcc.ca accessed Nov.30. 2024
Canada total cancer deaths 86700 cdn.cancer.ca pg. 35 accessed Nov.30. 2024
Cancer fraction of all deaths (86,700/330,380) ,26
Canada euthanasia fraction of all deaths .046 (note 2) Cancer fraction of all euthanasia .63 canada.ca chart 4.1a
Canada cancer euthanasia fraction of all deaths (.046 x .63) ,029
Canada euthanasia fraction of all cancer deaths (.029/.26) .11
***
Netherlands total deaths 170,100 statista.com accessed Nov.30. 2024
Netherlands total cancer deaths (2022) 49,790 wcrf.org accessed Nov.30. 2024
Netherlands (2023) total euthanasia 9,068; cancer euthanasia 5105 english.euthanasiecommissie
Netherlands cancer fraction of total deaths: (49,790/ 170,100) .29
Netherlands euthanasia fraction of total deaths: (9,068/ 170,100) .053
Netherlands cancer fraction of total euthanasia: (5,105/ 9,068) .56
Netherlands cancer euthanasia fraction of all deaths (.56 x .053) .03
Netherlands cancer euthanasia fraction of all cancer deaths (.03/.29) .10
[4] Hippocratic Oath wikipedia.org accessed July 22, 2024
[5] Quebec S-32.0001 - Act respecting end-of-life care accessed July 22, 2024
[6] Canada maid law as of 2024 (synthesis) accessed July 22, 2024
[7] Constitution of the World Health Organization accessed Jult 23, 2024
[8] Schadenberg, Alex, Euthanasia being forced on Montreal palliative care home, Euthanasia Prevention Coalition, December 2, 2023 accessed July 22, 2024
[9] Garcia-Santesmases, Andrea, El cuerpo deseado, la conversación pendiente entre feminismo y anti-capacitismo, Ed. Kaótica Libros, Madrid, 2023, pp. 210,211
[10] College of Physicians and Surgeons of Ontario HUMAN RIGHTS IN THE PROVISION OF HEALTH SERVICES September 2008 Reviewed and Updated: March 2015, September 2023 See Section 10 and 12 (not merely a permission, but a positive duty to raise MAID eligibility) accessed Nov. 30, 2024
[11] Collège des médecins du Québec, LE MÉDECIN ET LE CONSENTEMENT AUX SOINS, MIS À JOUR EN OCTOBRE 2023, see section 1.2, appropriate care-decisional process accessed Nov. 30, 2024
[12] Government of Canada Bill C-7 (2021): An Act to amend the Criminal Code (medical assistance in dying), eligibility changed to accept non-terminal patients accessed Nov. 30, 2024
[13] Canada, Special Joint Committee on Medical Assistance in Dying, Febrary 2023, Mature Minors accessed Nov. 30, 2024
[14] Coelho, Ramona Canada’s assisted dying regime should not be expanded to include children, Aljazeera, 16 Feb 2024 accessed Nov. 30, 2024
[15] Lévesque, Catherine, Quebec College of Physicians slammed for suggesting MAID for severely ill newborns, National Post Oct 11, 2022 accessed Nov.30. 2024
[16] (euthanasia of demented patients by advance request) QC Bill-11 (2023) An Act to amend the Act respecting end-of-life care and other legislative provisions , 29.1 and following: Special provisions applicable to advance requests for medical aid in dying" in force as of Oct. 30, 2024
[17] Ferrier, Catherine, Advance directives for assisted death a recipe for abuse Montreal Gazette, May 26, 2022 accessed July 23, 2024
[18] Canada to delay assisted death solely on mental illness until 2027, Reuters, February 1, 2024
[19] see note 17
[20] Schadenberg, Alex, Canada's health care savings attributed to euthanasia, Euthanasia Prevention Coalition, October 20, 2020
[21] Friesen, Gordon, Bad care brings euthanasia and euthanasia brings bad care, Euthanasia Prevention Coalition, May 30, 2024 accessed July 22, 2024
[22] Schadenberg, Alex, How the Ontario government hides the cost of MAiD (euthanasia), Euthanasia Prevention Coalition, June 30, 2023 accessed July 22, 2024
[23] Siegel, Mark David, To Comfort Always , Yale School of Medicine, June 24, 2018. accessed July 22, 2024
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