The Covid-19 crisis has led to more cultural loneliness. Have you called your mom today?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

I have published several articles about the epidemic of loneliness and isolation and how it effects the physical and psychological health of people. Loneliness and isolation also leads to requests for assisted death.

• Loneliness is an epidemic among seniors that requires a caring response. 
• Loneliness is an epidemic that can be detrimental to your health.  
• Being with others cures the epidemic of loneliness.  
• Suicide epidemic exacerbated by loneliness.

A British study found that 22% of seniors, over the age of 65 will talk to only three or fewer people per week. A September 7, 2019 article in studyfinds.org reported:

According to the survey of 1,896 seniors over 65 in the United Kingdom, more than one in five (22%) will have a conversation with no more than just three people over the span of an entire week! That translates to nearly 2.6 million elderly folks who don’t enjoy regular human contact on a daily basis. Perhaps most alarming though is researchers say an alarming 225,000 individuals will go a week without talking to anyone face-to-face.

We can reduce the scourge of suicide and the cultural abandonment associated with assisted death, by caring for and being with others at their time of need. It is essential that people who feel that their life lacks value or purpose, or feel that no one cares, is offered purpose, support and genuine hope from their significant community.

The Covid-19 crisis and social distancing has led to more loneliness and social isolation.

One answer is to call your friends and family. A call to your family and friends can make a difference. Some families are communicating by video over the internet. This is an excellent way to communicate with others.

Your call may be the only call that your mother receives today.

Dutch Supreme Court approves euthanasia for dementia.

This article was published by National Review online on April 21, 2020.

Wesley Smith

By Wesley J Smith

More than 20 years ago, the Dutch Supreme Court approved the assisted suicide of a woman in despair because her children had died. So we shouldn’t be surprised that it has now explicitly approved the forced euthanasia of patients with dementia if they asked to be killed before becoming incompetent. From Reuters:

The Dutch Supreme Court on Tuesday ruled that doctors could legally carry out euthanasia on people with advanced dementia who had earlier put their wishes in writing even if they could no longer confirm them because of their illness.

The ruling is a landmark in Dutch euthanasia legislation which up to now had required patients to confirm euthanasia requests. This had not been considered possible for mentally incapacitated patients like advanced dementia sufferers.

“A doctor can carry out an (earlier) written request for euthanasia from people with advanced dementia,” the Supreme Court said in a summary of its decision.

What the Reuters story failed to mention — and apparently the Supreme Court found to be irrelevant — is that the case in question involved a woman who fought against being killed. Nor does the story mention that the doctor had drugged the woman before starting to euthanize her, and that the doctor instructed the family to hold the struggling woman down so that she could administer the lethal injection. Moreover, the patient had also stated in her instructions that she wanted to decide “when” the time for death had come — which she never did. The termination “choice” was made by the doctor and/or family in violation of the patient’s advance directive.

But why would the Dutch Supreme Court let inconvenient facts get in the way of furthering the Netherlands’ ever-expanding national killing policy that already permits infanticide, joint geriatric euthanasia of married couples, termination of the mentally ill, conjoining euthanasia with organ harvesting, and the lethal injections of people with disabilities?

Ontario MAiD (euthanasia) deaths increase during Covid-19 crisis.

Sign the Petition: Stop euthanasia Bill C-7 (Link)

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Ontario Office of the Chief Coroner has released new data for MAiD (euthanasia and assisted suicide deaths). In Ontario between June 17, 2016 and March 31, 2020, there have been 4888 reported assisted deaths with 199 reported assisted deaths in March 2020 alone.
 
In Ontario there were 1789 reported assisted deaths in 2019, 1499 in 2018, 841 in 2017, and 189 in 2016. 

The new data indicates that there were 570 reported assisted deaths in the first three months of the year with 199 in March alone. The euthanasia rate is sadly increasing.

Sign the Petition: Stop euthanasia Bill C-7 (Link)

Parliament is currently debating Bill C-7, a bill to expand euthanasia in Canada. Bill C-7 amends the euthanasia law by eliminating the "terminal illness" requirement, allowing advanced requests for euthanasia, eliminating the 10 day waiting "reflection" period and it falsely claims to prohibit euthanasia for mental illness.

If Bill C-7 passes without amendments, it will give Canada the most extreme euthanasia law in the world and result in a greater increase in deaths by lethal injection.

A recent CBC Radio show by Duncan McCue, interviewed Stefanie Green, President of the Canadian Association of MAiD Assessors and Providers who explained how MAiD can be done on a patient with Covid-19. Green stated:

"I have provided for MAID on the same day that I've met someone on certain occasions," 

"It's not common … MAID is a process that requires rigorous procedure and safeguarding and is meant to be that way."

Green then explained that "MAID applications can be expedited if two assessing physicians agree a patient is at "imminent risk" of losing their capacity or life, they can forgo the typical 10 day reflection period required by law. Green then stated:

"If they're about to die, or we think they're going to die within 10 days, we actually can go ahead and waive that reflection period and move quicker,"

I recently reported on an article written by Globe and Mail reporter Kelly Grant stating that the Ottawa and Hamilton regions temporarily stopped providing euthanasia "MAiD services" during the Covid-19 pandemic. Grant wrote:

The Champlain Regional MAID Network, which serves Ottawa and the surrounding area, issued a notice on Wednesday that it was shutting down the service in hospitals and homes to prevent the transmission of COVID-19 and to conserve health-care resources. 

Hamilton Health Sciences, a hospital network with 10 sites, has also stopped providing assisted dying within its walls.

It is possible that the MAiD (euthanasia) data will indicate a slowing trend in April 2020 due to Covid-19.

Do you have a personal euthanasia story? Sharing your story may help us prevent other euthanasia deaths. Contact the Euthanasia Prevention Coalition  at: 1-877-439-3348 or info@epcc.ca.

Canadians oppose euthanasia for mental illness and child euthanasia. Canada must reject Bill C-7.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Petition: Stop euthanasia Bill C-7 (Link)

On February 24, 2020 Canada's federal government introduced Bill C-7, an act to amend the Criminal Code (medical assistance in dying). 

Bill C-7 is the federal government's response to the Quebec Court decision that struck down the section of Canada's euthanasia law requiring that "natural death be reasonably foreseeable" to qualify for death by euthanasia (lethal injection).

Bill C-7 amends the euthanasia law by eliminating the "terminal illness" requirement, allowing advanced requests for euthanasia, and removing the 10 day waiting period. It also falsely claims to prohibit euthanasia for mental illness.

Bill C-7, a bill to amend Canada's euthanasia (MAiD) law, if passed without amendments, will make Canada's euthanasia law the most permissive in the world.
 
Bill C-7, appears to be designed by the results of the online survey that was conducted in January 2020. On January 14, I urged EPC supporters to participate in the Canadian Department of Justice Medical Assistance in Dying consultation questionnaire. In my article I stated:

The language of the consultation questionnaire is not great, nonetheless, the questionnaire allows you to leave further comments.

On January 15 I published a Guide to answering the Questionnaire. The guide had more than 19,000 page views.

The assessment of the public consultation on Medical Assistance in Dying provides greater clarity concerning Bill C-7.

According to the consultation indicates that, Canadians don't want euthanasia for mental illness or child euthanasia. The assessment of the public consultation states:

Theme 4 - Concerns with expanding eligibility for MAID

Comments under this theme included concerns with expanding eligibility for MAID to those who suffer from mental illness and mature minors.

A majority of those who provided comments were not in favour of extending MAID to people who suffer from mental illness. They expressed concerns that people with mental health issues, such as depression, may feel that MAID is their only option, when effective therapies could lead to full recovery. Rather than extending the option to terminate lives, many respondents felt that the focus should be on increasing preventative measures, supports, resources, and intensive treatment for people with mental health issues, as well as increasing resources for people with physical disabilities. Some noted that people with mental illness, and those with physical and intellectual disabilities, are especially vulnerable to manipulation and abuse, or may feel like a burden on family, friends or the healthcare system, and suggested different and specific qualifying criteria for these groups.

In contrast, others felt that people suffering from mental illness should be eligible for MAID in certain circumstances (e.g., chronic, severe, disabling, treatment-resistant disorders). Some noted that mental health conditions can result in suffering that is as painful as physical disorders and not respond to treatment, resulting in people making dangerous suicide attempts rather than ending their life in a safe way.

Most respondents did not support MAID being extended to minors due to their state of development and the risk that they would make an irreversible decision and die before their time. Others were in support of extending MAID to minors in cases of terminal and incurable diseases, with proper safeguards in place.

Theme 4 explains why Bill C-7 did not extend euthanasia to children and why the government claims that the bill prevents euthanasia for mental illness. Sadly, Bill C-7 does not prevent euthanasia for mental illness.

I reported, in September 2019, that the Quebec court expanded Canada's euthanasia law by eliminating the requirement that only terminally ill people could be killed by lethal injection.

By eliminating the "terminal illness" requirement, the court decision also expanded euthanasia to people with psychological conditions alone. Canada's euthanasia law states that a person qualifies for euthanasia if:

the illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

Before the Quebec court decision, a person didn't qualify for euthanasia based on psychological reasons alone since the law required that a person's "natural death be reasonably foreseeable." Since the Quebec court struck down this requirement, the law now permits euthanasia for psychological reasons.

Bill C-7 pretends to prevent euthanasia for "mental illness". Section (2.‍1) of Bill C-7 states:

For the purposes of paragraph (2)‍(a), a mental illness is not considered to be an illness, disease or disability.

This statement does not prevent euthanasia for mental illness or psychological reasons since the law specifically permits it. To prevent euthanasia for "mental illness" the bill would need to properly define "mental illness."

The government has previously stated that it plans to have an official five-year review of the euthanasia law starting in June 2020.

The federal government needs to reject Bill C-7 and conduct a proper review of the law, as promised, starting in June 2020.

Petition: Stop euthanasia Bill C-7 (Link).

Eugenics Must Not Be Allowed To Sneak In With Coronavirus

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Gordon MacDonald

Dr Gordon MacDonald, who is the CEO of the Care Not Killing Alliance in the UK has written an insightful article that was published in the Huffington Post on April 19, 2020.

MacDonald writes about how eugenics must not be allowed to sneak into the healthcare system through our response to the Covid-19 crisis. MacDonald thanks the healthcare providers for their incredible response to the Coronavirus but he sends a warning to the British healthcare system about the dark history of eugenics. MacDonald writes:

Doctors will face difficult decisions over the coming weeks and months as the capacity of the healthcare system is pushed beyond its limits. But we must resist these siren voices, because we can’t allow a return to the eugenics movement and its dark past.

MacDonad explains the history of eugenics:

The eugenics movement started in Britain during the late 19th Century, arising in the context of social Darwinism and the theory of the survival of the fittest. It quickly spread to other Western countries. It led to abuses such as the sterilisation of people with mental illness or learning difficulties in the USA during the 1920s. The movement reached its awful peak in Nazi Germany during the late 1930s with the euthanising of disabled people and those who had learning disabilities.

The underlying philosophy was of racial and genetic superiority and anyone who did not fit this model, or that was considered to be less than perfect, had “a life not worthy to be lived”. This dangerous philosophy ultimately resulted in the slaughter of six million Jews and five million other people in the horrors of the Holocaust.

Following the war, eugenics was discredited because of these atrocities.

MacDonald then comments on the resurgence of the eugenics movement. He writes:

However, in recent years, a new eugenics movement has begun to appear with the opportunity provided by scientific advancement to alter the genetic make-up of human beings and to “breed out” disability and genetic conditions. The re-emergence of the idea that some lives are not worth living is being applied to vulnerable people who are deemed to have become a burden on society.

Worryingly this view has been given oxygen by former BBC Today presenter John Humphys, writing in the Daily Mail: “I know I’m among the vulnerable group for coronavirus, but just don’t believe all lives are equal.”

Similarly, Max Hastings, speaking on BBC World at One, stated that the elderly are “becoming a dead weight on the NHS”. Such thinking and sentiments are troubling.

MacDonald continues by commenting on actions by doctors during the Covid-19 crisis:

Already stories are beginning to emerge of GPs contacting their patients with existing health conditions to ask whether they would want a Do Not Resuscitate (DNR) order to be included in their notes.

This might simply reflect a desire to ensure that if one of their patients with another serious medical condition also develops Covid-19, or gets admitted to hospital for another reason, there is no lack of clarity over the patient’s wishes. But whatever the reason, we must be cautious when extending clinical judgements to the subjective measure of quality of life.

We have already heard reports of DNR notices being placed on groups of vulnerable patients, such as those in care homes, in a carte blanche manner and without any consultation with the patients involved or their wider families. This has now been forbidden by the health secretary, and care homes have been instructed to rip up existing agreements. But concerns remain about whether vulnerable people will receive life saving treatment should they be admitted to hospital with Covid-19, and whether they will even be admitted in the first place.

Although such examples do not constitute euthanasia or assisting suicide because doctors are not actively hastening the end of patients’ lives, there is a danger that the same eugenicist thinking can feature.

He then states that disability rights leaders such as Baroness Jane Campbell or Baroness Tanni Grey Thompson have expressed concerns that disabled people are increasingly being seen as “expendable”. MacDonald concludes his article by restating:

While we live through these unprecedented times, inevitably, very difficult decisions have to be taken about who to treat in a context of grossly overstretched healthcare resources. But we must be aware of the danger of changing medicine in a way which would be detrimental to the most vulnerable in society.

In responding to the Covid-19 virus, we must ensure no back door is left open to the dangerous philosophy of eugenics.

Thank you Dr MacDonald

Stop Assisted Suicide by Telehealth

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

*Sign the petition: Healthcare regulations must not permit assisted suicide approvals by telehealth (Link).

Recently, I received an email from an assisted suicide lobby group explaining how assisted suicide can be done during the Covid-19 crisis. The text of the email was based on  interviews with several leading death lobby activists.

This email indicates that assisted suicide by tele-health/tele-medicine is being implemented in US states that have legalized assisted suicide.

On March 20, 2020 EPC reported that the assisted suicide lobby was using the Covid-19 crisis to promote approving assisted suicide by telehealth.

This is not a new idea. In 2019 the New Mexico assisted suicide bill included a telehealth provision. Also the recent bill to expand assisted suicide in Hawaii included a telehealth provision.

On March 26, 2020 EPC reported that a group of  death doctors stated that during the Covid-19 crisis "aid-in-dying" needed to be approved by telehealth. On that same day, an assisted suicide lobby group thanked Congressional leaders for expanding access to telehealth during the Coronavirus crisis.

I understand the need to expand telehealth services during the Covid-19 crisis but assisted suicide is not medical treatment.

Approving assisted suicide by telehealth means that a person with difficult health issues who feels like a burden on others, or is experiencing depression or existential distress, could be assessed, approved and prescribed a lethal drug cocktail for assisted suicide by telehealth without ever being examined by a physician.

Considering the occurances of medical misdiagnosis, is it reasonable to give physicians the right to prescribe a lethal drug cocktail without examining the patient first?

In April 2013, Pietro D’Amico, a 62-year-old magistrate from Calabria Italy, died by assisted suicide at a Swiss assisted suicide clinic. His autopsy revealed that he had been a victim of a medical misdiagnosis.

It is unlikely that the US Department of Health and Human Services (HHS) realized that the assisted suicide lobby would take advantage of the Covid-19 crisis to begin approvals of assisted suicide by telehealth.

I urge you to contact Alex M Azar II, the HHS Secretary at: Secretary@HHS.gov or call his office at: 202-690-7000

Tell Secretary Azar to Stop Assisted Suicide by Telehealth. Assisted suicide is not medical treatment. Regulations must not permit approvals of assisted suicide by telehealth.

*Sign the petition: Healthcare regulations must not permit assisted suicide approvals by telehealth (Link).

Covid-19 crisis demonstrates the need for euthanasia and assisted suicide is abstract rather than practical.

Euthanasia is not an essential service.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Kevin Yuill

Kevin Yuill, the author of the book Assisted Suicide: The Liberal, Humanist Case Against Legalisation, and Theo Boer, a former member of a Netherlands Regional Euthanasia Review Committee (2005 - 14) collaborated to write the article: What Covid-19 has revealed about euthanasia, that was published by Spiked on April 14, 2020.

The authors begin the article by commenting on Covid-19 and healthcare:

There has not been, in living memory, more focus on healthcare, the vital role of doctors, the sacrifices made by nurses, and the wonderful efforts of everyone involved in the sector. Amid the coronavirus crisis, daily heroism, the scale of human loss, and the awful scenes in hospitals underline what is important – and what is not.

Theo Boer

They authors comment on euthanasia and Covid-19 in the Netherlands:

It will surprise some that in the Netherlands, the only dedicated clinic providing euthanasia and assisted suicide has closed. Euthanasia Expertise Centre (formerly known as End of Life Clinic) has suspended all euthanasia procedures. The clinic’s website says that existing procedures have been put on hold and new patients are no longer admitted. The centre – which in 2019 alone ended the lives of 898 patients suffering from cancers, psychiatric problems, early on-set dementia, and accumulated age-related complaints – is willing to make an exception only for those expected to die soon and those who may soon lose their capacity for decision-making.

They comment on euthanasia and Covid-19 in Belgium:

Similarly, in Belgium, Jacqueline Herremans, a member of the federal commission reviewing euthanasia, has noted that there are few resources and even fewer doctors available for euthanasia at the moment: ‘The most important thing right now is that we fight the coronavirus.’

They then comment on euthanasia and Covid-19 in Canada:

In Canada, authorities are also shutting down services. For a process that requires two different medical assessments and witnesses, the lives involved are not worth the risk. According to the Globe and Mail, two places in Ontario, where euthanasia and assisted suicide have been legal since 2016, have stopped providing medical assistance in dying (MAID) because of the coronavirus pandemic (one has since resumed for existing patients and those whose deaths are imminent).

In Ontario, only Hamilton and Ottawa are known to have decided that euthanasia is not an essential service. 

The authors point out that the Netherlands euthanasia clinic state that euthanasia is not a priority during the Covid-19 crisis. The statement from the euthanasia clinic follows an opposite statement last year where Steven Pleiter, the director of the clinic said:

‘If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person’

The authors say that palliative care institutions have not shut-down during the Covid-19 pandemic.

So what has the Covid-19 pandemic taught us about euthanasia? The authors state:

What the Covid-19 crisis has demonstrated is that the need for euthanasia and assisted suicide is abstract rather than practical. In the Netherlands in the 1980s, assisted dying started out as the ultimate solution to impending horrible deaths. In present times, with a high level of care for the dying available in most countries with good healthcare, assisted dying is not about actual deaths, but about deaths that people fear. The reality is that most people die peaceful deaths. But many fear loss of control and find the prospect of others caring for them terrifying. 

Covid-19 brings the reality of death, the necessity of caring for others and being cared for by others, into our living rooms, making the preciousness of all lives and the tragedy of all deaths real. We see the humanity of the elderly and frail; no longer are they burdens to be dispatched from this world, but victims of horrifying disease that all are invested in fighting.

The authors conclude by stating:

"Perhaps, though, we can remember this time when we made huge sacrifices to preserve every life, no matter how frail and vulnerable. We can remember this time when euthanasia no longer seemed necessary."

Thank you Kevin and Theo. Euthanasia is not an essential service and it is not healthcare.

Pressured to die by assisted death.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Candice Lewis

Candice Lewis recently died a natural death.

In August 2016, Candice Lewis, who was 25, while receiving treatment at the hospital was pressured by a doctor to "request" an assisted death.

No one questions that Candice was very sick at the time, but as Candice's mother told CBC news, the doctor pressured her to request physician-assisted death. The article stated:

"His words were 'assisted suicide death was legal in Canada,'" she told CBC. "I was shocked, and said, 'Well, I'm not really interested,' and he told me I was being selfish."

Kevin Dunn interviewed Candice and her mother Sheila for the Fatal Flaws film. (Link to purchase Fatal Flaws) During the interview Sheila said:

Not once did she say to them, "I want to end my life." The doctor came in the next day after he told me about assisted suicide, stuck his face down in Candice's and said, "Do you know how sick you are?" When I got his eye contact we went out in the hallway and I told him, "Don't you ever pull something like that again."

How many situations, similar to Candice Lewis have occurred in Canada and either died by lethal injection or were so shocked by the experience of being pressured that they will not speak about it?

I have received emails and calls about people being pressured to die by MAiD. Recently I received this email from a care-giver stating:

Several weeks ago, in the space of a two week time period, I was made aware of four instances in which nursing staff [in hospitals] ... seemed to be initiating discussion of MAiD with family/friends, and, in the last instance, a patient, without any apparent prior reference to MAiD on the part of the patient.

During my Vancouver Island speaking tour, a man told a group how his mother, who required dialysis, was urged by healthcare "professionals" to ask for MAiD (euthanasia). He said that if he had not spoken to his mother, she may have died by euthanasia.

At the next talk a woman came up afterwards and shared that her father, who had significant health issues, was urged by healthcare "professionals" on several occasions to consider MAiD (euthanasia).

It appears that many doctors and nurses are urging patients to ask for MAiD.

This type of pressure, at the most vulnerable time in a person's life, will lead some people, who would never have otherwise considered death by lethal injection, an option. In fact, it is likely that many people have died by euthanasia after being urged by a doctor or a nurse to do so.

If you have a story or a concern, please share it. Knowledge and awareness will help others to resist euthanasia when they are pressured.

I urge you to be involved in the lives of those who you know and care for. When someone is pressured by a doctor or nurse to ask for an assisted death, you can make a difference in their lives by saying - NO, I care for you, I will not abandon you. 

Euthanasia is not the answer.

Covid-19, Triage guidelines and nursing home deaths.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Nursing home residents, with Covid-19, may be experiencing discrimination by being denied beneficial life-saving treatment. It appears that some nursing homes are not transferring residents to the hospital, even when treatment is available. Some of these decisions should be considered elder abuse.

The disability movement is also concerned that people with disabilities are being denied medical treatment.

I understand that there are times when the person is nearing death and it is not reasonable to transfer the person to the hospital. I also understand that there are times when the hospital lacks the treatment capacity to accept the elderly person. I am concerned that treatable elderly people are not receiving treatment, even when there is treatment capacity.

I was interviewed by OneNewsNow about an article that I wrote concerning the Covid-19 triage guidelines developed by Dr James Downar, the former chair of the Physicians Advisory Council for Dying with Dignity, a euthanasia lobby group. OneNewsNow reported:

Alex Schadenberg of the Euthanasia Prevention Coalition tells OneNewsNow one of the problems is that if a hospital ICU is near capacity, then certain people would not receive medical treatment.

"Basically if a hospital, due to the COVID-19 crisis, [if] the ICU is full, then anybody who … has a medical condition [and] is less likely to recover, or they're over a certain age, they would simply not be given medical treatment," Schadenberg explains. 

But hospitals with a less populated ICU would treat them, and hospitals who are full could transfer patients to facilities that have beds available.

I continued by commenting about my concerns about the growing deaths of elderly people in nursing homes. I stated:

So Schadenberg is mainly concerned about elderly people in Ontario nursing homes

"What we've seen based on these triage protocols is that the decision is not to transfer these people to a hospital, even if they have a significant condition, that is treatable," he reports. "So what you're finding is somebody who's living in a nursing home … if they come down with COVID-19 … they're basically only cared [for] in that nursing home, which is very limiting." 

He says that means they are more likely to die.

Chris Aung-Thwin reported for the National Post that Theresa Tam, Canada's chief public health officer stated that:

the spread of the virus in care homes has been at the root of half of the more than 700 deaths across the country.

Covid-19 nursing home deaths is a national problem. Adrian Humphries reported for the National Post that: 

In Quebec, a police investigation is underway after 31 residents at a care home in Dorval died under what Quebec Premier Francois Legault alleged was “gross negligence.”

Pinecrest Nursing Home in Bobcaygeon, Ont., saw 29 COVID-19 linked deaths in its 65-bed home. In Toronto, 22 residents with COVID-19 died at Seven Oaks.

Eighteen residents at Lynn Valley Care Centre in North Vancouver died with COVID-19; 10 at Almonte Country Haven in Ottawa.

And on and on and on, in communities large and small.

Some would suggest that the large number Covid-19 deaths in nursing homes is due to the age or other health condition of those who died. I am convinced that there are other factors.

Some treatment protocols dictate that residents in a nursing home will not be transferred to the hospital, even when the hospital has the treatment capacity to care for them, leaving them far more likely to die.
 
Many residents or their families have stated, in a health care directive, that they would not want treatment or that they would not want to be sent to the hospital for treatment and that they would only want "comfort care" measures.

Order the Life-Protecting Power of Attorney for Personal Care from Euthanasia Prevention Coalition to protect your life (Link).

It is likely that some of the nursing home residents who died by Covid-19 may have survived with treatment. This is a form of discrimination, agism and elder abuse.

Elderly people need patient advocates. If your parent needs beneficial life-saving treatment that could enable recovery, then you need to demand equal treatment.

These are life and death decisions.

Decision Making Protocols during the Covid-19 Pandemic

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Canadian Medical Association (CMA) approved a Framework for Ethical Decision Making During the Coronavirus Pandemic that is based on the protocol by Ezekiel J Emanuel et al (the protocol) that was published in the NEJM on March 23, 2020 titled: Fair Allocation of Scarce Medical Resources in the Time of Covid-19

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of resources are limited then decisions are made which are often unjust and lack equality.

I am concerned that many Covid-19 deaths in Canada are related to decisions not to provide treatment for elderly people, even when capacity for treating these people existed. The high rates of death at nursing homes is not only based on the age of those who died, but also the decision not to transfer these patients to a hospital capable of treatment. This is why a doctor at one nursing home lamented that all they could do was provide comfort care.

The triage guidelines developed by the disability rights community seem to represent the fairest and most equitable response to providing treatment during a pandemic. (Link to the guidelines).

This article will provide some insight into the NEJM protocol by Emanuel et al that has been approved by the CMA.

The protocol states that the demand for medical resources may be greater than the supply of resources. I will not comment on the projections only on the proposed allocation of scarce medical resources. The protocol is based on utilitarian principles.

The protocol based on four fundamental values that they define as: 

1. maximizing the benefits produced by scarce resources,
2. treating people equally, 
3. promoting and rewarding instrumental value, and 
4. giving priority to the worst off.

They define each of the fundamental values in this manner:

1. Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.
2. Treating people equally could be attempted by random selection, such as a lottery, or by a first-come, first-served allocation. 
3. Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past. 
4. Giving priority to the worst off could be understood as giving priority either to the sickest or to younger people who will have lived the shortest lives if they die untreated. 

The protocol states that none of the fundamental values should be assessed alone but in relation to the other fundamental values.

The protocol then examines who would receive health resources in a Covid-19 pandemic. They state that the four fundamental values would be examined based on six specific recommendations for allocating medical resources in the Covid-19 pandemic, which are:

1. maximize benefits;
2. prioritize health workers; 
3. do not allocate on a first-come, first-served basis; 
4. be responsive to evidence; 
5. recognize research participation; and 
6. apply the same principles to all Covid-19 and non–Covid-19 patients

The protocol explains how the six recommendations work.

Recommendation one focuses on priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. ...There are many reasonable ways of balancing saving more lives against saving more years of life, whatever balance between lives and life-years is chosen must be applied consistently.

A controversial proposal is the withdrawing ventilator support from someone who is currently receiving ventilator treatment. Emanuel states:

Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.

This is simply wrong. There are many people with disabilities, including Not Dead Yet President Diane Coleman, who require oxygen assistance to live. In Withdrawing ventilator treatment is a treatment decisions and should require consent. Decisions to approve or withdraw treatment should be defined as treatment decisions and should require consent.

Recommendation two focuses on the care of front-line health care workers. Healthcare workers are needed to ensure a successful pandemic response, therefore their health is a priority. I agree with recommendation two.

Recommendation three states that when making decision for who should receive care among people with a similar prognosis that those decisions should be based on a lottery and not a first come first served basis. 

I personally don't agree with this point considering that our culture is used to a first come first served basis. Who will decide the parameters of the "lottery" and how is it to be fairly determined? I think that a lottery system will give the healthcare bureaucrat to more control of the system.

Recommendation four suggests that the approach should be based on scientific evidence, which may change over time. Therefore it is suggested that a vaccine, which are preventative, should be given to the elderly and other vulnerable patients first, to reduce the loss of life.

The protocol then states that ICU beds and ventilators, which involve curative treatments, should be allocated to those most likely to survive first. But the protocol goes further and suggests not only those who are most likely to survive but those who are most likely to survive the most number of years.

This proposal denies treatment to older persons and people with disabilities in a discriminatory manner.

As I stated in a previous article:

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment. 

In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care. 

A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment. 

A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.

Recommendation five states that people who are willing to participate in medical trials for Covid-19 research should receive priority.

Recommendation six states that if medical resources become scarce that all medical decision should be made based on the decision making protocol. For instance it states that if there is a scarcity of ventilators and a healthcare worker needs a ventilator for a different condition, that priority should be given.

The pandemic decision making protocols developed by the disability community represent a fair and equitable response to the possible scarcity of resources. (Link to the protocol). I am concerned that the quality of life ethic, mixed with a utilitarian and discriminatory ethic towards people with disabilities will only lead to ingraining decisions that will result in the deaths of vulnerable persons.

These utilitarian guidelines, such as the one designed by Emanuel et al, ingrains negative and discriminatory attitudes to vulnerable populations.

Medical decisions should be made based on Justice and equality (non-maleficence) and not the elimination of the weak.

More information on this topic:

1. Pandemic Palliative care protocol. Selecting people to die (Link).
2. As the threat of triage grows. Disability rights advocacy is needed more than ever (Link).
3. Euthanasia doctor developed Covid-19 triage guidelines (Link).

As the Threat of Triage Grows, Disability Rights Advocacy Is Needed More Than Ever

This article was published by Not Dead Yet on April 6, 2020

Diane Coleman, Not Dead Yet.

On Friday, April 3rd, six leading disability rights attorneys and their respective organizations issued a statement entitled Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. The statement, which helps to interpret the federal bulletin issued a week earlier, was joined by over 90 organizations, including NDY.

One of the most critical parts of the statement focuses on the following language in the federal bulletin:

“[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities. Decisions by covered entities concerning whether an individual is a candidate for treatment should be based on an individualized assessment of the patient based on the best available objective medical evidence.”

The disability advocates’ statement explained this, in part, as follows:

• All persons should be eligible for, and qualified to receive, lifesaving care regardless of the presence of an underlying disability or co-morbid conditions, unless it is clear that the person will not survive in the immediate term or the treatment is contra-indicated.
• Treatment allocation decisions may not be made based on misguided assumptions that people with disabilities experience a lower quality of life . . . .
• Every patient must be treated as an individual, not a diagnosis. This means that the mere fact that a patient may have a diagnosis of, for example, intellectual disability, autism, cystic fibrosis, diabetes, spina bifida, spinal muscular atrophy, or schizophrenia cannot be a basis (in part or whole) for denying care or making that person a lower priority to receive treatment.
• Generalized assumptions must be avoided and doctors must instead focus on the most current and best available objective medical evidence available to determine an individual patient’s ability to respond to treatment. . . .
• . . . [V]alue judgments about the fact that a patient may require extensive support in activities of daily living, uses augmentative or alternative communication, uses a wheelchair, or experiences a psychiatric disability are irrelevant to decisions about whether such individuals should receive life-sustaining treatment.
• Protocols which equate survival with “health” or the absence of chronically debilitating symptoms, risk importing quality life criteria on the triage process.

Clearly, a carefully conducted individual assessment will protect many people with disabilities from being assigned a lower priority to receive treatment. Of course, as disability advocates know from decades of experience, individualized assessment, planning and services are easy words to say but much harder to get in practice. Our community must continue to press for this. It will save lives.

An equal or greater concern is that people whose “individual assessment” suggests they may have a lower likelihood of survival from COVID-19, or (under some triage approaches) a shorter predicted life expectancy for other reasons, would be given lower priority for treatment that could benefit them in terms of potential for survival.

One such “model” policy that is receiving a lot of attention is from the University of Pittsburgh. It calls for prioritizing individuals based on a combination of two primary factors. First, the “Sequential Organ Failure Assessment (SOFA) score (or an alternate, validated, objective measure of probability of survival to hospital discharge) is used to determine patients’ prognoses for hospital survival.” The second factor is “the presence of conditions in such an advanced state that life expectancy is very limited” {less than 1 year or less than 5 years), which is used to characterize patients’ longer-term prognosis. This does not inspire confidence in the policy’s objectivity. It provides for the kind of blatant discrimination that worries many of us (see, e.g., Alice Wong’s moving article in Vox.com).

As the potential for implementing triage policies increases, advocacy will be needed more than ever. For more information, one excellent resource is the DREDF COVID-19 page.