CPSO Interim Guidance on Physician-Assisted Death – Discussion (Consultation Closed)
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Consider a central (MOH or CPSO) referral access service…the requirement to require a referral would not be a reasonable balance for those that contentiously objects. We should require that physicians not impede access and facilitate that access by sending records.
Define contentious objection (which is different than a preference). Korn v. Potter (BC Human Rights) tells us physicians can think their objection is defendable but is actually a violation of human rights (in this case on the basis of disability).
FYI – it’s ‘conscientious’ not ‘contentious’ – ie objection via reason of ‘conscience’.
Patients with advanced illness have considerable fear about potential symptoms near end of life. The physicians most skilled at identifying and treating symptoms near end of life are Palliative Care physicians. It would make sense that every patient requesting PAD meet with a Palliative care physician to review current symptom management and outline what problems can be effectively palliated and those that provide a challenge. It contributes to a process of informed consent. Sometimes knowing a physician is available to treat symptoms as they arise is enough to put patients at ease. This was my experience in treating cancer patients with advanced disease.
I wonder what you are defining as “palliative care physician”. In smaller centres, of which there are hundreds in Canada, there are no specialty level palliative care doctors. Although most of these centres have people on site with considerable palliative care experience.
If any policy is written that mandates a referral to a specialty level palliative care physician, there will be hundreds of centres that would be unable to meet that standard, And thus the assisted death option would not be available to them.
My extensive experience in small centres has left me with the opinion that as death approaches proximity to family in a local hospital is far more important than getting tertiary level service in the view of dying patients. I have had many patients in this state over the last 30 years that I have offered more advanced care in a distant centre, and never once was it ever considered for a moment as an option by them.
MARGARET'S HOUSING AND COMMUNITY SUPPORT SERVICES INC.
I agree… it’s important to ensure that the care received is patient-centered, even at the end-of-life stage. If this means family before ‘treatment’, so be it.
I was referring to palliative care physicians and physicians with expertise in palliative medicine i.e. including family doctors, hospitalists etc. An operational definition could be used i.e. attends to 50 or more palliative care/EOL patients per year.
Although I agree that palliative care physicians would be the most experienced and would be experts at addressing the issues and concerns surround end of life care, I also agree that given our current state in healthcare accessibility and availability that this is unlikely feasible for many.
I am not sure if a patient education guide that provides the opportunity for follow up with an end of life care specialist is available. Also, teleconferencing with patients that lack accessibility may alleviate some of the geographical restraints with accessibility. As examples, I think these may be appropriate starting avenues to aid in involving palliative care to those requesting it for issues such as truly having informed consent.
I imagine that there will be considerable challenge in discussing a “middle ground” between addressing the symptoms and the means used for physician-assisted suicide. For example, patients may fear that they will lose the ability to undergo means to end their with dignity if they no longer meet the criteria during their palliative state. Just another of the many issues that will need to be carefully considered and discussed as we proceed forward.
Requiring all physicians to refer patients for PAS is against the right of freedom of conscience and religion for those who conscientiously object to PAS. Having a list of physicians willing to perform PAS is enough access for those who ask for PAS.
palliative doctors even in small centers are generally very compassionate and passionate about their terminal ill patients an their family that they can provide the needed help towards treatable end of life issues.
1) Please reconsider requirement for a referral. We need to define ‘contentious objection’ (it’s more than a simple preference). Once the threshold of contentious objection is met, even requiring a referral would be a violation of that objection.
Solution here is to provide a central referral / information service through the MOH or CPSO. This would improve quality / consistency and avoid violating physicians long held moral convictions. PAD is unique and ought to be treated as such for the time being.
A central resource could also provide access to second opinions, perhaps data collection and quality of care tools.
2) Draft policy requires a witness but the criteria would seem to exclude people in hospital / LTC from receiving PAD. Who else would witness a request that is not 1)family 2)the physician 3)an employee of the hospital / facility…who else would you require or recommend?
3) Requirement for second opinion is reasonable. What is the action if the opinions disagree. Is it a veto? An opinion? Likewise, should that opinion come from a physician that is familiar with the patient. Can a GP make this decision without the related specialist involved? Can an oncologist/PC doc/neurologist make the decision without involving the GP?
In response to 1) I agree. Conscience rights must be upheld in accordance with Human Right legislation. It would be a grave and serious error to revoke the fundamental right and freedom of conscience, which all people regardless of profession possess.
The word is conscientious, not contentious.
Physicians who have such firm objections to the implementation of legal and medically acceptable procedures, that they are unwilling to refer patients to those physicians who do not or otherwise aid patients to obtain this treatment, really should not be placing themselves in this type of conflict of interest.
It is not a Human Right to care for patients who may require this type of service; it is a privilege.
That being the case, persons of conscience will themselves be discriminated against, as they will not be “allowed” into specific areas of practice in health care. This means not just physicians, but nurses, social workers, and pharmacists, to mention but a few.
That is not discrimination. Conscientious objectors (CO) chose to become physicians; patients do not get to choose if they are in intolerable pain.
Conscientious objection to legal options such as PAD is physician centred, not patient centred care.
It is not discrimination against the blind that they cannot become surgeons. ‘Conscientious objection’ does not allow a physician to avoid giving the patient informed consent; it allows to CO to avoid becoming a physician. An easy remedy for the CO is simply to refer on to someone else (assuming of course they are ethical, and therefore will not allow their beliefs to interfere with even that basic discussion).
When did physician assisted death was ever a medically acceptable procedure,? Remember , SCC only legalized it last year, whereas for the past hundreds of years the Hippocratic oath do no harm was the medically acceptable procedure. It has severed humanity well for all this years. Just because PAD is now legal, does not make it right all of sudden.
PAD is about to become medically acceptable; that’s why we are discussing it. I suspect abortion carries the same objection to the conscientious objector (CO), and that has been medically acceptable and legal for a long time. And every time a CO, because of their own beliefs, places barriers in the way of their patient who wishes an abortion, even as minor as failing to discuss it, or advising against it, for the CO’s own personal reasons (e.g. beliefs), they are practicing in an unethical manner.
The ethical expectation for the CO has been to refer to a physician who will arrange or perform it.
That is the expectation today.
That is the very least they can do. And so it should be for PAD. The CO’s only other option is to avoid this issue from coming up in their practice.
Hippocratic Oath has been out of date for a very long time; certainly, I did not take it. ‘Do no harm’ does not come from that oath.
Assisted death, like abortion, has also been with us equally as long, though only legally in the form of pain relief. Pain can keep patients alive a little longer, and when we relieve that pain, we can and do hasten death.
We do not have the right to tell patients what acceptable medical option they should choose, nor do we have the right to force our religious beliefs on to them by withholding information or otherwise providing barriers to something we think is opposed to our religious beliefs.
Woodstock Hospital
A central access is required in order for this process to move forward. Contentious objection will need a clear definition
Will the OHA be providing organizations with the guidelines and a framework to provide this service? As with Physicians, there will be front line staff who will object to assisting Physicians in this endeavour based upon conscience and religious beliefs.
I abhor this euthanasia, we are NOT dogs your putting down, and if it does become effective in Feb/16 and becomes legal then NEXT thing it will be that older folks will only be able to live to a “certain age” regardless of health or anything else their ‘time’ will be up, and will have to be ‘put down’ whether they want it or not, because it will be an ‘expense’ to keep them, , and if the Christian Doctors won’t do it, then the non-christian doctors will be only too happy to do it for them !! What do the 10 COMMANDMENTS SAY? THOU SHALT NOT KILL !! But the world has changed so much God’s word is no longer means anything anymore …. nobody cares less…. Sad when you look at it but true…..therefore I will fear any doctor and will stay to hell away from them regardless of how sick I am, that’s how much I trust.
I’m not a doctor or anything else, but remember right is right, wrong is wrong, and there is a price to pay for it all regardless of who or what position you hold. Think and think again, this is a human life, what are you thinking……
Each of us has to be guided in this — as in all things — by the dictates of whatever gods he follows. This commenter and I may make different decisions about ending our own lives and both decisions are equally right. I will not interfere with his decision and I ask him not to interfere with mine.
This point of view is called RELATIVISM. It states that you cannot tell me what to do and I should not tell you what to do. Society cannot operate like this. If my conscience told me that I should drive eastbound on the westbound 401, what would happen? “Assisted death” means killing no matter how you look at it.
The example you cite is fundamentally different from the matter under discussion. Your decision about what direction to drive on Hwy 401 is a matter of concern to me because the choice you make could put me, as another driver on that highway, in peril and therefore gives me authority about whether you should be allowed to make such decision. The decision you make about whether to seek physician-assisted death puts me in no peril and therefore is one in which I have merely a spectator interest and no authority.
The example given can actually illustrate the position that the Catholic Physician is in. Canadians supposedly have a freedom of conscience and religion. Tell me that this is so if the facts don’t add up. Approving the killing of a human being under some circumstances can be a choice. The killing of a human being under some circumstances is wrong for a true and practicing Christian. Helping in the killing of a human being under some circumstances is wrong for a true and practicing Christian. (Think about this from a Catholic perspective, for example. Doing something “wrong”, choosing evil over good or whatever you like to call it, can have bigger consequences than just affecting our lives for some more years). My faith prohibits me from taking such actions. How then, in Canada, do I have the freedom to be Catholic?
I am not exactly where to start with this…ultimately this issue boils down to your world view. It is not an issue of care or altruism or compassion…I hope all physicians have this…a pro-euthanasia physician has no more compassion etc…than me, who is against it. The flip side is true…I may not have any more compassion than them. It still ultimately comes down to your world view.
If you come from a Non-Christian/ non-religious world view, your values/goals/behaviour will be very different compared to those that have a Biblical Christian world view. Each group obviously believes their viewpoint is “right” and this will drive their behaviour (ie. take part in euthanasia or not).
My Christian world view, is that Human Life, is different than other animal life, and thus should be treated differently. I believe Human Life is sacred and that it should be held in high esteem (and thus protected). I understand the suffering that people go through and I have helped family members and patients through their suffering and death on many occasions, so I am not oblivious to the suffering. I hate the suffering as much as anyone.
My Christian world view also allows me to see how corrupt we all are in certain areas of our lives…there really is an arrogance of physicians to think that all physicians will actually comply with all the “rules and policies” set up to ensure that this process is legal and ethical. I am not saying that all pro-euthanasia physicians will break the rules…but guaranteed some will. Not all physicians are ethical all the time…if we were, the “CPSO complaints and discipline department” would not be needed. We physicians sometimes break rules and some break the biggies…so mark my words, this “Service” of euthanasia will be abused and some patient will be euthanized illegally.
Anyways, I have been quiet about this issue up until now. The comments by this member of the public has stirred in me the need to talk about this and campaign against it. Thanks!
I am happy to continue this discussion if anyone wants to.
I suggest that your argument would carry more weight if you did not frame physician-assisted dying as euthanasia. It has been clear from the get-go that this would be available only to those who actively sought it at the time — not even to those who had clearly stated that they wanted it under defined circumstances but were later no longer deemed capable of asking for it. Use of the term euthanasia just muddies the water.
Dear MOP: You are within your rights to not ask for physician-assisted dying; you do NOT, however, have the right to infringe on MY rights. Using religion and the old ‘slippery slope’ argument are red flags to many of us. It is my body, and my belief system, not yours, and any observation in countries where the right to die is in place would show you (do the research!) that such a law in NO WAY leads to abuse (the elderly, the handicapped, etc.).. that is a falsity and should not be permitted to bar seriously and terminally ill people who CHOOSE this option. As a senior citizen whose husband died in excruciating pain, I take umbrage at the idea that your religious beliefs trump my rights in a democracy. It is my body. Period. Hurrah for dying with dignity and for the CPSO!
Thank you for pointing out the competing rights. I suppose your comments means you cannot force me to perform a service that is against my beliefs, just as I cannot force you to accept one that is against your wishes (with exceptions outlined in law). Perhaps we could work together to find a way so we are both respected and served.
Choosing to die has been practiced for centuries and it is called suicide, and many unfortunately has chosen this route. The issue is forcing physicians into the equation when it is against their moral conscience to do so.
Please relax. No one is influencing anyone to die. It is a human right and choice.
Amen!
Ask any vet how difficult it is to euthanize an animal. The good ones still go off and have a cry afterwards. Others have become so desensitized that it no longer effects them. For them, that choice is all too easy.
I have 2 concerns about PAD
1) I think we are in danger of desensitizing doctors and, yes, that IS a slippery slope. They are, after all, only human.
2) What right does anyone have to ask another human being to take a life? If people don’t want to live with an illness, suicide is always an option. To ask another human being to kill them is cowardly and selfish. These people don’t care that another human being is going to have to live with what they’ve done for the rest of their lives.
I truly feel for doctors who are going to be put in this horrible situation. I wonder how many of us would like to be put into that situation?
Yes, the desensitizing of doctors is a slippery slope.
I agree with your concerns. We are all aware that significant fraction of soldiers come back form war zones with post-traumatic stress disorder. This does not happen to them because it was hot there or that food was bad but becasue they killed people and watched others killing people. In health environment, we may sanitize the killing somewhat but the agents of assisted death will be at risk of harming their own humanity and act as healers.
Try to imagine what it would like if you could not put down your dog what a horrible thing that might be depending on the situation having to watch it suffer knowing it will die anyway. This is the sort of thing we face every day.
There are times when the greatest honour you can do for someones life is to allow their suffering to finally be over. Far and away the most grateful patients I have had in my career were the ones where I guided them at the end of life.
Certainly there is risk for slippery slope but that cannot be the basis to deprive consenting adults from deciding what is most important in their life.
There is a fundamental difference between murder and a consentual act that is in accordance to someones deepest wishes.
I think the restrictions on who can be a witness are too strict in that they excluded workers at a health facility or care home. As family are also excluded, it may prove difficult to obtain 2 witnesses from outside the facility that have no interest in the case but have knowledge of the patient. I would remove that clause.
I completely agree. Obtaining a witness who satisfies all of those criteria may be a large barrier for some individuals. I would suggest omitting the hospital employee stipulation.
Yes, I also agree that this requirement needs further attention. Although the restrictions on witnesses may be well intentioned, they are not always practical, and may in certain circumstances provide an unacceptable barrier to access.
Employees of the institution in question, particularly those not directly/personally involved in an applicant’s care, should definitely be able to act as a witness.
I agree with previous posters that witnessing requirements could be a barrier.
Perhaps legislation should make it clear that hospital staff who act as witnesses in good faith should not incur liability for doing so.
What will be essential to know is where this “service” will be delivered and by whom.
Will some places be exempt, such as Hospice residences, or religious-based institutions?
What will be the impact on palliative care services.
Could the CPSO please comment on whether it expects facilities which are in opposition to Assisted Suicide/Euthanasia (AS/E) to be able to “opt out”? That is will patients know upon entering a hospital, hospice, nursing home etc, whether AS/E is carried out there or not. I believe this to be important and should be a matter of patient choice whenever possible.
There is still no discussion of advance directive. I am of an age when I and many of my friends are dealing with relatives with dementia, and our feeling is that we would rather have the option of ending our lives rather than living in the humiliating conditions that these relatives are enduring. The emotional costs of prolonging these lives is huge. We need some guidelines as to how competent people can delineate at what point they would like to put an end to it, in the event that we develop dementia. I believe this to be a problem affecting far more people than that of competent adults experiencing intractable suffering.
At the moment, the policy says that advance directives do not count. This is bizarre. We make advance directives so that our wishes will be respected when we are no longer capable of enunciating them. What is the point of such directives if the medical establishment refuses to accept them?
By definition, a person requesting assisted dying has to be competent. This excludes the use of an advanced directive in establishing eligibility for PAD since the patient speaks for themselves.
Advanced directives are at best difficult tools to use and need to be interpreted/confirmed by the POA.
This is dangerous territory and I would support the suggestion that advance directives have no role in AS/E.
In Ontario advance care directives have no legal status. Consent for anything must come from the patient or their substitute or if no one is designated the first person in the hierarcy for consent. So their is no point in talking about advance directives in this context. The supreme court decision also does not allow for advance directives to direct this at present. At best advance directives provide guidance to substitute decision makers to help them make decision for the patient but are not binding.
To my understanding, substitute decision makers can not presently decide for physician-assisted suicide in the event that the patient is deemed not competent/capable.
I can appreciate that addressing this would be very challenging and I suppose time will determine the evolution of including or limiting the role of SDMs in physician-assisted suicide. Perhaps SDM in combination with advance care directives.. or something of that nature.
While I am listed responding as a physician, I am a member of the public as well. In both cases, I believe that when a competent person creates clear, unambiguous advance directives for their care should they become incompetent, those directives should bind those substitute decision makers and those who would provide care of any kind, including physician-assisted death. Many people do not want to be a burden on family and/or society in the event of incapacity–to not follow their wishes could cause them unbearable psychological suffering even before incapacity! These tragic circumstances must be avoided; advance directives including physician-assisted death must be followed in cases of intervening incapacity, in my opinion both as a physician and as a citizen.
Please consider including collaboration with other healthcare providers within your document. Every member of the healthcare team for individual patients will be affected by PAD and physicians do not work in isolation. The collaboration will share the moral residue and provide the opportunity to debrief with colleagues. Bluntly put, you kill someone then go on with your day we all need support!
Dear #9 MOP: What is the ‘moral residue’ of which you speak? The choice of words “you kill someone” indicates that you are not in favour of dying with dignity. Why do you assume others feel as you do? Investigate the responses and experiences of health care workers in countries where this has been in place for years, and see, in a FACTUAL way, whether or not professionals who assist in easing someone’s passage due to their intolerable pain, feel morally compromised. I think what you will find is a sense of rueful release and the thankfulness that they were able to RESPOND to the PATIENT’S request to end the misery. Methinks it is more an issue of control (or your own lack thereof) that you find disturbing. But this is not your decision to make or control… it is the patient’s.
I disagree.
The Veterinarians are cautioning the medical profession that euthanizing their patients (animals) carries an emotional toll. Grief and PTSD (anxiety) are not uncommon in this scenario. So one would be short sighted not to consider the potential emotional fallout for those who carry out assisted dying/euthanasia.
I believe that there are several missing or inadequate elements.
1. No mention is made in the policy about allied health professionals, i.e. CCAC, nursing, pharmacy and chaplaincy. Included with this group should be hospice volunteers, for example.
2. No mention of communication within a team, with other physicians or professionals, is provided. Owing to the sensitivity of this topic, this is an oversight.
3. No mention is made of relationships between physicians, where, for instance, one may be an objector, and another be a provider.
Professionalism demands that each treat the other professionally, non-judgementally, and with respect. Further, comment should be made whether failure to so treat another physician or professional may be grounds for College disciplinary action.
4. More than the abortion issue, the severity of objection to these acts will entail even more emotional response from objectors. The process of generating this draft MUST be modified to ASK conscientious objectors how to balance patient’s rights with those of the professional. While very strongly supporting altruism, dignity, and non-judgemental approaches, nonetheless the present process does not fully allow me to opt out of providing this service, as it requires me to be complicit through direct referral. On the other hand, mandatory reporting within an existing framework would satisfy me, as the report to the framework would generate a much more indirect respect of the patient’s wishes, while not over-riding my beliefs. Strengthening the policy component about referral to an agency would satisfy this suggestion.
5. Duty for self-care is missing from this document, whether for the objector or the provider. Ditto for relations with other professionals.
6. Mention of dealing with conflict between the patient’s wishes and those of their Substitute Decision Maker or “family” is missing.
Recommendations on approaches to this conflict management are required.
7. Recognizing the multiple languages and health beliefs of our patients, there is no discussion of communication where language is a barrier between the physician and the patient, nor is there mention of who pays for this translation, if used.
8. Mandatory reporting to the Coroner needs to be added. At present, reporting of suicide and homicide are required by the Coroner’s Act.
It is hard to see what role the substitute decision maker would have. PAD is to be available only to those judged competent to make and enunciate the decision. There is no role for a substitute decision maker for such a patient. As to family, they have a right to make their views known, but the patient has the right to be shielded from their pressure when making and enunciating his decision.
I was very happy with these comments.
There is no mention of the pharmacy colleagues who will necessarily be involved in the dispensing of the medications.
More attention in the document needs to be paid to how the HCP can respect the privacy of the patient and family while proceeding and involving other team members.
In addition I think there needs to be special attention to those patients without life threatening illness who are suffering and requesting hastened death. Should such patients be offered the traditional palliative care approaches which may have been missing. These may be alternate ways of controlling their symptoms.
This may mean a swing away from the current conservative approaches to the management of chronic pain for instance.
Hello CPSO
Thank you for the draft guideline
- I would suggest that we outline exact protocols instead of providing pubmed links as some of the data is from the Netherlands – doses/names of medications may be different than in Canada and a suggest algorithm would be optimal to ensure standardization
- I see the reason for having a witness that does not have a perceived conflict but practically it may be difficult to find someone who is not a family member, employee of health care institution etc in order to witness and this could result in delays
- I would forsee at the beginning that the assessment of voluntariness and competence could result in significant delays if psychiatry or other consulting services are required – a time line metric to ensure compliance with these assessment consultations would also be optimal – we should be tracking these possible delays as there is no point bringing in legislation that will just result in more suffering for individuals as a result of waiting and being unsure if their request will be acted upon
People are always free to terminate their lives if they want to.
Those that want to – and are physically incapable to do so- represent a very TINY section of society- and the Government could easily train a small group of “paramedic lay life terminators”
I and thousands of other Physicians – the silent majority- will refuse , whatever the Government or CPSO says- to ever KILL OUR PATIENTS .
It was Psychiatrists in Germany between WW1 and WW11 who determined that there existed “HUMAN LIFE DEVOID OF VALUE” — obtained legal support – - and started the GAS CHAMBERS- – we all know the consequences.
Let us learn from history and not repeat its mistakes.
You should be aware that Canadian family physician attitudes are changing rapidly regarding this.
This year a poll of them showed 58% were in support of the SCC decision. 13% were considering their options. Only 29% are against.
There might be another group with a skill set that would allow them to provide this service. But family doctors have the life long exposure and trust of their patients, and the familiarity with most of the drugs used in the management of end of life care.
Your personal views do not reflect the majority
If I were your patient, I would immediately find another physician, one who understands that “first, do no harm” does not mean withholding my right to die, if there is no viable way of remaining alive without pain and suffering. You might be 100% healthy physically healthy, but in jail, and we’d be hard pressed to say “all is well” with you. Similarly, I could have millions of dollars and a hundred good friends, but if I am in constant agony, that is extremely harmful to me. You, by your refusal to help me go peacefully “into that dark night” are the torturer in my final days. Bully for you. Hippocrates weeps.
I respectfully disagree with your statement. Patients seeking physician-assisted suicide are doing so voluntarily. Therefore, your example does not apply.
Furthermore, even if it were true that there is a silent majority that opposes physician assisted suicide, that does not make it “right”. As numerous historical examples have shown….
I think this is a necessary and respectful step in Canadian health care. One of my close relatives had severe Multiple Sclerosis that left them in terrible pain, unable to walk, incontinent, and unable to care for themselves. By their own strongly-held beliefs and several years of consideration as the disease progressed, they traveled abroad to perform physician-assisted suicide. It was a hard time for our family and for them, but it was their decision, and would have been harder to pursue if we couldn’t afford the expense of that travel. Better to make it a more accessible option to Canadians and without the potential legal wrangling that followed.
I think this draft captures all the essential issues and is consistent with what has been done in other jurisdictions in Europe and the US and is not way off what was done or proposed in Quebec–with the likely postponement request from the Federal government being granted there is more time to fine tune the draft–but ultimately it must be congruent with the federal legislation which may allow provinces some flexibility–I concur with and want to emphasize from the perspective of clinical ethics and the duty to serve our patients–that conscientious objection should not and using robust ethical constructs and arguments cannot be used to avoid referring a patient–the argument that by doing so implies that the referring doctor support the decision which they do not which is why they are referring–failure to do so in essence sacrifices the fiduciary obligation of a doctor but more important from ethics deprives the patient from the autonomous agency to participate in decision-making that affects them–so I support the CPSO position that physician cannot refuse to refer elsewhere–so that a patient can engage in the conversation that they want to engage in–and the make the decision in keeping with their persona agency and autonomy.
I disagree.
Not every physician is required to provide every service, but only those within their expertise and chosen field.
Likewise, physicians should not be compelled upon patient request to refer for services that are either clinically not indicated or as in the case of Physician Assisted Suicide/Euthanasia, potentially morally unconscionable. In these cases alternate access routes, outside of direct referral, can be established to ensure the balance between patient autonomy and physician’s conscience rights.
With respect, I must also disagree. You are placing the autonomy of 2 different persons in direct conflict, and using one to over-ride the other.
A generally excellent draft. I have some concerns about opting-out physicians in small communities making referrals that oblige patients to travel far from home, and who should bear the onus for such burden — which could be a significant obstacle to a severely ill patient.
But my main concern is the last two points under the second opinion: “The written request must . . . include the signature of
two witnesses who can attest that the patient is capable, acting voluntarily, and free from coercion.
The College advises that one of these witnesses not be someone who is: the attending or consulting physician;
a relative; entitled to any portion of the estate; or an owner, operator, or employee of a health care facility where the patient is receiving treatment.”
On first blush this seems like a wise protection. (Though, incidentally, it should be signatures in the plural.) It is easy to see how any of the listed parties might be perceived to have a conflict of interest.
But who is left? The witnesses must be intimately aware of the patient’s mental condition and of the process leading up to the decision. Whom does the patient have to enlist in the process to achieve an acceptable witness? A lawyer? A neighbour? A patient in a nursing home might well not have a neighbour who was a credible witness. A third physician? How would any of these know that there had not been coercion at some stage?
I do not have an answer, but until I do I urge that this criterion be examined further.
As a Coroner for the Province of Ontario, and as a conscientious objecter to physician-assisted suicide, I would note that the Coroners Act needs to be modified to allow a new “Manner of Death”. Under the current act, only Natural, Homicide, Suicide, Accident, and Undetermined are the categories specified.
If a physician administers a deliberately lethal dose of medication, under the current Coroners Act the manner of death would be Homicide. If a physician prescribes sufficient medication, and the patient takes an overdose, then it is a Suicide. In the interests of transparency, I think a new category – Physician Assisted Suicide – needs to be added. The name of the physician involved should be mandated to be reported in such cases, in the interests of accountability. I will not call a spade anything other than a spade. Classifying such deaths as “Natural”, even if they involve a terminal disease, is a lie.
My Final Report on any death investigation is available to the family of the deceased. The cause and manner of death should be spelled out plainly for them, and not be disguised by euphemism. The families deserve no less.
It is my understanding from following Bill 52 in Quebec that they are looking at this from another perspective. Since they believe that suicide as defined by the criminal code has not occurred. And that the assisted death path is really just another palliative care option.
i interpret their advice to physicians filling out death certificates that this will continue to be a “natural” death caused by the illness which was being treated for example ” metastatic carcinoma of colon”
That is not to say Ontario might take another view of this.
This is an excellent point and definitely needs to be brought forth.
I, too, as a palliative care consultant have been puzzled by this issue and how a death by PAS or PHD or euthanasia could be reported as a death by natural causes. I am concerned about what I would put onto the death certificate as the cause and the antecedent cause whether or not it was myself that prescribed the deadly dose of medication(s). I am very much worried about applying medical solutions to existential problems like suffering and harken back to the work of Eric Cassels…..
Thank you for taking this important initiative on this extremely difficult issue. I highly respect opinions on both sides and appreciate the emotional gravity of the discussion.
I notice in the “Second Request” that a signature is required on a request written by the patient. Many patients at this stage of their illness might not have the fine motor function to be able to write the request or provide a traditional signature. Equivalent alternatives need to be considered so as not to discriminate against patients who have a motor disability and are yet of consenting mental function.
I also agree with the comments on the limitations on witnesses. Thank you.
My first objection is to the term Physician-Assisted Death. Most, if not all physicians “assist” patients in their journey towards death, but do not HASTEN their death. What we are actually discussing if Physician-Hastened Death. The ACTIVE termination of a life. Palliative care, on the other hand, is PASSIVE process of “allowing a natural death” by focusing on the comfort needs of the patient and their loved ones. The Canadian Palliative Care Association is very articulate regarding this distinction and CPSO should listen very carefully to this.
The document should be retitled: Guidance on Physician-Hastened Death.
My other concern is about the CPSO trampling the rights of physicians to be conscientious (not contentious!) objectors. This is based on the concept of Moral Complicity. If physicians are REQUIRED to make a referral for physician-hastened death, while they will be exonerated from any legal culpability in the death of the patient, they are still morally culpable.
A good analogy would be the current state regarding abortion in Ontario. Currently a referral for Abortion is not REQUIRED in Ontario. Patients can self-refer. What they do need is a copy of their BHCG and a recent ultrasound (at least this is what is required in London) and then they can go to the “Family Planning Clinic” at the hospital and arrange an abortion if they so wish. In the process leading up to that the family doctor could/should review all options regarding this pregnancy so that the patient can make an informed decision. This process is an Inferral not a Referral. It fulfills the responsibility of the physician to review all options regarding the decision and assists them in collecting information so that they can enact that decision but does not insist the physician is Morally Complicit in the ACT!!
Therefore I think the same paradigm should apply to Physician Hastened Death. It would require an infrastructure be set up (ie a list of contact information about MDs who would be willing to hasten death). The INFERRING physician could then provide the patient with appropriate copies of medical information supporting the existence of the condition they find “intolerable” and letter stating that the physician and the patient reviewed all options for treatment. Then the patient could contact one of the Death-Hastening physicians and begin the process with that physician.
This is NOT JUST SEMANTICS!! I feel these “clarifications” more appropriately clarify the process. It allows the physician to fulfill the requirements of the Hippocratic Oath and stay within the guidelines of Moral Complicity.
This is a very slippery slope. We need to be very clear about what we are discussing.
These are excellent points. I object to human euthanasia and I object to being required to refer to someone who does not object. Morally, they seem to be the same thing to me. Abortion is a perfect example, as mentioned by the physician above.
I do not want to be forced to refer.
I also agree with this suggestion.
Physicians should not be obligated to refer for a service they find morally unacceptable.
The above suggestion comes much closer to a balance of patient and physician rights as suggested by the Supreme Court in Carter.
As for the name… well in the Netherlands they call it Physician Assisted Suicide and Euthanasia which are more accurate and less likely to muddy the distinction from palliative care.
I agree with the above suggestion. It attempts to more appropriately balance the rights of patient autonomy and physician conscience as suggested by the Supreme Court in Carter.
As for the name….in the Netherlands they call it Physician Assisted Suicide and Euthanasia which I believe to be more accurate and maintain a clearer distinction with Palliative Care.
I would like to point out the current policy in Ontario re Professional obligations and Human rights. It is not written in a form that supports what you attest in my opinion.
ii. Ensuring Access to Care
Physicians must provide information about all clinical options that may be available or appropriate to meet patients’ clinical needs or concerns. Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.
Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health-care provider must be provided to the patient. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.18 The referral must be made in a timely manner to allow patients to access care. Patients must not be exposed to adverse clinical outcomes due to a delayed referral. Physicians must not impede access to care for existing patients, or those seeking to become patients.
The College expects physicians to proactively maintain an effective referral plan for the frequently requested services they are unwilling to provide.
It seems to me that we have to understand the difference between an inalienable right, right to life, conscience etc and an external right (euthanasia). An external right is more political. Can it be possible that a limited class of people’s external right potentially trump the inalienable rights of life to others? Look at the Netherlands, involuntary killings by physicians who have never been prosecuted. It is reasonable to expect this will happen. Secondly, we should not redefine Companssion, our ability as physicians, to suffer with our patients as our ability to put them out of their misery. They are not objects,statistics or cases. As a physician who does palliative care, who is inspired by his patients who give him the desire and energy to make sacrifices, friendships, experience the tenderness, connectedness, affection and empathy that we both experience. Doing away with compassion you do away with civility and by offering PAD/euthanasia you risk the option of Palliative Care. Why do it ten?
I find your argument confusing.
1. No one is infringing the patient’s right to life. It is only the patient who can trigger his PAD. It is his right to decide when to die that we are talking about.
2. Your willingness to suffer with your patient is praiseworthy. The difference, it seems to me, is that you get to decide how much of your patient’s pain you want to suffer. By your argument, the patient does not get the right to decide how much of his suffering he wants to participate in. You want to decide that for him. Is this patient-centred care of physician-centred care?
A physician who objects to referral for abortion is not obligated to refer, but they are obligated to inform the patient of her options, which must include informing her of where she can seek such service. This does not mean you are complicit in the patient’s decisions and acts. I interpret a request for assisted death to a physician who objects would carry the same obligations and exoneration.
I think the point that is not coming through is one of personal conscience and belief, i.e. that sending the patient to doctor X is, by the objector, seen as complicity in the act and therefore, objectionable. I would repeat my earlier suggestion – having outlined the underlying principles of respect, being non-judgemental, compassion, altruism, and timeliness of response, the CPSO ASK the conscientious objectors, like me, what process would be satisfactory to them, as some sort of action is required. The question to us objectors is what action(s) may be acceptable. My fear, right or wrong, is that failure to take this element into account will potentially dissuade individuals of similar beliefs to mine, from becoming any sort of health professional. In the Canadian setting of diversity, this element would be lost.
Sadly, as with the Professional Obligations and Human Rights discussion, I see the CPSO is going through the motions and has no intention of actually listening or regarding the opinion of its membership. I entered this profession with the “do no harm” philosophy of the Hippocratic Oath which this policy negates. It also negates the character qualities the CPSO states are so important by stating our moral beliefs (which is what makes us moral entities) are not germane to the discussion. Assisted suicide is a cop-out for good Palliative care. I will continue to provide the latter and will not participate in a process that is fundamentally bad care.
People are moral free agents and have the right to end their life but no person, government,or organization has the right to cause another to participate in the process. If a physician and patient have a disagreement, the patient is free to look on their own for a physician whose moral views align. It is immoral to suggest the physician divest themselves of their character to meet the wishes (not need) of the patient.
It is ludicrous, as the policy suggests that there would be an “urgent” need to end one’s life that necessitates a referral and then have a 15 day waiting period. If it can wait 15 days then the patient can find their own physician as well.
I agree. I participated in the CPSO process about Professional Obligations and Human Rights and the majority of physicians objected that it be mandatory that a physician provide an “effective referral.” But that made no difference. If society agrees this is a core human right then what is the problem with setting up a centralized place where people can go to get this (as exist with abortion with regional centers where people can self refer.) It rather astonishes me that for centuries the medical profession agreed that to do this would be immoral and now we are willing to sanction a physician for refusing to participate in it? You may disagree but you may rue the day when the Supreme Court says you have to do something that violates your conscience.
Although it is the right of an individual to request Physician-Assisted Death, and I think there are circumstances when the request should be granted by a physician out of compassionate care (doing them less harm than their remaining alive, so PAD is not *necessarily “cop out for good palliative care”), I agree with you that “if a physician and patient have a disagreement, the patient is free to look on their own for a physician whose moral views align” with the patient’s.
Totally agreed!
The major issue with the draft policy is that it does not protect the human rights of physician conscientious objectors. Patients and physicians alike share inherent rights of the Person. No one should have the authority to force someone to kill another human being against their conscience (yes, including in an “emergency”). This is a fundamental human right. I urge the CPSO to amend the policy to this effect before it is finalized.
Sincerely,
A Canadian Physician
I am so proud that the CPSO has tackled this issue and is on the forefront as far as guidelines in this area. It would be an ideal situation in my mind were this to be assumed by the Palliative care teams. It would eliminate the need for a central referring agency and it might relieve the referring physician if they are conscientious objectors from feeling complicit as he/she could still hold the hope that the best of palliative care might be adequate and prevent the assisted dying. . Most of these patients facing unbearable suffering from a grievous and terminal illness should be referred to a PC team anyway. I understand that there will be PC physicians who do not want to be involved but surely each team could come up with 2 physicians willing to participate. I find the vetting process a bit onerous. Why would 2 witnesses be necessary for the first assessment? There will be another opportunity for the patient to change their minds( the visit to the 2nd physician) and perhaps one witness would suffice at the time. Perhaps it is important enough that a legal representative should witness the signing. Keep in mind that this will be a rare request for the most part. I too would like to see the development of guidelines for the medications used in the procedure (whether self administered or physician administered, though I understand that this is probably not the mandate of the College.
The trouble with this is that there are many people who form those palliative care teams that are conscientious objectors. Indeed this occupation tends to attract the religious.
I suggest (as have many others) that we a have a central referral service and a voluntary list of killers. (Although don’t be surprised if the number of doctors on the list dwindles. Facing death every day is tough enough – knowing you caused it would likely be even tougher for many.)
I would guess that the writer who submitted this above is NOT a Palliative Care Physician. Those of us who are are astonished by the expectations of our colleagues that they expect this of our specialty!
My own motivation over 30 years as been to provide excellent whole person palliative care which would be an option to euthanasia/PAS. Suffering is a very complex experience and not truly amenable to a simple medical solution. We can silence the sufferer without changing the suffering.
Those of us in PC are struggling with how to approach this. Should we provide excellent PC options (which under the current SC decision the patient has no responsibility to accept) and then “abandon” the patient to others who would euthanize them OR should we journey with them through the process of euthanasia/PAS?
This is a major dilemna for us.
Truly the responsibility for PAS should be seen to be equally borne by family physicians, specialists and indeed all physicians who are not conscientious objectors.
Though many PC physicians may be seen to be “religious” in some derogatory sense…….because we have tried to provide whole person care for decades we have needed to explore physical, psychological, social, spiritual means to do this work. Without some spiritual roots the work would seem to lack meaning and resilience.
I am a palliative care physician. I love this work and do it well. I object to being told by the CPSO that I must refer a patient for physician assisted death if they so desire it based on the guidelines. I believe this is murder and it violates my rights as an individual. Also it violates the oath I took on graduation from medical school. Other countries that have physician assisted death do not require the physician to refer a patient against his or her moral conscience. The CPSO has done a great disservice to it’s physicians by making this a standard of care. As a result of it, I will be giving up my palliative care work as soon as the law comes into effect.
Of course the physician who conscientiously objects must not impede the access of a patient desirous of this process. Those of us who at all times endeavor to put patients first would find this abhorrent and that is what should be called into account.
I agree with the above and moreover am saddened by the news that my colleague, and others like him, who will be forced out or feel compelled to leave Palliative Care.
This in itself is enough reason to cause the College to reconsider the obligatory “effective referral”. I implore the College to listen to people like my colleague above and modify the policy.
Although the College will likely be in the position to formulate a policy on this. I suspect it will be done in a fashion similar to the current “Professional Obligations”policy. On one hand physician manpower issues will influence the decision. But in my opinion satisfying the Canadian Charter of Rights and Freedoms will play a larger role. Physician religious objection will drop down a tier of significance if there is any threat to patient wellbeing. Of the many patients who have asked me for accelerated death over the years. All of them were having big symptoms, that even a days delay would likely be considered unacceptable by many observers.
A bit early to be digging in hard on something that hasn’t happened.
The first fundamental freedom listed in the Charter of Rights and Freedoms is conscience.
Autonomy, although implied, is not named.
Objectors are asking for direct patient access to assisted death so as to reconcile these two opposing “rights”. This need not cause a delay and in fact may very well avoid it. Patients won’t have to go see their doctor before initiating the process. Effective referral does not reconcile these rights. This was strongly argued at the time of the Professional Obligations Policy consultation but overruled. Will the College now re-consider?
I am saddened to hear that some physicians with your expertise feel that way. That means that you are putting your own fears and beliefs before your patient’s needs, at a time of extreme need. You should (and I’m sure do) know that the best of palliative care remains incapable to relieve certain patient’s pain, and you would just insist that they suffer to the bitter end?… and you are palliative care specialists?…
It would appear to me you are making a principled decision to resign. Which will likely save you a lot of grief. If i had a physician who declined this service to me when I was under the impression my immediate cancer symptoms were unacceptably controlled and preferred an immediate exit. While in that vulnerable state, if timely referral to an accommodating physician was refused. I would ask my family to lodge a complaint to the college, and a concomitant civil action after my death.
As I read Carter vs ‘State, once this becomes law. The ownership of the rule set surrounding death gets shifted from the doctor to the patient. We have not seen the final wording on timely referral, but regardless of the wording. If anyone has symptoms that they think are being neglected, religious rights will be in conflict with personal rights to safety and will leave such objectors open to Charter challenge.
In my opinion
Exactly!
Why would the College have a policy that is sure to lead to this kind of confrontational stand off.
Would it not make sense to have you or your delegate access what you desire independent of a doctor’s referral.
How can you claim to “at all times endeavor to put patients first” when in fact you are trying to force your values on other competent adults, and refusing to respect their wishes? That is not putting patients first, it’s putting yourself first. The SCC ruled quite clearly that denying people who are suffering the right to a humane death is violates their basic human rights. You are not respectful of your patients, you are simply trying to maintain your former control over them.
There needs to be a way for patients to access a PAD physician and system, but allows palliative care MD’s who conscientiously object, to avoid a referral. This is a serious issue and CPSO must respect the conscience and ethics of its members, especially in life and death matters. Please reconsider requiring a referral. Some palliative physicians will stop practicing palliative medicine if the policy goes through as is.
I couldn’t agree more!
The Supreme Court said to reconcile the rights of patients and doctors in this matter. There are other ways to accomplish this which are more prudent and less conflictual than an “effective referral”.
Would the CPSO please explain why they are insistent on following this course of action.
Should there be assessment to rule out major depression / other axis 1 illness?
Apart from the 15 day wait, consider a longer ‘cooling off’ period between onset of the condition and request for PAS (consider cases of spinal cord injuries for example), this in conjunction with a psych assessment would prevent decisions made in desperation.
In addition to the above, ensure that the patient has had access to the full spectrum of care available for their condition, whether medical, surgical, psychiatric or palliative, prior to granting any requests for PAS.
This brings up the conundrum faced by our colleagues in Psychiatry who spend considerable time and effort trying to “treat” suicidal patients.
What now of a person who suffers intolerably with a refractory depression and requests assisted suicide?
Are there safeguards in place sufficient to deal with this situation?
I find the suggestion that competent patients with chronic depression or other tenacious mental distress should somehow be discriminated against when it comes to physician assisted suicide deeply offensive.
I think this prejudiced viewpoint stems in part from two common misunderstandings about mental health that need to be debunked here and now.
Firstly, many subscribe to the misguided idea that those with chronic mental health issues somehow suffer less than those with physical issues. This is, of course, completely false, as is the notion that conditions like depression can be easily “treated”. Nothing could be farther from the truth, and most sufferers (approximately 70%) will continue to be symptomatic for the remainder of their lives, regardless of whether they receive ‘treatment’ (and every competent patient has the right to refuse treatment should they determine it is not in their best interests).
Almost all those who suffer from depression are mentally competent to make reasoned decisions regarding all issues involving their health care, including PAS.
Anti-depressant medication brings remission for less than one in three patients, and this remission is almost never permanent. (Also, some of the drugs used cause side-effects that are arguably worse than the disease itself, just as is the case for anti-psychotics).
Any prospect of remission as a result of ‘talk therapy’ has similarly dismal success rates in the long term…hardly surprising if we are dealing with a physiological illness.
The SCC was quite clear that those with mental health issues are not to be excluded from access to physician assisted suicide. Their ruling was as follows: the patient must have a ‘grievous and irremediable condition’ (and depression is often that), including ‘illness, disease, or disability’. One certainly need not suffer from a terminal illness or a physical illness to qualify.
The client also must be ‘experiencing suffering that is intolerable in the circumstances of their condition’. As everyone experiences suffering differently, and has a different tolerance regarding what level of illness and disease is acceptable to them, it seems obvious that ONLY THE PATIENT can possibly determine when they have had enough. This is equally true for mental or physical pain.
So, to answer the above question about what should occur if a person ‘who suffers intolerably with refractory depression and requests assisted suicide’: well, the same thing should happen with this client as with any other. Ask yourself whether the person meets the SCC criteria (not your personal criteria). Obviously they do. Therefore, as long as they are a competent adult, they should receive the same access to PAS services as any other person. Failure to provide it would be a basic violation of their human rights. Period.
Agreed. Too much of this discussion seems to put physicians’ interests first and patients’ interests second. The SCOC has told us that that approach is too yesterday.
I agree that a central (MOH or CPSO) referral access service is a great solution to this difficult situation. It would balance the rights and autonomy of both patients and physicians.
Dear Sirs
I object to the following statements -
An effective referral to another health-care provider must be provided. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician or agency.
Providing a referral to a non-objecting, available, and accessible physician or agency is tantamount to me providing the service myself and violates my rights.
I swore the Hippocratic Oath that, in part, states that I won’t give poison to patients, nor will I counsel anyone to do so (by memory). This isn’t a personal or a religions objection so how is it that I advise patients who may request death.
Clearly you are not a medical oncologist.
What this and other guidelines seem to have missed is recognizing from other jurisdictions that the majority of assisted death results occur in elders with advanced disease usually cancer, with intractable pain.
As a Canadian physician with full spectrum practice including end of life care, for 33 years I support this observation. Over my years, I have never had a request from a younger patient with a chronic disability such as ALS for assisted death. But when given open ended options for care at the end of life with advanced cancer with rapidly multiplying and increasing symptoms. I have had many patients request this service. It has been difficult under current legislation to be putting my incarceration fears and needs ahead of my patients, but they have been largely understanding my avoidance of 14 years in jail.
This leads me to want to address one of the most glaring inadequacies in this draft policy, which is the topic of cool down periods.
For a 40 year old with ALS and years of life in front of them. A cool down period of a week or two is of little consequence.
But; for a ninety year old with advanced metastatic cancer vomiting up feces, in pain from several sites, no curative options, and very few comfort options allowing normal cognition. If it is their choice to exit with dignity today, any cool down period of over a few hours is inhuman in my mind.
Perhaps the guidelines could be written to reflect this concept. The duration of cool down periods could be pro rated proportionally to the duration of life expectancy at the time of the request for the service. (e.g., if the duration of life remaining is hours or days, the cool down period needs to be very short. If it is a depressed 18 year old with a 70 year life expectancy a long cool down period and some extra assessments might be appropriate)
Given my experience correlating well with the real life experiences of other jurisdictions, I wonder why you have written the shorter cool down periods in such a prejudicial fashion, recognizing they are likely going to be the norm.
I think you make a great point about a pro-rated cooling off period based on the acuity of the illness and how many projected life years are at stake.
In regards to deliberate iatrogenic homicide:
I think the Supreme Court erred in implying physicians should be the providers of assisted death “services”. From http://impactethics.ca/2015/03/01/the-supreme-court-of-canada-decision-allows-for-the-prescription-and-the-syringe/ I have extracted the following:
First, at the trial level in Carter v. Canada, Justice Lynn Smith carefully and clearly defined the terms for her decision:
[39] “Assisted dying” and “assisted death” are generic terms used to describe both assisted suicide and voluntary euthanasia. “Physician-assisted death” and “physician-assisted dying” are likewise generic terms that encompass physician-assisted suicide and voluntary euthanasia that is performed by a medical practitioner or a person acting under the direction of a medical practitioner.
And (edited for EMPHASIS)
Second, the Supreme Court struck down two provisions of the Criminal Code: section 241(b) and section14. Section 241(b) expressly prohibits assisted suicide: “EVERY ONE who (b) aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.” Section14 effectively prohibits voluntary euthanasia: “NO PERSON is entitled to consent to have death inflicted on him, and such consent does not affect the criminal responsibility of ANY PERSON by whom death may be inflicted on the person by whom consent is given.”
Since the relevant Criminal Code sections use the all encompassing terms “Every One”, “No Person”, and “Any Person”, the Supreme Courts should have stuck with “Assisted Dying” and “Assisted Death” and left “Physician” out of the discussion. The provisions struck down applied to ALL persons in Canada, and thus it is not longer prohibited for ANY person in Canada to aid or abet another person to commit suicide or to inflict death upon that person with their consent. The court only struck down existing law, it did not create new law, NOR CAN IT.
The Supreme Court did not order physicians to provide Assisted Death & Dying services, they only removed the proscription against doing so. Do all physicians perform circumcisions? No, nor are they obligated to (though perhaps in some jurisdiction non-providers must now refer to providers). Do all physicians perform ELECTIVE abortion? No, nor are they obligated to (and throughout the 20+ years I have been practicing patients have been able to arrange consultations for such on their own – a formal referral only slightly raises the fee OHIP pays). The scope of an individual physician’s practice has been left to the practitioners choice, whether based on training, recency of performance, economic interest, or conscience. It should always be so.
So since Any Person will soon be able to aid or abet another person to commit suicide or inflict death upon that person with their consent, here are some suggestions of persons who could fulfill that role:
a. Euthanasia Advocates (whether MDs or other) should be able to find willing persons amongst themselves to provide such “services”.
b. Hitmen “easing into retirement” and away from legally proscribed killing, although they may need training in “cleaner” methods. They might find themselves sleeping better (assuming they ever have disturbed sleep from their work).
c. ELECTIVE abortion practitioners who are already accustomed to ending human lives. They too will need to learn other methods, and may also sleep better when the requester and victim are the same. If forced to refer to an MD, that is where I will refer such requests.
d. Veterinarians might be the most natural provider as they already have the training and only doses would differ. Euthanasia proponents have long argued that their pets had access to more “compassionate” end of life procedures than they.
e. Pharmacists could be allowed to dispense a lethal oral cocktail directly to the patient, at their request, without prescription, with the lethal element containing a digestion-resistant serial number “labelled” nano-substance for identification, if for some reason it is administered to someone other than the patient.
Now, it appears the CPSO got some things wrong in its statements on the subject.
You wrote “Carter v. Canada, lifts the blanket prohibition on physician-assisted death.”
Carter v. Canada lifts the blanket prohibition on any assisted death. It does not require physician involvement. The College has swallowed someone’s agenda. The College is not leading, but following.
You wrote “The decision legalizes physician-assisted death …”
The Act made such actions illegal. The decision means such acts are no longer illegal. For such acts to be legal requires legislation specifically stating such acts, with or without conditions, are legal. There is a difference. For something to be legal or illegal requires the existence of law. Where law is absent there is neither legal nor illegal.
In the draft, you wrote:
15 … February 6, 2016 …
17 On this date, …
18 … physicians will be legally permitted to assist …
Actually, such a statement is incorrect, and should instead read “physicians will no longer be legally prohibited from assisting …”
In the draft, you wrote:
52 • Demonstrating professional competence
I have not been trained to kill patients, so to do so intentionally would be outside my scope of practice, and to practice outside my scope would be unprofessional. This situation should likely be currently true of ALL Ontario physicians, that killing patients is outside our scope of practice.
In the draft, you wrote:
68 … . At this time, the College advises that
69 Ontario physicians should only provide physician-assisted death to residents of Ontario, who are
70 insured under the Ontario Health Insurance Plan (OHIP).
Does the College advise Ontario physicians to only provide traditional physician services to OHIP covered Ontario residents? Does the College not expect its licensees (euphemistically referred to as members) to provide services to patients covered (more or less) by other provincial or private health insurance plans, to self paying patients, and in emergency situations to save life, limb or senses those from whom payment could be in doubt? Is the College two-faced?
In the draft, you wrote:
158 … . The SCC noted that the Charter rights of patients and physicians would have to be 159 reconciled.
Has the College trampled physician rights in being so obviously “progressive” in its position. Not all change is progress.
In the draft, you wrote:
168 … . Physicians
169 must not impede access to care,
To impede, or hinder, is an action. Not assisting is inaction, and is NOT impeding.
In the draft, you wrote:
174 … . In the course of communicating an objection, physicians must not express
175 personal moral judgments about the beliefs, lifestyle, identity or characteristics of the
176 patient.
A statement that the physician regards a particular ACTION as wrong or contrary to the patient’s best interests would not run afoul of those criteria.
In the draft, you wrote:
178 • In order to uphold patient autonomy and facilitate the decision-making process,
179 physicians must provide the patient with information about all options for care that may
180 be available or appropriate
So a physician is not obligated to provide information about options he or she judges to be inappropriate, or for various reasons “not really an option”.
In the draft, you wrote:
181 Physicians must not withhold information about the existence of any procedure or
182 treatment …
What if the physician choses not to mention the existence of something the physician deems inappropriate? Of course, a physician could not really be faulted for not knowing.
In the draft, you wrote:
184 • Where a physician declines to provide physician-assisted death for reasons of conscience
185 or religion, the physician must not abandon the patient. An effective referral to another
186 health-care provider must be provided.
If the reason a physician declines is OTHER than conscience or religion there is thus NO requirement to refer?
Why require referral to another HEALTH-CARE PROVIDER when the lack of law means NONE are prohibited and ANYONE willing could provide the “service”. Perhaps instead write “assisted death provider”.
Second, does the College consistently encourage this in regards to other procedures? What is College policy in regard to circumcision? Must a physician who has been habitually opposed to circumcision refer parents who seek this for their sons? Has the College published statements to that effect? If the College does not so insist in regards to circumcisions then why should it so insist for assisted death provision or any other procedure?
Finally, in the draft, you wrote:
” the College expects physicians to make reasonable efforts to remain apprised of resources that become available”
Some regard the use of marijuana as beneficial, whether casually, recreationally or regimented and medicinally. Perhaps a physician’s children think so. Should that physician thus then make reasonable efforts to remain apprised of sources of marijuana for his children regardless of the physician’s conscience or religious views of the use of marijuana? (Indeed, if (s)he know (s)he may be better able to steer the children away from such providers, and would not be faulted for doing so.) Is the College consistent in applying the “principles” and “guidance” demonstrated in this draft policy to all such controversial topics?
I am a physician and used to be a veterinarian (there are many of us who have done both)…
As a veterinarian, I have seen euthanasia being used in unethical ways often. Animals are routinely euthanized for compassionate reasons but are also euthanized for unethical reasons…ease (ex. tired of caring for the animal), revenge (ex. euthanized to upset divorced spouse), cost (ex.can not afford animal anymore or not-being adopted or reclaimed by certain date from the pound), legal reasons (ex. I was asked to euthanize a cat because it was in the will of an owner, that his cat was to die the day he did), can’t afford the proper care (ex. medical expenses too much)…and on and on.
While these may seem trivial because they are animal examples, similar events will occur with human euthanasia…we just try to cover it up under the auspices of CPSO guidelines, which make us, the general public and the Politicians, feel better.
WOW!
Thank you so much for sharing.
From what you said, it is mandatory that we as a profession and the CPSO in particular ensure there are safeguards in place to protect the most vulnerable in our society. It sounds like just saying “doctors’ professionalism is the safeguard” isn’t enough.
What risk of unlawful death are we as a society willing to accept, in order to grant the right to choose the timing of one’s death?
Thank you very much for this careful analysis. It is refreshing to consider the logical steps that have taken us from Carter to the CPSO document, and to see the many alternate approaches that could have been chosen. I appreciate your due diligence on this.
Personally, I am in favour of assisted death.
Providing the guidelines set are adhered to.
Saw my brother in absolute agony for weeks before succumbing to cancer.
Not an emotional decision, a decision I have felt should have been on an agenda years ago.
I am sorry to hear of your brother’s experience. I am sure it was also difficult for the family as you suggest.
Did in fact your brother have access to good palliative care and if not, could his experience have been different?
I am wondering how aware some physicians actually are that palliative care is NOT for everyone. I am very much in favour of ensuring that this type of assistance is available to all those who wish it, but I would never choose this type of care for myself.
I would much prefer to die when I determine the time is appropriate, and for me palliative care would be an intolerable violation of my personal values and autonomy.
Requiring that an attending physician, whose best judgment is that the suicide of the patient is not in the patient’s best interest, arrange the suicide by referral to someone known to be willing to carry through with suicide assistance, is a violation of the professional judgment of the attending physician.
This creates unnecessary conflict. It would be better to have a well known website, 1-800 number, and other means of access available to the general public who could refer themselves for consideration of suicide assistance. The rigorous and stringent criteria demanded by the Supreme Court could then be applied by a central screening agency, ideally culminating in a court process to obtain an order for the suicide assistance. This could be done with the same expeditiousness with which urgent injunctions are routinely obtained.
This would remove physicians who object on grounds of professional judgment or other forms of conscience from the invidious position of being coerced to be complicit in actions with which they profoundly disagree. Any policy, such as this CPSO policy, which appears to require such coercion is badly defective and should be corrected.
It appears to me that the SCC Carter vs State decision has made a determination pointing out that the Charter defends the rights of patients to be the ones who determine what they view as quality of life as the end nears. So as much as up to now you have had the belief that you were the one making that determination, it will no longer be a valid argument come February 6 2016.
Perhaps the College will give doctors a facilitated exit path for this one situation. But as the CPSO “Professional Obligations Policy” is written now it is clear that if you don’t like providing a service that is part of the basket of Canadian health care services. You are obliged to provide appropriate and timely referral.
You do appreciate that over 80% of Canadians want to have access to this service if necessary. A principled approach might be to ask all of your palliative patients early on in care if they are part of that group, and refer them on before you get into a battle with them or the college.
Are we so great that we always know what is in the best interest of the patient? I think that a dose humility is in order. We are serving our patients, not the other way around.
I am a 48-year-old late-stage recurrent ovarian cancer patient. I fully intend to take advantage of Physician-assisted suicide when it comes into effect in Ontario. I hope it is not delayed beyond the deadline set out by the Supreme Court.
With all due respect to the physicians who object to the new law for religious or ethical reasons, they should not impede or delay patients’ right to dignified death by refusing referrals. Why not take them out of the equation by creating a public directory of medical providers who ARE on board with the procedure?
I don’t agree with disregarding assisted suicide requests clearly expressed through the living will / advanced directive or through medical proxy.
I am not clear if requests could be made prior to Feb. 6th, 2016 and count towards the waiting period. I discussed it with my palliative care doctor and he had no idea either, though he indicated that he would comply with whatever College of Physicians decides.
From the draft I don’t understand whether the lethal drug will be administered orally or intravenously, by the patient (assisted suicide) or by the physician (euthanasia) and whether patient will have a choice of the route. It matters to patients unable to swallow / ingest or with poor hand coordination.
I am so sorry to hear of your struggle with cancer. I trust you have a strong support system, both family and health care.
I am one of those objecting physicians who feels that I can not refer a patient, in all good conscience, for assisted suicide.
You say “Why not take them [me] out of the equation by creating a public directory of medical providers who ARE on board with the procedure?” Many of us objecting doctors are pleading with the CPSO to do exactly that!
Thank you for showing the CPSO that this is a common sense approach. I trust they will take your suggestion seriously.
My thoughts and prayers are with you.
Do not put in byzantine referral/paperwork policies. The process should be as simple as signing a consent form/providing informed consent as it is for most other medical procedures – such as induction of labour, c-section, abortion, plastic surgery etc.
We do not require ‘psychiatric’ referrals, we do not require ‘palliative care oks’, judges opinions etc. etc. for any of these discretionary medical procedures, and we shouldn’t for these vulnerable patients.
In other words – KISS – keep it simple. Have guidelines for the procedure itself (i.e. if euthanasia or physician assisted death is asked for, and the patient has a terminal illness that in the opinion of the physician is very likely (>70%) to cause death in the next 6 months, and patient has consented of own free will or their recognized substitute medical decision maker has consented, then consent should be documented in the medical record, and the following drugs are recommended….).
I agree with the comments that palliative care should be offered and an option, and many patients really appreciate palliative care. Other patients frankly are more comfortable with having a quick death, and not going through the dying process, for a variety of reasons, all of which are personal to that patient. Not everybody with advanced cancer wants chemotherapy which can prolong life and improve quality, not everybody wants palliative care which can improve quality and prolong life, and not everybody wants radiation treatment which can improve pain etc. Please respect their wishes, even if better medical options exist in our minds.
I think you are in error when you equate assisted dying to any other medical procedure.
In many ways it is anathema to what medicine is all about; above all do no harm.
I agree as you say that these patients are vulnerable but I say all the more reason they need to be protected by appropriate safeguards.
Above all, you say, do no harm. Agreed. The question is, what is harm, how do we balance harm against good and who decides what the balance is?
If you cut off my leg, you are doing me harm. If the leg is gangrenous and will kill me, I am very likely to decide that the good you achieve outweighs the harm. If you put poisons in my body that cause unpleasant results, you are causing me harm. If those poisons arrest my cancer, I will probably decide that the good outweighs the harm.
If you refuse my request for an early death to end my suffering and insist that I continue suffering until my poor body gives up and I die, where is the harm and where is the good and who is to decide between them?
I believe that you are going where Hippocrates never intended.
To physicians who want to follow “do no harm”.Change your perspective to that of the patient. They do not consider it “harm” to have an assisted death. For them, a refusal provide their request is harm!
Patient centred care, remember?
I totally agree with you.
A self referral mechanism to a centralized access point is a must.
Thank you for the opportunity to provide feedback on this critical issue.
I have several comments.
Line 38-40 speaks of the key value of “trustworthiness”. How will physicians like myself be able to maintain this value in therapeutic relationships if we are asked by the College to go against our conscience by referring for a procedure, like Physician Assisted Death, which we find morally repugnant?
Line 75 talks about “competent adults”. The CPSO is willing to consider mature minors in this category. So individuals in our society will need to attain the age of majority to vote, consume alcohol legally and enter into a legal transaction but not when requesting to die. This is inconsistent. I suggest you ask the SCC to tell us what they meant by their term “competent adult”. I would be extremely surprised if that is anything but the age of majority.
Line 163 mentions the policy Professional Obligations and Human Rights. Is it not true that this policy was established after much heated debate and persistent disagreement over some of its statements which are now quoted in the current draft policy under review? To do this is unfair and intellectually dishonest.
Line 185-6 speaks of the controversial “effective referral”. I stand strongly in opposition to this obligation and now touted “standard of care”. As a primary care giver, a referral of one of my patients means I approve of or at least acquiesce to their request. I take this responsibility seriously. It is not simply a mechanical action. In referring my patient, I am part of the process and share in the outcome. I am culpable. In this light, I cannot refer for something I find to be morally unconscionable. I implore you to find a better way to balance my patient’s request for euthanasia and my right to be true to my conscience. There is a precedent here in the case of induced abortions. There are opportunities to establish direct patient access which would reconcile these opposing rights.
I urge you to listen to what a significant portion of your constituency is saying and act wisely. Don’t make the error of plunging on ahead to certain conflict.
Once the courts have determined that a medical procedure is a right guaranteed by the Charter of Rights and Freedoms.
It would be my impression that same court will view that the patients right to that care is weighted at a higher value than your dislikes, even if it is a really really abhorrent dislike.
So far there is no Charter ruling stating you have a right to practice medicine according to a set or moral constructs you have devised. Especially if your moral code opposes that of the patient whom the state is paying for you to look after.
In other words , practicing medicine is a privilege, not a right. And yes the ground is shifting under our feet.
The ground is more than shifting, it is shaking and we are at risk of falling down!
I guess one way of looking at this is that the courts and their delegate, the CPSO sets our “moral code” or construct by which we practice medicine. Everyone has to live by some set of rules. I imagine we all would prefer to live by our own.
Yes, it would be foolhardy to believe that the practice of medicine is a right. It is indeed a privilege. I also believe that our patients desire and deserve a physician with moral integrity. That is all that conscientious objectors of PAD are asking for. To maintain our integrity.
I agree. The danger as I see it is that was is legal becomes normative then it becomes moral. Heaven help us all.
I believe I have very high moral integrity. It is not the monopoly of the religious or the conscientious objector.
Dear colleagues
Passing physician assisted death is no doubt the human race taking hemlock …… A true Pandora’s box .
I usually refrain from comments on actual medical behavior but feel obliged to answer the physician assisted suicide debate.
As long as I remember physicians were “licensed” to help the sick or alleviate the pain but never to assist suicide.
If any government wants to legalize helping to perform suicide, that is a legal question. If it is made “legal” this is a political move and will not be persecuted by legal procedures. That has nothing to do an “act of a physician”
The procedure is simple: somebody has to start an iv; again special trained personnel (e.g an iv Nurse) is better trained for this than a physician. The medication(s) to stop living have long established (by physiological and pharmaceutic research) and their preparation again is a pharmaceutic action, never done by a physician. To inject the solution needs no medical skill, a well instructed technician can do it very well. To establish that death occurred,again can be a delegated function.
I am accepting the principle that diagnosis is a medical act. Prognosis that disease will lead to death (“incurable”) can be almost 100 %-Ly predicted and pain involved less certainly projected.
All this indicates that the only medical act is in making the diagnosis and prognosis. From here only legal questions arise and eventually a technical (but not medical) procedure is to be followed.
Each physician may have his own religious or conscious opinion how to feel about this vicious debate. To help such actions is again a personal decision. I strongly feel however that any suicide (even “legal”) is not a medical matter must be dealt and performed by legal means and should be discussed, decided on legal levels only. If a physician participates on any level beyond diagnosis and prognosis is not a matter of medical action and should not be controlled by the CPSO but by the law which all residents must obey.
When patients are allowed to communicate freely in a non judgemental environment as death approaches.. The exact mechanism of death is often discussed., and many ask about options for accelerating death. I have been personally asked many times to end a patients life under these circumstances. It is usually an advanced cancer with a rapidly building set of symptoms from new meds. Another common thread is a patient who values being alert, and not in a vegetative state. All involved in palliation know there are some that only get relief of their suffering when they approach sleep.
So I as a physician am very comfortable being able to help my patients achieve their goals. The drugs used to end life are largely ones that palliative care doctors are already familiar with. In fact I am often having to write orders carefully to avoid appearing to accelerate death because the type and doses of medicines used could very easily end a life prematurely in the eyes of some observers.
I think you are mistaken about the drugs used to end life being similar to those used in palliative care. The Quebec model calls for very high doses of midazolam, propofol and rocuronium. I have not used theses drugs in palliative care before, have you?
Other jurisdictions include barbiturates.
Int he management of end of life anxiety and seizures I have used several benzodiazepines including midazolam. For the management of seizures I have used barbiturates. For intractable pain requiring terminal sedation I have used all of the above plus propofol.
Although I am very comfortable with the use of non depolarizing muscle relaxants including rocuronium, I have never seen it used in palliative care in Canada.
As a terminally ill person who specifically desires assistance with my end of life measure I applaud you for your compassion. I find too many physicians believe in the ‘extend life at all costs’, despite the fact that it’s the patients themselves who suffer greatly under this mentality. I don’t think that those who object to ‘end of life’ measures are truly aware of the suffering the terminally ill go through and to intentionally extend life in certain circumstances amounts to nothing less than torture. I truly hope this is not delayed.
Primum non nocere. I will continue to care for my patient with that essential guideline.
Any patient has the right to seek care elsewhere but does not remove my right of conscience. Doubtless services will appear to assist towards a hastened death without my help.
The draft looks fine with the exception of one clause, starting line 220 and under the heading of Stage 2: Prior to the provision of physician-assisted death, “If at any time the patient loses the mental capacity to rescind his/her decision, physician assisted death ceases to be an option.”
This is in direct conflict with a persons rights within a ‘Living Will’. / Section 3 – Power of Attorney for Personal Care
Clause: Name one or more persons to act as your attorney for personal care in the event that you become mentally incapable. In which I specifically give an ‘advance directive’ of what my wishes are under certain conditions.
I absolutely want the assistance of a physician to end my life, even if I have lost mental capacity and that is the reason for stipulating my desire in the Living Will. My Power of Attorney has instructions from me via my Living Will to proceed with life ending measures, regardless of my mental state, plus this is the whole purpose of defining my wishes in advance.
I specifically want my wishes adhered to if they are reflected in my Living Will, a DNR Order, or whatever documentation is necessary to ensure they are carried out. A minor wording change to your draft along the lines of, “unless otherwise instructed in a Living Will” is all that would likely be required.
I object to euthanasia and physician assisted suicide in any form. I entered medicine to cure,in some cases only to care. Life is worth living from birth to natural death. My ethical and religious belief prevent me from agreeing to this policy.Who is going to protect my rights?
Will a Coroner be consulted in the process ? A physician-assisted death would seem to be one which should be reported to a coroner ,under the Ontario Coroners Act as it stands .
I do not think there will be any willing MD member to put the designate “Special interest in assisted killing” next to their MD degree. Government endorsement does not equate to physicians’ responsibility to follow. Are we obliged to ask medical school applicant if they conscientiously agree to kill before we accept them. Dear MD members, please conscientiously object to accept the responsibility of killing and leave it to other professional to do it even if you agree to the handling of life and death!
Thank you for the opportunity to respond. The authors are to be commended for taking this on.
First, two observations/suggestions:
1. The law and implications for practise are, at best and most generously described, uncertain and in rapid flux. The constitutionality of Quebec’s law has been successfully challenged, and the provincial government has mounted an appeal (to be heard shortly). Meanwhile, it says its law remains in force. It would appear that there thus remain serious risks for physicians.
Similarly, the criminal code provision against poisoning (I am told the route of prosecution for the intentional administration of lethal doses of drug) remains in force, neither mentioned nor vacated in Carter;
Administering noxious thing
245. Every one who administers or causes to be administered to any person or causes any person to take poison or any other destructive or noxious thing is guilty of an indictable offence and liable
(a) to imprisonment for a term not exceeding fourteen years, if he intends thereby to endanger the life of or to cause bodily harm to that person; or
(b) to imprisonment for a term not exceeding two years, if he intends thereby to aggrieve or annoy that person.
R.S., c. C-34, s. 229.
All of which is to say the very legal structure under which any college recommendations would come into effect is uncertain at present.
Along similar lines, the very recent letter to doctors from the CMPA in effect offers no guidance, for similar reasons.
The just released Report of the FPT Committee on the subject takes a very liberal position, and has engendered, at this early date, considerable negative reaction.
2. If the profession is to develop a coherent understanding, the OMA, College and CMPA ought to join forces to develop a unified, or at least mutually understood position(s)
Beyond that, a few specifics:
38-40
fiduciary nature of physician-patient relationship. i.e. prioritization of interests. Question: Is this consistent with College policies regarding insurer/government restrictions on elements of access. For example, if government won’t provide palliative care access in some region, and that has some bearing on the patient’s request, how is the physician to act ‘in the patient’s interest’? Put another way, does the College, in every instance, put the patient’s interest first?
141-150
as an example of the vagueness at the core of the issue. Many have commented that patients who suffer major, sudden disability through accident or (for example) stroke, feel utterly despondent and, given the opportunity, may request ‘assisted dying’. Months later, their view often changes. Where does patient’s perception,absent a professional’s knowledge and experience of natural history come into play.
222
there needs to be a defined drug protocol. Quebec has developed kits, each containing two lethal doses, in case one is inadequate. The suggestion in the box, bullet 3 is dangerously vague. Also the references are not directly available on the site, only the abstract. A colleague posited this scenario: A fully consenting adult (etc) is administered the drug, which fails to end life. He/she is now in a vegetative state. Is consent still valid? What happens if a family member who then holds the patient’s directive rights objects?
226 – 233
from my perspective the oversight and reporting structures must be both a priori and post facto and include a detailed understanding of the specific rationale and justification in each instance. If we are to view this as a last resort therapy, then we must ensure that all prior resources have been brought to bear, and especially there are no systemic issues which need to addressed (e.g.. lack of access etc)
…….
My guess is that this is an issue which will resist clear policy. As others have written in the past, law and medicine view some subjects with very different lenses. Not least, law acts on actions completed, while medicine mandates actions in the midst of uncertainty. If that is the case, maybe the ‘Double Intent’ concept, may in the end offer one potential resolution.
Thank you for clarifying the difference in perspective between the medical and legal perspective. While much has been made of the religious-atheist polarization on the issue, little has been said about the tension between the legal and clinical approaches to terrible suffering. On a related note, it is interesting that in the era of “evidence-based medicine” we find ourselves engaged in this debate where little authoritative scientific literature exists. On either the pro or anti euthanasia side. As a physician, I will at times talk to patients about the areas of uncertainty within their situations – prognosis, etiology, etcetera. I cannot imagine what a lengthy list of uncertainties would emerge with a discussion of hastening death, outside of patients with metastatic cancer in mutiorgan failure, I.e. Rapidly dying.
This is a dangerous step for physicians. I am generally not in favor of the process but am becoming more open to the idea that it might at times be appropriate for ending suffering.
I believe that the political process is partly using physicians as a way of sanitizing the whole process. Once the decision has been made, there is NO REASON why it must be conducted by a physician.
In fact, politicians have killed far more people in incredibly efficient ways than all doctors combined!
We need to avoid placing ourselves in a position of mistrust with our dying patients.
Professional Association of Residents of Ontario
Response in PDF format.
I am impressed with some of these questions and requests for clarity.
Quite insightful and most appropriate coming from members still in formal training programs.
I trust feedback will be given before any formalization of the CPSO policy.
The CPSO guidelines on physician-assisted death are excellent, especially in their handling of the difficult issue of conscientious objection by physicians. They also align well with the recommendations in the recently-released report of the Provincial-Territorial Expert Advisory Group. I hope that the guidelines will serve as a model for all of the provinces and territories.
Perhaps we need to change our attitude towards death! We have gone to the other extreme where people are not allowed to die but are kept alive through artificial means to the point that life no longer has any meaning. We keep the terminally ill alive long after we should have let them go on their way. We also insist on saving every baby no matter how premature or how many birth defects or serious illnesses they have. These babies grow up to have a lifetime of health problems.
The medical profession seems to view the death of a patient as a failure on the profession’s part to keep them alive.
If we stopped fighting the reality of death, we could learn to let people go when it is their time instead of endlessly prolonging their suffering. I know that’s not a final answer but that would at least be a start.
There are no easy answers….certainly none that will satisfy everybody.
You have a point regarding the sense of failure that may come with the death of a patient. This should not lead to futile treatment. We are agreed there.
This discussion needs to differentiate between dispensing with treatment thus hastening death and dispatching someone to their death. As to “letting people go when it is their time”, some would argue this determination should not be within our control- neither care giver nor patient.
The theme of “torture at the end of life” comes up frequently among proponents of physician hastened death. I believe that palliative care came into being precisely to put an end to a tortured death. I think about curative and palliative actions as complementary – there is no conflict between trying to cure someone and making them feel comfortable in the process.
As a physician, I feel fulfilled when accurately diagnosing and effectively curing disease. And equally with removing suffering.
As a profession, we need to listen carefully to family and friends of patients who “died badly.” And learn how to improve. Every clinician needs to excel in palliation.
There is an inherent contradiction in the policy in that it respects a physician’s right to conscientious objection but expects a referral, effectively aiding and abetting. A central self-referral option would be better.
Thanks so much for the opportunity to comment on the CPSO Interim Guidance on Physician-Assisted Death. Overall, I think this guidance is excellent.
My comments are primarily editorial (rather than substantive) to bring clarity in some key areas.
• Line 33/34: The implication of this sentence is not entirely clear. Does it mean that the Interim Guidance would be sunsetted, or instead that it would be revisited/revised accordingly?
• Line 49: I suggest changing “their autonomy” to “patients’ autonomy. As the paragraph starts with Physicians, they might also be the referent of “their”. Clarifying that this refers to patients will help to avoid confusion with the concept of “professional autonomy”.
• Line 79-80: What guidance is CPSO offering in terms of how to reconcile Ontario’s mature minor rule, which applies to other treatment decisions including EOL decisions, with the SCC’s reference to “adult”?
• Line 98-99: Given that the guidance later refers to patient self-administration, I suggest using inclusive language here to clarify that CPSO recognizes both physician-administered and self-administered PAD.
• Line 103: I think it’s important here to be explicit that the patient must meet the eligibility criteria and give informed consent. It’s not sufficient alone that the patient gives informed consent – s/he must also have a grievous and irremediable medical condition, etc.. I would also recommend making reference to capacity assessment here, e.g., applying current practices to assess patient competence.
• Line 126-27: This section reads as if the assessment of “grievous and irremediable” is solely determined by the MD. However, the SCC states that “irremediable… does not require the patient to undertake treatments that are not acceptable to the individual”. In other words, there would be a role for the patient in the assessment of “grievous and irremediable”.
• Line 130-131: “…chronic conditions that by their nature cannot be cured” overstates the case and may add confusion by introducing the cure concept. It would seem sufficient to simply say “terminal and non-terminal conditions” .
• Line 146-147: This should specify that it is the patient that communicates this sincere desire and that the sincere desire is his or her own (i.e., not the MD or some other party).
• Line 154: It seems odd to state that the physician “must not charge patients directly”. On the one hand, it invites a question about what charging directly vs. indirectly would mean; on the other hand, it muddies the point of this statement, which is that billing for PAD and associated services should be through OHIP and, if need be to underscore the point, that the patient should not be charged full-stop.
• Line 168: “patient dignity” – “dignity” is a contested term, so I would avoid using it here; it’s probably better to spell out what is meant by dignity in this context, e.g., respectfully, without judgment, etc.
• Line 169: Suggest changing “access to care” to “access to PAD” – this will make the point clearer.
• Line 172: Suggest adding “conscientious objection to providing PAD” – to clarify that the objection is to PAD not to the patient or the patient’s request per se
• Lines 185, 188, and 217: You might consider using “effective transfer” rather than “effective referral” (185, 217) to clarify that the overall care of the patient is being transferred from one MD to another (not just the PAD component of it). What would follow from this is transfer of records and the non-objecting MD becoming the Attending MD. I wonder too if you might want to reframe “timely manner to allow patients to access care” (188) as “timely manner to ensure continuity of care for the patient”.
• Page 6, 2nd Request, 3rd bullet: This bullet is a little confusing. Is this saying that only one of the witnesses should not be “the attending or consulting physician; a relative; entitled to any portion of the estate; or an owner, operator, or employee of a health care facility where the patient is receiving treatment” or that none of them should be or that if one of them is, e.g., the attending or consulting physician”, the other cannot be “a relative, an owner, operator, or employee”? Also, should this read “a relative entitled to any portion of the estate” or “a relative; an individual entitled to any portion of the estate”?
• Page 7, Stage 2 Capacity Assessment: Capacity/voluntariness are key components of Stage 1 as well – I suggest making these as explicit in Stage 1 as in Stage 2.
• Page 8, Section V Reporting and Data Collection: In the interim, will the CPSO play this oversight role? If so, is it envisioning a mechanism for data collection and reporting?
Good luck! I look forward to reading the final version of the interim guidance.
Am equally baffled by the discussion of billing. It is important but rather premature? I do not believe that any billing structure exists around physician hastened death – but would appreciate correction.
There should be rules saying who are qualified for dying with dignity, such as family status, ages of the applicants, family status, financial back-ground, etc.
I completely agree with Doctor-assisted suicide. However, I want to be the one to decide that my pain and prospects are too dismal to carry on and what if my doctor at that time doesn’t know me well enough to want to help me? Why couldn’t my pharmacist or my partner assist me with administering that medicine?
We live in Canada which has the Charter of Rights and Freedoms. In place is the Freedom of Conscience for those who object to Physician assisted suicide or Euthanasia. A physician should not be forced to perform a medical procedure like killing a patient with a lethal injection, if their conscience tells them this is murder. A doctor should not lose his or her job because of moral conviction. Policies need to be in place to protect conscience rights of those in the medical community.
I urge you to respect and support the rights of Doctors to practice medicine with their moral convictions intact. Do not force physicians to act against their moral convictions, even by forcing them to refer a patient to a third party.
We already have a shortage of doctors, and there will be those that might be forced to leave their practice, because they will not comply with performing lethal injections and are not willing to lose their integrity of providing a safe environment of care for their patients.
See this article written by a doctor who has seen what legalized assisted suicide does to patient’s mindset and our “health” care practices. (Even with safeguards in place.)
Waiting for your response on how Doctor’s rights will be protected under the Charter in your Guidance on Physician Assisted Death policy.
The question of requiring doctors to refer a patient to another doctor is not as simple as is presented. Doctors are not simply technicians providing medical services. They are also gate-keepers to the world of medical service.
As such, it is an abuse of their role to use their personal moral precepts to obstruct a patient’s access to lawful procedures. Referring a patient to another doctor to avoid personally providing a service does not make a doctor morally responsible for providing the service.
Physician assisted death should not be allowed to anyone under the age of 18 who is a minor. This should be considered and specified in the guidelines.
I also agree with a central referral access service that patients can access themselves without involving physicians. This would actually allow patients to more speedily access this if they so wish. Many physicians do not want to be directly involved in PAD, even via referrals.
I completely disagree with a specific age limit being placed on access to PAS; it will prove far too inflexible in practice.
Instead, the focus should be on the competency of the individual. Even young children are permitted to testify in court, or to inform a judge of their desires when decisions are being made that effect their lives.
Suppose we face a situation where somebody who has not yet reached 18 is dying a terrible death from cancer, for instance. Why should this individual, if they are judged competent, be made to suffer horribly against their wishes? Are we really more comfortable with torturing children to death than we are with torturing adults???
I find the interim guidance problematic in several ways.
The term adult is not defined. This leaves open the possibility of including mature minors, as has been done by the Alberta College of Physicians.
The policy defines irremediable condition in such a way that it could include many treatable conditions such as diabetes, schizophrenia and fibromyalgia. What is all the more troubling is that the criterion as to whether an individual is experiencing intolerable suffering is subjective, meaning it is assessed only from the individual’s perspective. The correct answer can often be found in adequate treatment rather than in physician assisted suicide.
According to the policy, physicians who object to PAS must make a referral to another physician. However, those physicians who object to PAS as immoral cannot in conscience contribute to it by such a referral.
Indeed, the criteria for deciding whether suffering is intolerable are entirely subjective. Can I decide whether you suffering is intolerable? I can have opinions and I can offer suggestions, but the only person who can decide is you, the sufferer. For me — or any other me — to impose such decision on you would be patronizing, disrespectful and abusive.
I am an objector to the physician assisted ruling of the courts .I think this puts physicians in conflict with their covenant with the public .Morally there is no difference between doing the act and referring to someone who can do the act ..either way you are willfully procuring the death of a patient
I agree that the stipulations around conscientious objection are contentious. It is profoundly puzzling to me how our proudly democratic country would see fit to coerce a group of citizens into violating their moral/ethical/religious precepts. Surely our proud and enlightened country can find a way forward without coercion.
I have just filled out the survey for this online consultation and want to express my views by email as well. I do not agree with many points in this interim guidance. Here are my points.
1. PAD should only be offered to patients over the age of 18. In the document, it says those who are competent adults can get it, but doesn’t specify an age. As those under 18 are still minors, they should need the consent of their parents or guardians before getting something this serious.
2. The criteria listed open up the possibility of PAD being given to patients with serious chronic diseases like diabetes, depression, etc that are normally treatable by modern medicine. The two cases involved in the Carter vs Canada court decision were patients who had ALS or spinal stenosis, which are typically incurable, while many other illness, diseases, disabilities that would be allowed under PAD, are treatable and curable which would then lead the person to not ask for PAD. This criteria leads to possibility of many vulnerable people from being abused and given PAD against their wishes. There is a slippery slope especially with regards to the elderly, the disabled, mentally handicapped (who can still make some competent decisions on their own), etc.
3. I do not agree with requiring an effective referral for physicians who conscientiously object to PAD. An effective referral is directly helping a patient get PAD which is morally wrong in my opinion. I should have the freedom of conscience to also decline referrals or offering procedures that I don’t agree with based on my research and morals. This is a direct violation of our freedom of conscience.
4. There should be a way for the government or some external agency to track PAD and how it’s done. This is not clearly stated in the document.
I strongly urge the CPSO to revise the interim guidance by considering the points I have listed above.
People suffering from mental illnesses deserve to have accessibility to the same end of life choice as people suffering from a physical illness.
Living life should be based on the quality of life that the person is living and has lived. People suffering from mental illnesses live a very poor quality of life – not all, but many do. I am one of the many who has been battling for 14 years with no progression. I am exhausted and my body is slowly deteriorating with my emotional and mental state.
Death is inevitable; But, dying with your dignity is possible. I hope you all as physicians can agree to help support people with mental illnesses on their wish to die.
Thank you for your attention to this email.
I cannot agree.
I am sorry to hear of your prolonged struggle.
If indeed one of the key criteria for assisted suicide is competency, it will be extremely difficult in my view to know whether someone suffering severely from mental illness is truly capable of making an informed choice.
Suicide itself will still be an option. May I ask you in all sincerity, why is it so vital that it be assisited by someone else especially when that someone else may have strong objections to participation?
The theme of mental illness is central to this discussion, and thank you for sharing your experience. As an emergency physician who deals with acute and chronic suicidality every week, it is imperative that this is explicitly addressed in detail by any guidelines or rules on physician hastened death.
I could not agree MORE with the physician posting @ # 57. Firstly, I would like to offer my deepest sympathy to the author. I commend them for taking the time to educate some of their colleagues about the reality which faces many of those who must live with constant mental distress/illness for years on end, if not their entire lifetime.
Despite the self-serving psychiatric industry’s claims to the contrary (i.e. pharmaceutical companies and the doctors who distribute their products), mental illness is often not successfully treatable, and is typically of a chronic or recurring nature.
This individual is a good example: they have been tenaciously struggling on, obviously enduring great suffering, for 14 YEARS. How much more do you expect from this poor soul? How dare anyone suggest that they do not deserve a humane and painless end to this state of affairs should they independently decide that it is in their best interests?
The attitudes of the medical profession MUST change to accept the new situation emerging in Canadian society: it is the one who is enduring the suffering who decides when it must cease. Nobody else is in a position to do so, and physicians will be forced to let go of the notion that they know what is in the “best interests” of other competent adults. That is an incredibly arrogant and disrespectful attitude which has been a hallmark of the medical profession for far too long.
Further, I suggest it is not usually difficult to determine whether capacity for consent exists in those who suffer from depression, bipolar disorder, psychosis, or other mental health issues. In other words, you use the same tests regarding ability to consent for PAS as you would for any other life changing or possibly life ending medical procedure: is the pt. lucid and logical, do they understand the consequences of their decision, are they clear regarding risks vs. benefits of their choice? This is entirely consistent with the SCC’s findings. If a doctor can decide a pt. is able to consent to electric shock therapy, why is it that you suddenly are at a loss to determine whether they are competent to consent to PAS?? It is because of your own prejudice regarding the procedure, not because competence is unable to be assessed.
To state that “suicide is still an option” is disingenuous: why should this physician be forced to become a ‘criminal’ by prescribing/illegally obtaining barbiturates to effect his or her own death? Most of those who end their life in Canada are reduced to using a firearm or hanging themselves. Is this the kind of agonizing death that you would want for your colleague? Please think about it.
To the author of comment #57…rest assured that you have made a poignant and invaluable contribution to this discussion, and I wish with all my heart that you find the peace you are seeking.
To the College: there should be no discrimination against those who are suffering from intractable mental agony, instead of physical agony, and the SCC decision makes no differentiation between the two. Discrimination of this nature, should the CPSO or their members chose to indulge in it, will end up back before the courts.
Catholic Organization for Life and Family
Response in PDF format.
Regarding elderly people, it is critical that access to PAD is not limited to just those with physical diseases that cause pain, such as cancer. Mental/emotional anguish due to serious decline and weakness and dependency is as devastating, or more so, to the elder who has lived a good long life and appreciates it, but knows that quality of life has permanently ceased. They must not be discriminated against or denied the PAD care that would show respect and honour for their good life. Do not make this procedure subject to discrimination.
How can anyone deny a “slippery slope” argument when hearing a comment like the one above. Yes the case for discrimination will be made and heard many times in our courts if we proceed with this policy and legislation.
Oh yes, it’s a terrifying “slippery slope” alright…if we’re not careful we’ll slide all the way to a place of respect for individual choice and human rights!
The SCC made clear that there is no such thing as ‘a duty to live’. The CPSO, for the most part, is abiding by the court’s decision with their draft proposal.
Why does the idea of allowing thoughtful, intelligent ‘members of the public’ (i.e. #59) to make decisions about their own lives and their own deaths according to their own values bother you so much?
1) Witnesses: I’m not sure I understand the role of the two witnesses at time of second request. Will the physician(s) have to determine whether the witnesses are capable of making an attestation regarding capacity, etc of the patient? Is the intent of this point not met by two independent physicians?
2) I believe all cases will require notification of the coroner, since death will not be by natural causes. If so, this is part of information needed for home deaths.
As the Supreme Court, the CPSO and the (disrespector of professionals’) Human Rights Commission have decided this will happen, they ALSO need to pay special attention to and ASK conscientious objectors what mechanism(s) achieve the goals of altruism, professionalism, respect, timely access, etc. while continuing to allow physicians of conscience to be physicians. I fear the loss to society of all health practitioners who may be forced to abandon these wonderful professions due to societal pressure.
1. What is the College’s response to the principle of non-maleficence when it comes to physician-assisted death.
2. Will there be new billing codes for the primary physician conducting the physician assisted death, the capacity assessment, the second opinion by the consulting physician? If so, where will these funds come from?
3. In Oregon, my understanding is that there are no additional billing codes for these procedures and the number of procedures is under 1000 over many years. However, in other jurisdictions, there are billing codes specific for the processes associated with physician-assisted death and the numbers of people opting for termination are much larger than in Oregon.
Compassionate Violence: the Oxymoron of Euthanasia:
We often have the impression that violence is necessary to righteousness and a means to something sacred. Extremist religious groups advance violence as a means to the sacred. By contrast, medicine has traditionally positioned itself to help the victims of such violence. It would appear that our world is torn by tension between two paradigms of belief: violence vs. compassion. When end of life looms in the course of illness, two possible sets of goods come into conflict: the violence of self-destruction and the travail of self-compassion. But according to Rene Girard, violence merely masquerades as a good; in truth, violence is the evil that begets suffering. The true good is a healing recollection of suffering enabled by compassion.
Those who advance the position of physician-assisted suicide hold that there are situations in which violence becomes a good. On this view, the quality and meaning of life is reduced to definitions of utility, efficiency, and productivity. When utility is lost, slick self-destruction becomes the last meaningful act. This line of reasoning presumes death and destruction to be the underlying idioms of our existence, and so self-annihilation makes sense. But a word of caution is in order. Might other, less dismal idioms of rationality be equally persuasive?
The approach to suffering in the spiritual traditions of the world can enlighten this dilemna. Compassion, forgiveness, and kindness are the terms of such an alternative rationality. Compassion does not have quantifiable outcomes and thus defies the equations of evidence-based statistics. Like compassion, suffering, is not a numerical quantum. When we approach end-of-life with physician-assisted suicide, we are treating suffering as a problem and euthanasia as the solution, the “compassionate” solution. Suffering is usually viewed as the “x” that we solve for. What if suffering was the “remainder” after all solutions had been exhausted?
When we problem-solve, we use empirical observations to come up with a universal equation, and then apply it to solve the particular disease-problem at hand. We become the detached observer, stripping the narrative of particulars in order to apply the universal equation. By contrast, when we practice compassion, the particulars remain. Our own subjectivity resonates deeply, and, like a mother attending her crying baby, we accompany the other by sitting, breathing, holding, groaning, dozing, weeping, sorrowing…. We perform a lament, not a mathematical solution. When all interventional efficacy has run out, the compassionate witness simply remains humbly and arduously present to the other.
When thus accompanied, self-compassion at end-of-life becomes possible. The recollection of experiences of violence—unjust subordination, silencing, and personal fragmentation—is difficult. But when done in the receptive posture of healing, rather than the stance of accomplishing a solution, a mysterious experience of equanimity may happen, especially as we face death.
As we flesh out the policies and procedures for physician-assisted-suicide, the foundational questions are, “Which goods do we seek to protect with this legislation? Is it good to become increasingly compassionate witnesses? Or is the good an impersonal equation of productivity and efficiency, advancing solutions of violence and heroic self-annihilation?
I am grateful for the groups who have pushed this issue to the forefront of the public consciousness precisely because it reintroduces dialogue about suffering into the public square. While I reserve judgement as to whether hastened death is likely to relieve suffering, it is healthy for all of us to be asking the question ” how can I relieve another’s suffering?” I hope that through this debate, we discover new ways to compassionately work with suffering on a societal level.
Dear Posters – this is the letter I wrote to the College, for comment if anyone wishes to comment.
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I thank the Council for providing an interim policy statement on the subject of physician-assisted suicide and euthanasia (“CPSO Interim Guidance on Physician-Assisted Death”). I realize the regulatory environment is in flux at this time and that drafting policy statements is therefore difficult. However, I think there are serious deficiencies in the existing document which I will outline. Some of these deficiencies are carried over from problems in the recently adopted policy on Professional Obligations and Human Rights (POHR) from March 2015. Furthermore, I do not think this policy adequately addresses the scope of the problem of physician-assisted death (PAD), particularly given that provincial regulators are likely to look to the policies of the CPSO in drafting their own legislation.
The SCC overturned the “absolute prohibition” of PAD and specified certain criteria which should govern access to it, and it did so using broad and subjective language. As presently written, the College’s draft policy merely restates the Court’s ruling, which was never intended to be a regulatory framework in and of itself. The policy does nothing to advance public deliberation on this subject and provides inadequate guidance to physicians, the public, and the province. The policy of the College should articulate specific and objective criteria for situations when PAD could be accessible. The College should require that PAD be considered as a last resort, in cases where disease or disability is either imminently terminal or where there is no prospect of improvement and suffering is severe. In its current form, this policy shows a lack of physician leadership and a missed opportunity to influence the legislative discourse in such a way as to maximally protect vulnerable patients.
It is profoundly disappointing that this draft guidance document builds so strongly on the requirement of “effective referral”. This requirement fails to respect the serious moral concerns of some physicians, and disregards the Charter-protected right of physicians to act according to their consciences. This is inconsistent with the SCC’s decision, which specifically required that the Charter rights of both physicians and patients be honoured. As the CPSO councillors are aware, the “effective referral” requirement is new, having been adopted only in March 2015. It was adopted despite grave concerns of members of the public, members of the College, and members of religious and other minority groups that it could be used to force objecting doctors to provide PAD or to refer for PAD. Obviously such concerns were well-founded. It was adopted despite alternatives that would have clearly protected both conscientiously-objecting doctors and the rights of patients to access care, and may in fact have enhanced patient’s access to care. One such possibility would be a public registry of providers offering various insured services, which would preserve the diversity that exists within the medical profession and could assist patients in decision-making when choosing a provider. I accordingly urge the College to revise its current policy (POHR) on “effective referral” in order to more vigorously promote and defend the moral integrity of its members, an integrity that is required to maintain trust between patients and their physicians.
The CPSO has quasi-legislative authority in Ontario, which it has been granted in the hope that the regulation of medicine by medical professionals would be beneficial to the public and to the integrity of the profession. This is a profoundly important responsibility and I strongly urge the Council to carefully consider whether previously (POHR) and presently articulated policies of the College truly serve these noble ends.
I thank the College for the opportunity to respond to this consultation process. I would appreciate being involved in further discussions on this issues. I apologize if my words have been blunt. I am truly fearful for what will become of our profession in the future if this issue is not more carefully considered and reflectively evaluated.
I wish I could have written this response.
It resonates exactly with my own feelings after 40 years of medical practice and 30 years of providing care to the dying.
I must admit I have come to resign myself to the fact that PAD is a “fait accomplis” and despaired that further public discussion of these issues will accomplish any change.
This piece is very well taken!
A solution can be found to providing access to services that the CPSO wishes patients to access (in this case, physician-assisted death) and respecting the dignity and consciences of physicians who do not wish to participate. Either a database can be created with a listing of physicians who are or are not willing to participate, or a central access service run by the CPSO/MOHLTC can be created so that patients who want these services can access it themselves. This will not reduce access to care by patients and physicians who are uncomfortable with physician assisted death do not need to participate or refer. There is no gain by forcing doctors who are opposed to physician assisted death to refer, other than for a shallow ideological victory. The CPSO has options that will allow them to truly respect physicians of all moral beliefs.
Moreover, the CPSO should respect patients who do not support physician assisted death. Patients who are opposed to physician assisted death have the right to access a doctor who they know will never refer them for such a service.
Additionally, if the CPSO is unwilling to reconsider their position to support physician assisted suicide and referrals for it, the CPSO should introduce strict safeguards to prevent abuse of physician assisted suicide. In particular, a mechanism to verify second opinions and a data collection system is needed. If the CPSO is truly committed to protecting and advocating for their patients, good data is needed to evaluate the success of current policies in the future.
Since a patient must actively seek PAD and be found competent to make such decision, it is hard to see how a doctor referring them to anyone could put them in any risk.
Dear Committee,
Thank you for preparing this document. It will be of great help to physicians in this somewhat challenging time of transition.
A couple of comments:
1. Page 2, Line 75 – ‘Competent’ – the explanation in this section should include mention of having a reason that is not based on delusions or other misperceptions of reality (see the article on Capacity by Appelbaum from NEJM in 2007 which outlines the components of capacity). It is important to ensure that patients do not request PAD due to delusional beliefs and we must protect our patients from this by ensuring it is in writing for physicians who may not consider asking these questions. Many physicians may not ask as they would not want to appear ‘judgmental’ and believe (rightfully so) that people can make unreasonable decisions if they choose to. I teach medical residents and the vast majority have been taught that you do not need to ask a reason for someone’s decisions when determining capacity although they often would do so anyway to build an alliance and understand the situation.
If we do not ask about delusions or paranoia, we will not detect it and unfortunately this will put some people at risk for having PAD when this would not have been their desire if not delusional.
2. How will physicians who are not willing to provide PAD going to find physicians who are willing? Will a database or central referral centre be set up? I suspect some who are willing to do so for their own patients may not want to receive referrals from others for patients they have not met before.
I am a physician and an objector to the physician assisted death ruling of the courts .
CPSO guidelines states “effective referral” must be made in cases of patients requesting PAD. I am opposed to making an effective referral in this situation and setting it as a standard. If I refer patients for PAD I then agree or at least acquiesce and am complicit in this action. This is morally repugnant to me.I urge you to listen to what the significant portion of your constituency that is opposed to what you are proposing. Until now this action was considered murder and so punished under the law. Is it too far a stretch to believe there are many who still oppose this action and would still consider it such and, therefore want no part of it?
Any patient has the right to seek care elsewhere but this does not remove my right of conscience. The obligation imposed on physicians morally opposed to euthanasia and assisted suicide to refer patients to a third party willing to comply with the request is a violation of the rights of conscience and of freedom of religion- both of which are guaranteed by the Canadian Charter of Rights and Freedoms.
The SCC responded to concerns from intervenors in the case that doctors not be forced to assist in suicides and that the court craft a remedy to account for physicians’ freedom of conscience and religion.
I have practiced and fully support excellent palliative care for those who are suffering. I also feel that if this is imposed on palliative care physicians, a considerable number of them will stop practicing palliative care.
Dear Sir/Madam:
Thank you for the opportunity to provide feedback to the College on the Interim Guidance on Physician-Assisted Death Policy.
I appreciate the time and effort required to prepare this document – it is well-written and clearly summarizes legal and professional expectations and boundaries. Thank you.
I would like to provide input on the issue of conscientious objection management.
Conscientious objections should be respected insofar as they are grounded in rational and reasonable concerns. Having diligently reflected on and studied the ethical issues surrounding physician-assisted death, I am of the carefully considered opinion that it would be wrong to intentionally cause the death of a patient, even if she/he were requesting death. This opinion is grounded in the belief that the intrinsic worth of the human person is the very foundation for medical ethics, and in the recognition that PAD cannot be considered beneficial apart from some knowledge of what it is like to be dead (i.e. whether or not there is an afterlife, and if so, what it is like) – claims about the afterlife (whether or not it exists, or its quality) lie outside the purview of medical knowledge and expertise. Therefore, physicians cannot confidently claim that PAD is beneficial. My point simply is that my objection to assisted death is grounded in rational considerations, not merely personal/arbitrary beliefs.
Furthermore, providing an effective referral renders objecting physicians morally culpable as the referral is a key step in the causal chain of events leading from patient request to intentional death. It is therefore morally unacceptable for objecting physicians to provide such referrals.
I ask that the College reconsider its requirement for an effective referral, and propose an alternate process as follows:
I understand and agree with the College that patients requesting death should not be abandoned by physicians and should not be unduly obstructed by their physician from obtaining access to PAD.
The guidance document suggests that an unwillingness to provide an effective referral constitutes both abandonment and undue obstruction. This is not necessarily the case. A physician may (and ought to) continue to provide outstanding palliative care even while refusing to cause death. Moreover, outpatients can seek alternative consultation with another physician or self-refer to an assisted death clinic (similar to the process for providing terminations of pregnancy). The College could provide a list of physicians or organizations willing to provide a referral. Thus patients could still readily access the service, even if an effective referral is not provided by the patient’s personal physician.
I think expectations for the outpatient and inpatient settings could be different.
In the inpatient setting (such as the ICU where I work), patients requesting assisted death under the care of an MRP who cannot in good conscience provide PAD or refer for PAD could be transferred to a different MRP. This simply respects the patient’s right to an alternate MRP. Refusing to transfer a patient would constitute an undue obstruction of access to PAD, given the constraints of the inpatient setting. A transfer would also ensure that the patient is not abandoned.
This transfer process I am proposing for the inpatient setting is consistent with critical care professional society recommendations (see the statement by the American Thoracic Society on this issue).
In summary, if conscientiously objecting physicians are rationally and morally justified in their opposition to PAD, then the medical profession would do a great wrong by forcing them to participate in the provision of PAD; providing an effective referral constitutes such participation. Outpatients would not be unduly obstructed if they were expected to employ alternate means of obtaining access to PAD. Inpatients will not experience undue obstruction if their MRP is permitted to simply transfer to an alternate MRP.
In light of these considerations, I ask the College to reconsider its policy on conscientious objection and to reach a position that respects the personal autonomy of patients and the moral and professional judgment of fellow members of the medical profession.
Feedback to the “CPSO Interim Guidance on Physician-Assisted Death”
Over the last year, I have read about and listened to much rhetoric on the issue of physician assisted suicide. What I have not heard are the realities, the practical day to day difficulties that physician assisted suicide will cause added to the complexity of all the issues associated with the journey towards death and the ongoing bereavement after a death.
When I read the CPSO interim guidelines, it appears to me there is an assumption that the very real issues of death and dying and the decision to request physician hastened death can be easily explained and understood by Canadians. (When I use the term Canadians, I include those dying, their families who are accompanying them, the professional caregivers, including physicians who do not frequently deal with patients who are dying and the general public who are healthy and have never been closely involved in the care of a loved one who is dying.)
The reality is that the issues associated with death and dying are complicated and filled with high emotions. Communication is often very difficult with family members disagreeing about best course of action, treatment decisions or place of care. There are so many misconceptions. Patients and families frequently change their minds about the most important of decisions.
What authority do I have to make these statements?
I am a family physician. I have focused my practice solely on providing community palliative care for patients at near end of life who wish to stay in their homes or in a community hospice until their deaths. I have being providing this care ensuring 24/7 coverage for my patients for the last 20 years. During this time, I have had an average of 1 death every 2 days; 80% of my patients have died in their homes, 15% have needed a community hospice admission for the last few weeks of their lives, only 5% have returned to an acute hospital or have been admitted to a specialized palliative care unit.
I wish to comment on 3 areas of the draft document, from a very practical point of view, from a physician who has been on the front lines of caring for the dying.
103 – 110 Consent to Treatment including the term “fully informed”
In order for me to be successful in my practice of community palliative care I need to:
• Be very practical
• Deal in the realities of day to day care
• Ensure that my patients and families clearly understand what it takes to care for a loved one at home
• Educate them on the process of dying including the likely complications
• Provide good symptom control
• Sort out the resources
• Problem solve and try to bring some kind of order into the chaos of sudden complications including emotional ups and downs, communication problems and differences in opinions of family members.
I believe that unless all these very practical issues are clearly laid out for patients and families with ongoing discussion to help them really understand what is happening to them and what might happen as they approach death, a competent adult cannot make a fully informed consent to treatment.
I know there is a huge gap in Canadians’ knowledge about death and dying because my patients and families have clearly demonstrated this reality to me. Sadly, I find that the knowledge base has not improved over the years of my practice. I think I can safely extrapolate that Canadians not experiencing a life threatening disease will have similar gaps in their knowledge of death and dying.
What are the most important gaps in knowledge of all Canadians about death and dying as demonstrated by my patients and families?
When I first meet my patients and families, I ask if they have any questions. The vast majority immediately ask: “How long do I have to live?” “What will it be like?
Therefore the first and most important priority is to help my patients and families clearly understand the process of dying. This principle is even more important for patients thinking about physician assisted suicide who will be asking for an irreversible intervention.
In order to explain the process of natural death, I have prepared a teaching card. I review this card with my patient and family, and leave the card with them for future reference. The information on this card is the basis of my approach to care, and lays the foundation for when and how I intervene. It helps with the discussion of prognosis. I use it to explain the changes at each major step in the process.
Interestingly, once my patients and their families have understood the concepts, all comment: “Now that we understand what is happening, it is much easier. Why did no one else ever explain this to us before?”
Canadians must then understand how their particular disease which overlays the general shutting down process of the body will affect their individual journey. It is different for everyone and therefore this knowledge plays a huge role in the decisions throughout the dying journey.
Canadians must understand that dying is not easy – even the gentlest of deaths. The process is not what is depicted on television – one injection, then seconds later the drug takes effect! Our body is programed to survive. We do not want to leave our loved ones. We are filled with ambivalence – one moment wishing to end life, the next wanting so much to continue to live. Early in the disease process, or when we are healthy, we make decisions about life and death with our minds. When we are faced with imminent death we start to make decisions with our hearts and often our decisions are very different.
Canadians must understand that physician assisted suicide will not make the dying process easier. It will actually add a very complex layer over all the other multiple issues. It will also have a major impact on the ongoing bereavement process after the death.
Canadians must understand that physicians do not hasten death at the present time. There is such a fear that palliative care is really hastening death. In the 20 years of my very focused practice of palliative care, in which I have been faced with a patient death every few days, I have never given medication nor withdrawn treatment with the intent to kill a patient, nor have I encountered a physician who has tried to kill a patient.
82 – 90 Competence
Canadians must understand, contrary to popular opinion or what is said in the media, that not many patients who are near end of life meet the criteria of being “competent” as is required to qualify for physician assisted suicide.
This statement is very easy to understand if we review the natural the dying process.
Patients who have a sudden major CVA in the brain stem are not competent.
Patients who are at end stage respiratory or cardiac failure with severe hypoxia are not competent.
Patients who are at end stage renal failure and cannot maintain their inner environment nor remove waste products are not competent.
Patients who are at end stage liver failure and cannot remove waste products are not competent.
Patients who have dementia and acute delirium are not competent.
Canadians must understand that most patients who have a life threatening disease yet are still mentally clear, with good functional ability and a good quality of life are not ready to die and so would not request physician hastened death.
Canadians must understand why patients with ALS are so frequently the most vocal advocates for physician assisted suicide or euthanasia. Understanding the ALS illness gives clues to this phenomenon. ALS is a neurological disease that slowly destroys the innervation of the voluntary muscles. Patients with ALS have a long early phase of their disease with only the muscular system being affected, interfering with the ability to ambulate, feed themselves, care for their basic needs. They remain completely mentally clear, their essential organs are not affected, but they see their world shrinking more and more. They see themselves becoming more dependent. They feel loss of control. They wish so much to regain control over their lives. If they cannot retain control over their lives, they choose what they consider the next best option – control over their deaths.
I have cared for over 60 patients with ALS and they have taught me well. Patients with ALS have more control over their lives than any other group of dying patients because they are completely competent until moments before their death. Therefore they can participate in any decisions regarding their treatment throughout the whole course of their illness. Their greatest fear is that they will linger for months or years being totally dependent, unable to communicate. The reality is very different.
• The end stage of this disease is extremely rapid and very gentle.
• This group of patients does not need physician hastened death – they just think they do.
• Because the end stage is frequently so rapid, and patients do not believe that are dying until they are just about to die, it is doubtful that most of ALS patients will have enough time to go through rigorous protocol that will be needed to request and be accepted for physician assisted suicide.
The video “Gloria’s Story” – a documentary about the patient in Carter v. Canada case, demonstrates very clearly the typical physical progression and all the psychological issues experienced by patients with ALS.
A few key points are important for Canadians to understand:
• Gloria did not want physician assisted suicide, she wanted to live as long, as well and as independently as possible. She clearly stated in the video that she really just wanted to know that she had the option to have physician assisted suicide if life became intolerable.
• Gloria was so afraid to lose control that she tolerated pain refusing to take opioids, afraid that she would become addicted to the opioids or that they would cloud her mind. Her pain could have been controlled without confusion and addiction.
• Gloria did not die of her ALS. The video describes that one morning she developed abdominal pain. While being filmed, she was told by the photographer to call 911 to go to the hospital. On admission, about 5 days before her death (according to the video), she did not think she was dying, she had not yet decided if she would accept or refuse resuscitation.
• Gloria died of an acute abdominal disorder. With my experience in caring with patients with ALS, because she had advanced ALS with weakness of her respiratory muscles, requiring bipap support, she was not able to compensate for the stress of this new insult to her body, and she died quietly, gently, quickly as she wanted to, without being totally dependent and without the need for physician assisted suicide. But of course, her death was totally out of her control.
In summary re competence, Canadians need to understand: If we eliminate the patients who are not competent to request physician suicide, those who are competent but have good quality of life and would not request physician assisted suicide, and the patients with ALS and other peripheral neurological illnesses who really do not need hastening of death, there remain very few patients who could benefit from physician assisted death. For myself, in my community palliative care practice, over 20 years, I have never been concerned about the law prohibiting physician assisted suicide or euthanasia because I have never felt the need to hasten the deaths of any of my patients.
184 – 189 Medical act, physicians must refer: “An effective referral to another health care provider must be provided”
Canadians need to know that the choice to stop active treatment and begin palliative care is not ‘giving up’ nor is it a choice to hasten death. It is a choice to take a more gentle, natural and holistic approach to the dying process – a focus on quality of life. Intuitively, we have learned that this approach to the dying process more likely prolongs life.
Canadians need to know that the treatment decisions based on a palliative approach to care are indeed medical decisions. I explain my approach to patients and families as follows: I know that the body, a most powerful, sophisticated and discerning organism is in control. Therefore I make sure that the body is our partner. Together with the family and other caregivers, we try to make the physical environment as perfect as possible. I explain that the patient to learn to listen to the body’s signals. We, the caregivers, need to learn to interpret these signals and act on them before a crisis occurs. If a crisis does occur, I bring my medical expertise and use medications to rescue the body, quickly control the complications and help bring the body back into equilibrium. I know that, with this help, the body plays a far greater role at survival than any of my interventions; and when survival is no longer possible it is the body that knows how to shut itself down in an orderly manner, causing minimal distress.
Canadians need to know that physician assisted suicide is not a medical act. Rather, it is a crude attempt to mimic the body’s shutting down process in a chaotic manner at a time when the body is not ready to give up living. The body is no longer in partnership with the physician. The body is the opponent, a very powerful opponent. Diverse strong medications are given in doses 10 to 100 times the therapeutic doses. Physicians cross their fingers and hope that some side effects of these medications will overwhelm and kill the body before it starts to mount a defense against this assault.
Canadians need to know studies reviewing the physician assisted suicide and euthanasia experience in the Netherlands and Belgian have demonstrated that the body will indeed try to defend itself, at times ultimately failing but causing significant slowing of the dying process with distressing symptoms; at other times succeeding, ie. failing to die.
Canadians, who are contemplating requesting physician assisted suicide, and physicians who are willing to provide the service, need to ask: “What happens if the patient does not die – what then?”
Canadian physicians who are opposed to physician assisted suicide, who do not regard the killing of a patient to be a medical act, should not be forced to refer to another physician as if it were are medical act.
A separate system should be set up whereby the patient has access to all the information so they can make an informed decision to seek physician assisted death, and then can self refer to institutions set up to provide the service and deal with the complications which will surely occur.
Thank you for allowing me to feedback to the draft proposal.
We all should be humbled by your vast experience and take your comments very seriously.
Thank you!
‘This group of patients(those with ALS) don’t need a hastening of their death…they just think they do.’ The supreme arrogance of this statement is precisely why I would have preferred to see Canada emulate the Swiss model and keep the role of doctors as restricted as possible.
My father developed ALS, and I know all too well that the statement of this physician is sugar-coated nonsense, probably based on an inherent prejudice against patient choice (and a wish to impose their own values on others). I know very well how my Father suffered: unable to eat/swallow, speak, walk, and constantly in danger of drowning in his own saliva.
If it was his conviction that ‘living’ like that was not acceptable to him, no human being with compassion would stand in the way of providing a peaceful and humane passing for him. But as we see in so many of the comments posted here by physicians, their main focus is always on their own ‘rights and freedoms’ (i.e. their wish not to provide an OHIP funded medical service, or even supply a referral to another more responsible and caring physician who puts the wishes of their pt. before their own preferences). Concerns about patient suffering and autonomy appear to come almost exclusively from members of the public.
I am forever grateful to the Swiss people for respecting my Father’s choice…thankfully he was not tortured to death by Canadian doctors like those above, but so many others have been. It physically sickens me to imagine what it must be like to go through the horror of having a religious palliative ‘care’ doctor and an irresponsible government completely control one’s own body and one’s own death. MY life, MY choice.
I would never wish a horrific disease like ALS on anyone, but must admit I would like the physician who posted this insensitive disgraceful comment to have lived just one week in my Father’s shoes. He or she might find themselves making a rather rapid change in their ridiculous assertion that dying from ALS really doesn’t involve much suffering!
Let me respond with the experience of a relative in Europe who was dying of cancer. He was not in significant pain but, after two years of extra life through aggressive treatments, he could see that his health was detiorating.
My relative arranged with his doctor for the means to give himself an overdose that could reasonably be expected to be fatal. After a good-bye party with his family, a son actually started the drip and the father died a few hours later.
My relative was a strongly religious man and believed that he would eventually re-united with his wife and family in the after-life. The family were happy with his decision and celebrated the extra time that medical intervention had given them.
I find it hard to believe that there will be no Canadians who will want to hasten the inevitable and — because they know that advance directives will not be honoured — will seek PAD while they are still relatively healthy and still have a chance.
I really have to wonder about vast experience and how your patients may have viewed your care. Your comments on the ALS patients are particularly offensive.
I do commend you on the efforts to educate your patients. Knowledge is so important in good decision making. Providing excellent palliative care can obviate the need for PAD in many cases but not all. The controlling tendencies exhibited can be inhibiting to a patient or family wishing a second opinion.
Thank you for your comments however.
Thank you for your very detailed comment that describes both your experience as well as your concerns. In any policy/guideline, the concerns of those who are regularly caring for a specific population, must be prioritized or there will be a disconnect between what’s on paper and what is actually practised. I trust that the College will take very seriously the issues that you have raised. We all hear and empathize with the individual stories of those who have commented (esp negatively) on your points but your wide range of care over so many years, needs to be prioritized as the College considers this extremely important decision.
As a physician who has focused my career on vulnerable women and children, I am particularly concerned about this policy. Having reviewed the hundreds of comments above that have gone before this one, there are many questions about the policy’s interpretation as well as gaping holes (eg. other health providers — having a mother and a sister who are nurses, I have been sensitized NOT to forget those who work with physicians. This document doesn’t even address the impact of the college’s policy on other health workers—as physicians, we seem to be reverting to our authoritarian voice of the past).
You refer to patients who are at the end of life–and your points resonate with physicians and health workers who have cared for these patients in the past (though obviously, not everyone agrees with your perspective), but included in the patients who are eligible for PAD are those with ‘enduring and debilitating’ conditions. The global community has greatly improved its services and assistance to people with significant disabilities (some of which are enduring and debilitating) and yet it is clear from the CPSO policy (and many people’s comments) that these individuals cannot be completely safe guarded from strongly consider ( or even being pushed towards) PAD. These vulnerable individuals (who due to disability and potentially worsening conditions) recognize their dependency on others and will feel a new burden: to consider PAD. There is no recourse to PAD – the patient dies. Any other clinical decision will have other alternatives once the patient has made their choice….but with PAD, there is no other option.
As physicians who want to ensure the true autonomy (or ability to ‘self rule’) of our patients as well as the obligation not to harm our patients, the CPSO policy simply does not meet the standard. In fact, I’m amazed to see that the medical references (for lethal doses) being quoted are from 1999 and 2001—the second one being from a journal in obstetrics. Surely, the CPSO can do better! Can a patient really ‘self rule’ when they are totally dependent on their family care givers and know that there is an alternative option to minimize the burden on their family. I doubt any of us would call that ‘self rule’ or at least we can see the potential for conflicting pulls for such a patient.
Most certainly, physicians should not be obligated to refer patients for a procedure that has so many uncertainties and which violates the physician’s obligation to not harm their patients. There is no option for a randomized control trial on this issue of PAD or even the obligation for physicians to refer. Many people (both physicians and the general public) have commented on examples in the past where physicians have been obligated to be involved/refer patients against these principles, so I won’t reiterate the examples but the outcomes have been consistently negative and fatal. I think we can learn from those case examples. People (including physicians) cannot function optimally in a situation where they are violating their own conscience.
Please accept my approval of the main points (below) of your paper on this subject:
A harmonized, patient-centred approach to end-of-life choice.
Key recommendations include:
• Providing access to assisted dying as part of the publicly funded healthcare system;
• Requiring physicians who oppose assisted dying to transfer care of patients who request it to another doctor or institution;
• Requiring life insurance providers to pay out benefits for claims resulting from physician-assisted deaths;
• Allowing eligible patients to consent to assisted dying in advance via a binding patient declaration in case of future incapacity (resulting from a coma or dementia, for example).
The recommendations are impressive, and they address many of the concerns our supporters have raised in the wake of the Supreme Court’s decision.
I would first like to commend the CPSO for its leadership in this area. I would also like to applaud you for taking a sometimes unpopular stand with respect to conscientious objection – your commitment to the rights and interests of patients is evident, appropriate, and appreciated.
By way of constructive feedback, I offer the following:
- line 47 I would recommend editing the text as follows: “Acting in the best interests (consistent with the wishes) of their patients…” This would avoid the appearance of a paternalistic approach and keep the Guidance consistent with normal consent law which clearly establishes that a physician’s view of the patient’s best interests can’t override a patient’s wishes.
- line 79-80 I would recommend giving guidance re: how to interpret “adult”. As you know, while the SCC used the term “adult”, it did not define the term. It is likely that, without guidance, physicians will assume that this means that assisted death is limited to individuals over the age of majority. However, given the SCC decision in AC v. Manitoba (precluding irrebuttable presumptions of incapacity) and the embrace of the concept of the mature minor in Ontario, I would argue that “adult” should include mature minors and should be defined in functional rather than chronological terms. I would note that this position was taken by the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying.
- line 88 I would recommend editing the text as follows: “The patient must be able to understand…” This would keep this consistent with normal consent rules.
- line 98 I would recommend editing the test as follows: “The patient must be able to understand…” This would keep this consistent with normal consent rules.
- lines 115 I would recommend reconsidering the requirements of “due consideration” and “non-ambivalent”. It is not clear where these requirements come from. These are not usual requirements in “other medical decision-making contexts”. It seems like a higher standard is being applied here. This is especially significant given that Justice Smith included “non-ambivalence” but the SCC didn’t. One could argue that it is reasonable to assume that they meant for it not to be a requirement. I would recommend requiring that the consent be “clear” as that is what the SCC stated in its declaration.
- line 145 I would recommend editing the text as follows: “the physician must be satisfied that, in the opinion of the patient, the patient’s condition…” It is really important not to let the physician’s opinion slip in here — the SCC was very clear that the suffering is a matter for a subjective assessment by the patient.
- Line 156 I strongly support the position that you have taken with respect to conscientious objection. I believe that, as required by the SCC, you have reconciled the physician’s freedom of conscience with the patient’s freedom of conscience and right to life, liberty, and security of the person. You might consider using the language of “transfer of care” rather than “referral” as some conscientious objectors believe that “referral” implies endorsement of the intervention sought by the patient whereas “transfer of care” carries no such implication. This edit might the position more acceptable to more people without threatening access in any way. See, for example, the recommendation re: conscience made by the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying.
- Stage 1, First request. I would recommend editing the text for (1) as follows: “be competent” rather than “be a competent adult”. Consistent with the point made earlier, that will then include mature minors. I would recommend editing the text for (4) as follows: “in the opinion of the patient be experiencing enduring suffering…” Consistent with the point made earlier, this will keep the subjectivity of the assessment of suffering clear.
- Stage 1, Waiting Period. It is not clear to me where this requirement comes from. I do not see it in the SCC decision. I would encourage you to instead say that there should not be an arbitrary time period (because there is no justification for a waiting period – especially if “due consideration” and “non-ambivalent” are deleted as above) or vague guidance as in “a shorter timeline may be considered” (because this seems to gut the requirement of a waiting period at all). I would argue that a more principled position would be to indicate that the physician should take as much time as is required for her to be confident that the criteria have been met. For complex cases, this may well take some time and legitimately so. For straightforward cases, it need not. The focus is then not on the passage of an arbitrary length of time or a struggle with whether the vague flexibility is triggered by the circumstances. Rather, it is on what matters – is it clear that the criteria for access have been met.
- Stage 2 final bullet – the position taken in the draft means that someone who has met all of the criteria and then fallen incompetent just waiting for the assisted death to take place, will not be able to get it. This seems cruel and unnecessary. At the least, I would argue that it doesn’t cease to be an option if the person has met all the criteria and then lost capacity. I can understand that the College might want to be conservative at this time but I would argue that the position in the draft is too conservative. I would also note here that the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying took the position that competence should not be required at the time of the provision of assistance but rather at the time of the request (with the requirement that the person have received a diagnosis of a grievous and irremediable condition).
- Stage 3 – I hope that, by the time the final Guidance is produced, you have accessed more up-to-date drug protocols. For example, for euthanasia, from Quebec and for assisted suicide, from Oregon, Washington State, or Vermont.
In conclusion, I would like to congratulate you on producing what is, in my opinion, the clearest, most useful, and most defensible position statement on the issue of physician-assisted dying of any College of Physicians and Surgeons in Canada. It is a model that I hope others follow (even those who have already drafted their own).
Whereas I disagree with many of your points, I do agree that the CPSO is trying to elevate patient “rights”. They have a long history of doing that.
A point about “referral” versus “transfer of care”. In the context of community primary care and especially in solo practice, there is no distinction between the two. It boils down to the same thing. Therefore forcing either of these is equivalent to obligating a physician to go against their conscience. There are better ways to reconcile access to Assisted Suicide/Euthanasia and conscience rights.
I commend for your concise comments. I think the suggestions you make are helpful and I hope the CPSO uses them. While the document is a draft, overall it is good. I am so tired of whinging physicians and paternalistic comments. If they don’t wish to do be involved don’t be. But let those of us who seek to support our patients get on with it.
I am grateful for the opportunity to provide feedback on the Physician Assisted Death Draft Guideline.
My bias is that this is too complex a clinical and ethical decision to leave with a patient and two physicians. I would prefer to see these decisions referred to a panel, similar to a transplant board or CCCB Review Board. A panel consisting of a physician, a lawyer, perhaps an ethicist, and community member, would provide a more broad based exploration of the issues and decision-making process.
While I applaud the goal of not making the process excessively onerous for patients, I also worry about decisions being made emotively and fast. If there were tight time frames placed on panels for decision making and adequate resources provided, as there are for the two examples provided, I believe that a necessary “slowing down” to ensure that the decision has been rigorously and comprehensively reviewed need not be at the expense of providing patients with timely responses.
As a psychiatrist, where these applications promise to be even more complex, given the lack of clarity regarding the boundary between the symptoms of certain psychiatric illnesses and a desire for death, I particularly see the need for external input apart from patient and physician, including a consultant, to ensure the safety of everyone involved.
Thank you again for the opportunity to consult on the draft policy.
I object to my profession being obliged to assist in actively taking patients lives .the circumstances are vague and subjective and could lead to the vulnerable requesting such a death on the grounds of being a burden on society and family …moreover the obligation to refer in good faith to someone who will act in the event of conscientious objection is ethically wrong and carries the same consequence as doing the deed ..I see this as a slippery slope for our profession
Line 47: equitable access to care should include access to palliative care, chronic pain, mental health services as a PRECURSOR to any access to assisted dying. It is hypocritical to demand universal access to assisted dying before universal access to all of the former.
Line 63: I believe the College should be more prescriptive in the types of medical conditions, at least initially, given the concerns voiced over mental health diagnoses and vulnerable patients such as the disabled, etc.
Line 89: What if prognosis is uncertain or unknown? What is the prognosis of a patient with a non-life threatening disability ie spinal cord injury or a mental illness like depression or bipolar disorder?
Line 112-113: It is impossible for a physician to know if the decision is without coercion or undue influence. This sets an impossible standard.
Line 141-142: “intolerable suffering is subjective…assessed from individual’s perspective” This line essentially opens up the criteria to any and all symptoms and/or conditions. But Line 145-146 states the “physician must be satisfied” This sets up a paradox. Individuals says it is so, but physician may not agree.
Line 126-127: Once again, what if the prognosis is unclear or unknown? Is this immediate grounds for refusal?
Line 187: what if said physician is not “available” or the service is not available?
Line 189:
Stage 1 “where time is of the essence” This is ambiguous and lends itself to a very open interpretation. Someone suffering from a “grievous” condition may always argue that time is of the essence, rendering the waiting period moot.
Stage 2: Given the serious nature of the intended intervention, should a specialized capacity assessment not be mandated in all circumstances?
Stage 3: Should the CPSO provide policy on assisted dying, I would suggest limiting it to patient administered hastened death rather than physician administered euthanasia. This would be consistent with the more limited and conservative model in the United States rather than a much open and liberal form in Europe which has raised concerns about criteria, monitoring and quality.
I hope these editorial suggestions prove helpful. While most palliative care physicians view PAD as separate from PC, we also understand that we will need to provide care in a new and evolving environment. I hope the CPSO will take the CMA, CSPCP and CHPCA policy statements on this matter into account.
As a physician with MS I am relieved to know that PAD will be enacted. MS is not an acute illness and it gives me comfort to know that I will have a choice when and if the situation arises. I do believe this document allows anyone to exercise their own moral judgment and no one has the right to stand in the way of this.
I have read this forum in its entirety. I have been an anaesthesiologist for 40 years. I am a member of the group: Dying with Dignity. I would not like to be involved in assessing the eligibility of patients for PAS because I probably do not have the qualifications to do so. I, however believe that I would be the ideal candidate to administer the end-of-life medications needed whenever the decisions have been arrived at by more qualified physicians than me. Maybe I could be the expert hands needed in cases where the decisions have already been made and such physicians feel uncomfortable with administering the IV medications at the end. I wonder if the college would have a need for a “technician” like me to come in at the last minute to assist the physician who has made the judgment to go ahead with PAS but does not feel comfortable administering it. By the way, I do not agree with the medications used for PAS. I think they could be improved upon. Strong successive doses of anxiolytics, induction agents, neuromuscular blocking agents are correct but should be quickly followed by a heavy dose of potassium chloride to induce immediate cardiac arrest rather than waiting for anoxia to do it over 5 to 15 minutes.
At first I was shocked by your submission but then I found it enlightening and so I would like to reply.
Although less experienced than yourself, having worked only three and not four decades in anaesthesia, I also have experience with primary care (I am a GPA). Let me make several comments.
Reducing euthanasia to a “technical” service, as you have done,serves to demonstrate how the Canadian discussion on this subject in many instances has been robbed of its ethical and moral significance and accountability. This kind of reductionist world view leaves no room for the moral imperative. Have we really descended to this level in modern medicine?
As to the question of death by hypoxia or cardiac arrest, based on the drugs used, why should it matter? It certainly is of no significance to the person undergoing euthanasia as they are unconscious. I presume from your statements that it is more palatable for the observers which include the family and the service providers. This is also indicative of another under-expressed point. That is, whose wishes are we really trying to honour here? The patient or those around them? I think some, if not many, people who will choose euthanasia will feel compelled to do so for the sake of those others. Again a practical point which demonstrates the lack of moral imperative.
Whereas I am trying to understand your offer to help, I am more struck by your apparent opinion and representation of euthanasia as just another day at work.
If this is what it all boils down to, then I must say “shame on us”!
I have been a physician in practice for 26 years. Unfortunately I have had to care for countless patients who were “competent individuals suffering from a grievous and irremediable condition”. These patients ALL expressed concerns that they had to suffer needlessly despite palliative care treatments. I hear physicians quoting the Hippocratic Oath when dealing with such patients. I feel that we are doing them harm by forcing them to live with these horrendous conditions. The public and physicians should take their religious beliefs out of the equation! DON’T DO THE PATIENT FURTHER HARM BY FORCING THEM TO LIVE!!!
What a wonderful offer. You indeed have the compassion and skill set to help your colleagues. Also the CPSO does need to provide up to date drug information!!!
Dear CPSO
Although I highly doubt you will take into consideration my comments, but I ask you to reconsider the need for referral. This is in violation of conscience rights of physicians. Due to the CPSO’s recent policy Professional Obligations and Human Rights (requiring referrals for abortion) and now for euthanasia, I have left the province of ON to practice in MB where my conscience rights are protected/respected in that province.
The interim guidelines on PAD are clear and well defined. I agree with several respondents that a referral service in Ontario be implemented that would be accessible to anyone who wishes assistance in ending life. Licenced facilities similar to a hospice would provide end of life care that would allow family members to be with their loved one at the time of assisted death. There should be provisions for those who wish to die at home. I also think that advanced directives should be honoured. I have watched while several of my loved ones have died a very slow death with dementia eventually dying from starvation because they could no longer take nourishment. My POA should be able to give consent , following both my written, signed and witnessed directive and the guidelines afforded to fully competent individuals.
I understand that for many physicians this is a very difficult policy and no phycian or health care professional should be required to provide this end of life service; however, those who agree that PAD is an individual right should be respected. We also need more palliative care centres, Physicians , Nurse Practitioners and Nurses who are trained in end of life care.
What you write seems very strange to me, I cannot comprehend it. During 30 year of oncology practice I came across only a handful of patient who expressed interest to die as soon as possible. Almost all were asking to give them more life, every week every day extra seem to be of value to them. Some of those who had incurable and progressive illness were able to achieve many things not done before: get married, create an object of art, heal a longstanding family dispute, make a sound business decision for their family.
The idea to have a designated licensed facilities to provide assisted death is a sound one, I believe. It would better then to force this service provision on hospices – the idea is in conflict with principles of palliative care. And it would be better then have people receive assisted death in hospitals, which focus on life prolongation.
The great majority of suffering patients who will come forward requesting assisted suicide will not be articulate, nuanced, pain free, gradually and inexorably failing. They will be anguished, struggling, and depressed, with complex medical conditions and often pain.
In these most complex situations judging “Grievous” is fairly easy. But “irremediable”? Does that mean improvement is “unlikely”, very unlikely, or “inconceivable’?
And who will say that one suffering patient feels depressed but is “capable” and another depressed and “incapable”.
Inevitably, some physicians comfortable with assisted suicide, will view “irremediability” and “capacity” much differently than those of us deeply uneasy about assisted suicide. I wish I could say that the decisions and ethics of my colleagues were uniformly excellent, but that is not the case.
I do not agree with empowering doctors in this way. I am an enthusiastic supporter of conventional, competent, palliative care.
As far as I am aware the meaning of ‘irremediable’ according to the court was as follows: the grievous condition cannot be alleviated to the satisfaction of the patient (as suffering is subjective and therefore cannot be quantified by another party), with any treatment deemed acceptable to the patient (as every competent patient has the legal right to refuse treatment).
I agree that this should be made clear by the College so that physicians realize it is not up to them to determine whether other treatment options could hypothetically bring about some improvement or not. Of course, all treatment options must be brought to the attention of the patient, but it is not the physician’s responsibility to define ‘irremediable’ for the patient.
The current status quo is dishonest – the distinction of active vs passive does not hold up under scrutiny anyway. The person who was principally entrusted for sustaining the life of that dependant is actually making an active decision to stop sustaining life where death is the final outcome of that decision. In allowing death, you are causing death by removing the forces that were holding it back for a time. Whether the death occurs by passive neglect or by deliberate action, the result is the same – the only difference is the rate of mortality, not the principle
We have appropriately accepted that life does not need to be preserved at all costs, but that patients can define for themselves when they no longer wish to maintain active treatment as well as the basics of life like hydration and nutrition. We have already conceded that we do not have an obligation to sustain life except on the patient’s own subjective terms. On what basis can we then turn around and deny them the right to choose the time and manner of their death and instead force them to continue to live against their better judgment? This constrains them to a slow death by starvation and/or neglect of basic life sustaining care to the same end.
I can see the gray in slower, chronic illness. However, when we are at an imminent end of life, I do not see what purpose there is to sustain life for a moment longer if the patient and/or family do not wish for it.
The outcomes and intentions between these two modes of euthanasia are not different in principle and that distinction between active and passive euthanasia is a false distinction. We need to be more honest into what we are already comfortable doing with withdrawing care as well as acknowledge with a clean conscience that there is no moral difference, and now no legal difference between withdrawing care and going one step further and putting an end to someone’s suffering at their request.
At this point, the only thing that is important that appropriate due process is followed.
The biggest uncertainty in all this for me is what about the situations where we need substitute decision makers to make decisions, how will that be ultimately handled – especially if there was a clear advanced directive?
The current document advises against for now, but this would seem to be contrary to the spirit of the law and I wonder how that will be resolved
Briefly: The “Professional Obligations and Human Rights” policy was railroaded in despite significant majority opposition in the formal feedback process. I fear that state-sponsored coercion to PAD for objecting physicians will likewise be forced upon us, despite our concerns listed here.
Nevertheless, as a physician practicing inpatient care for chronically/critically-ill patients, I add my voice to the concern expressed above regarding the corrosive effect of PAD, especially coercion to PAD, on the culture of our profession and the virtues of a good doctor. Moreover I am very skeptical of our ability to protect the vulnerable (frail elderly, socially disadvantaged, mentally ill, addicts, etc.) from systematic murder. Already we are providing them with substandard care in our very imperfect system – killing them to eliminate the problem is the next logical step.
The reluctance to establish an external, non-physician-based system to perform this act (a la “Soylent Green”) speaks to a fascistic tendency in the CPSO and our current government, which seeks not only to attain its ideological goals, but also to destroy all who would oppose them.
Well, I am saddened to see the gradual progression of this country over the last year over this issue. There has been great “normalization” of the concept of killing our patients early as a treatment option, and very successful promotional campaigns. I remain very grateful to those of you who are vocal and are still inspiring to me. It is a little lonely to be practicing and hearing the scary new rhetoric and the new policies that might be affecting me. I wonder will I have the courage to stand up to them if they are implemented? I am frightened by a policy that states that I must refer against my conscience
I try to remain dedicated to my patients care, and believe in the beauty and delicacy of their lives right to the end. I have not always done an ideal job of palliating, and continue to learn. I have many times been faced with my patients despair, either in the end of life, or in other periods of their lives, and I wonder if that is truly what we are failing to respond to adequately.
For most of our patients problems, we are dutiful in our responses with hopeful investigations and treatment plans. Our relationship is validated by our usefulness – at least in my eyes. What will I do? what will I offer? what will I fix? Indeed even in palliative care now there are evolving algorithms and nice treatment options for each symptom component. Each symptom can be alleviated into oblivion, often.
except despair. I cannot easily compel my patient to hope when all that is left is the end in their eyes. This is the ultimate symptom to bear.
Many patients do not have this despair, thank God, and it has been a tremendous privilege to share in their peace. I know where it came from.
I see despair as a symptom that has not been well elaborated in palliative care and that required better scrutiny, better algorithms, and better treatment. I appeal here to the many experts who have already written and those silent out there who know… It feels like we are instituting a “treatment ” in physician aided death for despair, when we probably should develop a better organized approach:
To me, when someone asks me if there is a reason to live, I start looking for depression, obviously, but then other unresolved causes of unease – despair is often spiritual – or relational. or even financial. Sometimes it is about a poor understanding of the end processes? fear of being alone..
I am worried that many of us will be tested. The real “enemy” is relativism, it is important to remain true to what is true and good for our patients. Some things are immutable.
I believe most of the issues have been highlighted by others. I would just like to underline my concerns that have been noted :
1) mechanism for referral to second physician is problematic for many physicians who do not support PAD
2) consent cumbersome ( who doesn’t fit into the excluded categories?)
3) how the second opinion is to be utilized if it conflicts with the first needs to be clarified
I would just like to record my total opposition to any doctor being involved in assisting patients to end their lives. I did not sign up for this when I became a doctor and in my view it is contrary to the Hippocratic oath. I have no issue with palliative care protocols and ensuring comfortable death when nothing further can be done, but this new situation is open to dangerous escalation.
I presume that I can opt out, from an ethical position. A lot of my colleagues share a similar viewpoint and I hope that they also express their misgivings.
Dear Sirs
I have significant concern about a small part of the CPSO on MD assisted death draft when a patient autonomy to have death provide the relief they seek is not observed once they become incompetent. This may not be right in many circumstances . May I give an example.
Imagine a patient wishes to have an assisted death if an ongoing dementing illness or brain tumor progresses to the point they are no longer competent. They very clear articulate and plan for this . Once the point they have expressed the need for relief from an intolerable condition is reached the draft now takes this from them. The draft would push them into the choice of an earlier demise or deny them the choice they have planned for.
I ask the committee consider this point and to develop better language that is less rigid and problematic for cases of disease that by its nature will lead to loss of competence and it is the loss of competence that patient finds intolerable.
In my opinion the end-of-life issue is far too complicated to be turned into a science or pseudoscience as it relates more to cultural, religious, and philosophical beliefs. I have a family member on her 4th cancer over a 30-year span; she worked till retirement at 65 with interruptions for hospitalizations and chemo,… Just like her attending physicians I have not yet understood where she finds the courage to state “you know cancer is a chronic condition one learns to manage like any other chronic condition”. The college may want to explore or address the issue of an exponential rise in narcissism as it relates to “the need to be perfect or else”; in other words it is not that simple, but life never is, is it? Why should dying be?
I feel more brainstorming is called for, legislation often complicates issues rather than resolve them.
We as a profession may have to revisit why we chose that profession in the first place; policy makers (even when they are physicians) do not see patients.
Physicians per se should NOT be involved in killing patients. Maybe a patient of sound mind has a right to die, and if necessary assistance to do so – but surely that can come from family, friends, or even the local hardware store? Why us?
All that is needed is for physicians not to PREVENT patients of sound mind killing themselves, or being assisted to do so. That meets Charter obligations, eh?
One Dutch FP was so disgusted when the local hospital “euthanazed” his elderly unwilling patient (they needed the bed on a busy weekend) that he emigrated to Canada! He reported this case to a Canadian government commission years ago. Let’s not go there!
If a doctor must kill people, it should be in a special non-health facility (death clinic?). Otherwise we will lose public confidence.
Good afternoon,
I am very grateful the CPSO has chosen to take a proactive direction on the guidance around PAD, and has nicely complemented this with the previous release of the End-of-life policy in September.
I have concerns however about the specific lack of guidance on how to interpret (and also WHO deems such a state) a condition as causing irremediable suffering. Will there be further details on this? Will it require specialist level opinion to be deemed as such?
I think to my practice as a resident in General Internist and the patients I see with dementia. It would seem callous and irresponsible to provide PAD (if requested) when first they are first diagnosed, given these individuals relatively preserved functional abilities at the time. And yet they are left to slowly deteriorate in a LTC facility and are often deemed not capable for personal care at more advanced stages.
The current policy does not provide any insight as to how to reconcile this dilemma. Many of my patients have indicated their intention to end their life should they receive such a diagnosis, but I am uncertain how that will be carried out. I of course understand the ethical concerns around having the decision made by a surrogate decision maker who may not have the patients best interests at hand in all situations.
But how can we provide an intervention such as PAD only to individuals whom are capable at the time they receive the treatment, when many of those who need it most (and have expressed a desire for it in an advanced care document) indicate that their wishes would be as such?
I look forward to your thoughts on this matter.
You have put your finger on the biggest hole in the document. If this Catch 22 remains until I reach my final decline — whenever that may be — I will have to seek PAD while while I don’t need it because I know that i will be denied it at some future time when I do need it.
Talk about killing people in order to save them.
I too am very concerned about this issue. I believe the SCC decision indicates that a patient must be able to consent DURING their application process. However, it would certainly be against the spirit of the ruling if a successful applicant was subsequently precluded from accessing PAS because their condition worsened and as a result they could no longer express their consent.
Should the College prevent the patient’s wishes from being carried out as a result of them losing competency AFTER their application had essentially been completed, one could certainly argue that the intent of the SCC decision was being intentionally subverted.
Something must be arranged to protect the patient’s wishes when their declining health, or even another unexpected medical event, renders them suddenly unable to consent, but their choice has already been verified. Perhaps a binding ‘Advance Care Directive’ would be one possible solution.
The Swiss actually have a careful ‘pre-registration’ system, where a patient can receive approval for assisted suicide in advance. Then, should the patient’s condition deteriorate to the point where they no longer want to continue suffering, or are incapable of expressing their consent, the service can be provided in accordance with their already documented wishes.
Thank you for the opportunity to review this document. My only comment would be that the literature that is cited regarding medication protocols for PAD are very dated. Are there no other resources (published or not) that can be referenced? Or are these papers what other jurisdictions rely upon? Is there any scope to look at what Quebec is doing?
I have worked as a psychiatrist at a hospital in Toronto for almost 20 years. For the past five and a half years I have been doing psycho-oncology assessments and treatment/therapy. I have followed the development of the Physician Assisted Death issue with very attentive interest for some time. I would like to highlight the following points and offer a few suggestions.
No doubt you have considered that the wording of the SCC ruling potentially encompasses any psychiatric condition if it is grievous to the patient and irremediable (i.e. if it has for practical purposes been treatment refractory based on the particular patient’s treatment history). Mental Disorders listed in the DSM-5 or ICD-10 are, if I am not mistaken, all generally viewed as medical disorders. I know of no generally agreed-upon objective criteria by which to parse ‘medical’ from ‘psychological’ mental disorders. Since many mental disorders impair rational judgment, insight and perspective, and often in subtle ways, competence assessments are all the more complex and challenging in such disorders.
That said, I fully support and agree with the SCC ruling and I do think that psychiatric patients should not be discriminated against in determining their eligibility if requesting physician assisted death. Even though as a psychiatrist I am committed to the prevention of suicide, I have worked with many patients suffering (purely) from psychiatric disorders who in my opinion would legitimately meet the SCC criteria. Such patients should however be very carefully assessed to determine whether their decision is really competent and rational, from as objective a point of view as possible. An additional important criterion applicable to psychiatric conditions for this purpose might be that the wish to die should be consistently sustained over a long period of time. And collateral/corroborative opinions from family members would also be especially important.
I am sure you have also carefully considered the question of whether a psychiatrist should routinely be involved in all competence assessments for physician assisted dying (i.e. for all patients, not just for psychiatric patients). The advantage would be that many psychiatrists have more experience and a more nuanced understanding of the issues pertaining to competence and rationality than do most other types of physicians. A possible disadvantage might be the potential for delays if availability of suitably experienced psychiatrists is limited.
I am surprised to not see the above issues already covered in the physician feedback pages on the CPSO website. This has motivated me to submit this email at this time.
Thank you for taking leadership on this exceedingly important, sensitive and timely issue.
Please add my input to your consultation.
1) I have no doubt in my mind that physician-assisted death – suffering relief will become like physician-assisted death – unborn children. Humanity does not have the capacity to self-manage well enough to constrain its self-centeredness and be judicious or rightful in how it mitigates self-suffering. Belgium is a perfect example and I am so sorry that Canada is sure to follow. I truly believe that this is simply the beginning, and that ultimately, “useless” senior citizens will be fed into the physician-assisted death machine.
2) It is cruel and ridiculous to make physicians who conscientiously object to physician-assisted death to ensure that the seeker has access to physician-assisted death practitioners . Why would you put the onus on the soldier to find their own replacement? The most frightening thing is how it reveals your punitive and retaliatory mind-set.
Regarding physician assisted death:
I have been a practicing physician for over 40 years
I respect the right of a person to decide on their own to do whatever they wish within the law BUT I object strongly to being told I must provide a referral to a physician who provides this option regardless of my own personal value system and beliefs.
I can see the necessity of providing a patient with their medical record to take to someone but I see no reason for me to get involved in this issue if I choose not to. The Government or CPSO should supply the public with an access number to participating physicians and let patients make their own arrangements . I feel it is an infringement on my rights to be told I must provide a referral regardless of my personal beliefs on the matter. It is reminiscent of the old abortion committees and the “necessary “ referrals prior to the women’s rights movement and subsequent and appropriate yellow pages access for those who chose on their own to seek an abortion from a clinic willing to do it.. I feel very strongly that only patients seeking assisted dying and people comfortable with that route need to become involved in this process. I have no problem expressing my personal beliefs to a patient and turning it over to them to access their own choice but I do not feel I can be legislated into becoming involved in this program by writing referrals at the request of a government and college who should solve the problem on their own by providing equal access to patients wishing to seek this service by some other means. This is a very personal issue and the legislation should be rewritten to leave out those physicians who wish to be left out completely, specifically regarding the legislation of mandatory referrals . This in no way is meant as a moral judgement on a patient who chooses this route but it is very clearly an objection to the wording of the present legislation which ignores the rights of physicians to stay out of something which they do not wish to become involved in which might be, in their opinion, pushing medical ethics and “care” to very uncomfortable limits. Please find another solution to ensure people have the access they wish without involving physicians who wish not to be involved . Writing such a referral letter might seem to be a trivial matter for someone unable to put themselves in that position but from my vantage point it is clearly not.
The College has to respect individual’s rights as to their choice. I believe that Advance Directive by an individual should be respected one way or another. Many times it is NOT possible for individuals to make a choice once the diagnosis of fatal neurodegenerative disease is made. These individuals are then stuck and sentenced to suffer the fate of the disease, which, perhaps would not have been their choice. The “next of kin” then is unable to carry out the individual’s wishes.
I went thru this over the last 12 years, with my wife , who was diagnosed with Dementia and then was told that she was, then, incompetent to make a decision. She expressed wish was NOT to suffer this fate. Her choice was to live till she had a “meaningful” life and did not want to be a burden and live in a nursing home etc. Poor woman had to suffer this fate and made everyone suffer with her.
Kindly respect individual’s personal choices whatever they may be thru Advanced Directive. I feel that the individual should seek legal opinion and draw up legal documents and then the courts would have to respect that.
The College needs to work with the Law Society in getting some standardized documents regarding the Advanced Directives and the profession be made aware of it so we can let our patients know what resources are available should they want to express their wishes for their long term care.
In jurisdictions where assisted suicide is legal (Belgium is an example), there has been an increase in the rate of suicide in the general population. Suicide becomes acceptable and a “right”. Values and mores tend to be guided by what is legal. Do we want to see more suicides generally?
I think the Supreme Court of Canada made a big mistake.
Catholic Women League
We do not agree that a doctor assist a person to die. That is God’s decision and not for us. God gave us life and it is up to him to take it.
We should all be able to support the Catholic Women League in their position for them, their members and their co-believers that they not be forced to interfere with God’s plan for their lives.
Similarly, can we expect the CWL to support those of us who believe in other gods or none and who wish to decide how much of life we want to endure?
The position of the CWL is consistent with standard and norms of physicians since the time of Hippocrates, who states in the “Hippocratic Oath”: “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so…”. Here, he outlines the code of ethics prohibiting euthanasia and physician assisted suicide, that has been followed by physicians for millenia, until only recently. Hippocrates was neither Jewish, Christian, or Muslim. He would oppose euthanasia and physician assisted suicide, and would condemn others who promote it, regardless of faith background. CWL’s position is in line with over 2 thousand years of tradition, embodied by this “non-religious” man. Thank you CWL and other groups for standing up for what is right.
Thank you for a well written policy. You have addressed my concerns. I feel it is important that patients demonstrate consistency over time, here 15 days, and that there is a second opinion.
I would like to see “spiritual angst” be removed from being an acceptable indication for terminal/palliative sedation as there is no requirement for consistency and a second opinion. It is more suitable to be considered a request for PAD.
Please find below a letter written to the College of Physicians of Quebec, in response to an editorial on the Collège website on physicians’ freedom of conscience and the euthanasia law: “Referring the patient’s request to a health care professional who would follow through with it would then seem the ultimate compromise, respecting patient’s and physician’s rights.” November 10, 2015
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“First, let’s recall this excerpt, from of the Superior Court ruling (par. 97): “The lawyer of the Attorney General of Canada also expressed her concern about article 31 of an Act respecting end-of-life care, obliging physicians who do not want to grant a request for physician-assisted dying, to participate, despite their objection, in the process of finding a willing physician. She sees in this fact itself an indication that even a physician, conscientious objector, would inevitably become involved in a process leading to the commission of a criminal act under the current state of the law”.
This summarizes without ambiguity the thoughts of the Attorney General of Canada and the Quebec Superior Court concerning your “ultimate compromise” on the subject of conscientious objection, also shared by the Collège des médecins du Québec.
This form of collaboration in killing a patient, with all due respect, is not the ultimate compromise. It is an obligation to collaborate — which can be experienced by a physician as complicity in an act he considers to be harmful to his patient, irrelevant whether the act is criminal or not (the crime evoked here only compounds the insult of the obligation).
As for me, I want to continue to offer care to my patient; not sever the relationship. I simply refuse to cause his death. What will you do against my medical judgment?
If you suspend me, you are the one severing the care relationship by depriving a patient of his physician, whereas I am willing to continue caring for him. I do not consider sending my patient to be killed as providing care because… to be killed is not a treatment, neither for me, nor for the overwhelming majority of physicians and medical associations all over the world. This then is a question of medical obligation, because I apply the international norm, while the Collège has decided unilaterally to disagree.
The issue here is much more a question of scientific objection than an objection of conscience because the purpose is to apply the international norms and standards the Collège decided to disagree with.
Given that most physicians will never agree to stop preventing suicide among their patients, we cannot compel them to stop this prevention because their medical judgement and expertise—that they have applied for years—tells them not to do it. Simply put, preventing suicide remains good medicine.
Likewise, a hospital director cannot force me to perform surgery on my patient if my medical opinion tells me the surgery would be harmful. It does not mean that I sever the professional relationship with my patient, only that I exercise my profession with my judgement and my competence, which means to say that I am not a simple technician who will only serve to be “someone else’s hands.”
In the same way, no patient can force me to perform surgery that I consider bad or harmful, and it is understood that the minimum degree of professional consistency would prevent me from referring him to someone who would perform it in my place. I would simply tell him that it is not recommended, and he would be free to go elsewhere. If however, I were to transfer him to a colleague or health care professional knowing that the procedure I consider harmful will be conducted, it would be as though I performed it through the hands of another.
The Collège needs to recognize this logical response from physicians (palliative and other) who do not want to collaborate in paving the way toward the medically assisted death of their patients. These physicians, who are neither fanatical nor arrogant, see this intention of the state (and of the Collège) to impose on them a forced collaboration like an abuse of authority. The use of the term “ultimate compromise,” in this context, sounds a lot like “this is my final offer.” That, would sooner be called an ultimatum—and the Attorney General of Canada did well to note the real intention behind the words.
In conclusion, if the Collège hopes to avoid unjust and unnecessary confrontation with qualified and attentive physicians of integrity, it should find a way not to compel them to assist in the death of their patients against their medical judgement and their professional conscience.
Even if the new exception measures (not to read “rule”) that will soon be established in the Canadian Criminal Code allows for euthanasia or assisted suicide under certain conditions, you must remember that forcing physicians to refer—moreover to threaten them—is a sure-fire way to cause unnecessary and damaging battles for all, to cause division and spoil the collegial environment in our hospitals.
If, one day, euthanasia or assisted suicide are decriminalized, a true compromise—one that would respect everyone’s autonomy — would be something like this: let patients carry out their own wishes by putting a voluntary system in place, forcing no participants to act against their will—neither their doctors nor anyone else involved.”
There will need to be 2 separate clinical strategies for assessing patients who state that they wish to have assisted death.
Young people (<70 ?) who suffer from a severe physical or mental disease or disability would need to be thoroughly studied to determine if any possible new intervention, treatment or therapy could improve their quality of life enough to make them want to continue living. They deserve medical care.
Very elderly people, who have had and appreciated a good long life, but are now facing general decline or an illness like pneumonia, dependency, lack of interest, and frailty which permanently diminish their quality of life should receive PAD in a very timely manner to not punish them with the physical indignity and the mental anguish they face. Respect must be shown to them in honouring the good life they had, by enabling the "good death" they have the right to choose.
(I come to this view through intimate personal experience. I watched my 95-year old mother starve herself over 11 days in order to bring about her desired death. She'd had a wonderful, long life.)
Recognizing that these are only draft guidelines for physicians in the murky waters of assisted death, I would suggest much greater attention to the last paragraph of the guidelines, ie) reporting of these deaths. The Quebec law which is still new and under continued scrutiny covers this topic of reporting in considerable detail, and reminds physicians that although we have our patients’ interests in mind, we do not practice in a vacuum. The recording of how many cases, and what kind of cases, etc. would be of interest to all concerned.
Thanks for the opportunity for feedback.
It states that patients have to request it – does this mean I am not allowed to mention it along with a list of other options to make them aware it is legal?
otherwise I would say something like “care options include: full care, limited care, palliation, or if desired euthanasia” and then leave it to them to make the case for their own euthanasia (i.e. I would not be pressuring them, only making them aware that it is now (or soon to be) legal.
I primarily deal with acute care medicine and a 2 week waiting period is often far too long for the scenarios I deal with. I have no problem waiting for 2 weeks in ambulatory/ chronic situations but when someone is actively dying, what would be a reasonable waiting period – I would think that hours to day(s) would be more reasonable for someone I expect to die within a day – week.
Is the model given something that the college will hold rigidly to as standard of care, or is it more of a suggestion/ advice that we don’t necessarily need to rigidly adhere to?
The part about “The College advises that one of these witnesses not be someone who is: the attending or consulting physician; a relative; entitled to any portion of the estate” creates a lot of difficulty for me.
I am not sure who that leaves left to sign other than random friends or perhaps a chaplain after you exclude relatives and MD’s, but not everyone has that kind of support around. What would be reasonable for me to do in that situation? Is this something you expect me to rigidly adhere to or just do my best to try and get someone as removed as I can? I can see this being an unfair limiting factor for many of my patients.
Can you make the reference papers listed in your document available – despite my best attempts, I am not able to access those documents as they are so old.
Have you thought about what you are going to do to physicians who refuse to provide an “effective referral” for physician-assisted suicide?
Have you thought about why it is that over 90% of palliative care physicians are strongly against PAS? Are you going to suspend them all when they fail to make an effective referral? Or maybe you’ll find physicians who provide the “full gamut of palliative care procedures”. If you did any such thing, many of us strongly believe you would be acting in a manner not dissimilar to the Nazi regime. You would be committing a terrible injustice. Please reconsider this entire draft. As a moral imperative and duty of the College to protect and nurture human life, do not go down this path. Stand strong against physician assisted suicide and defend the integrity of the medical profession.
The father of medicine states in the “Hippocratic Oath”: “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so…”. Here, he outlines the code of ethics prohibiting euthanasia and physician assisted suicide, that has been followed by physicians for millenia, until only recently. Hippocrates was neither Jewish, Christian, or Muslim. He would oppose euthanasia and physician assisted suicide, and would condemn others who promote it, regardless of faith background, simply because it was the right thing to do. I urge the CPSO to rescind this draft, and protect the moral integrity of the medical profession.
It doesn’t matter whether we call this euthanasia or physician assisted suicide. The result is the same. The patient is dead. What are we doing. It appears that many people want a death camp alive and well here in Canada. If you are sick or depressed the option of being killed or killing yourself is an option next month. Do we think that people will not be forced to accept this as time goes on. Look at the abortion situation, it has grown from a committee in the hospital allowing the mother to kill her baby, to now family members and others forcing a mother to abort at any time in the pregnancy. Do you think that people will be different when it comes to PAS. If you think that guide lines will help, you are wrong. Forty years ago people would not have agreed to PAS at all but now those who support it say that if it is requested then the country should allow it. We are on a slope that will go faster than abortion. All we have to do is look at Holland and Belgium were patients who go into the hospital can be euthanized even though they have not requested it. Poor Canada after we finish killing our citizens will there be any one left.
There is another way. Patients who go into our hospice in my town are well looked after to the natural end of life.
As for physicians, why should they decide when a patient dies even if the patient is very sick or in pain. Most of all why should a physician be forced to euthanize a patient. This is a sorry state for our medical community. What will happen to research in the future. There will be no need for it. Just die patient.
I would suggest that the Interim Guidance document include reference to the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying Final Report (November 30, 2015), as an excellent reference for all Ontario physicians. This would provide a broader context for understanding the issues arising from the SCC decision.
The CPSO Interim document is concise and well written, but limited in its purpose and coverage.
If society decides (and I suppose it has) that euthanasia should become legal, the very last people who should do it are physicians and nurses. I think our medical leaders have abrogated their responsibilities in this matter by so casually discarding principles held by our profession for thousands of years. There should be an entirely new profession established, consisting of people who believe strongly in this issue who are trained to terminate life, and they should be brought in whenever a patient requests it. Physicians should continue to provide treatment including pain management and palliative care, but the act of euthanasia itself should be carried out by the “euthanist”. Physicians have been dragged into this issue only because the small numbers of physicians supporting it give it a sense of legitimacy, and I can’t believe that the leaders at CPSO and the CMA cannot sense the dangerous ethical and legal quicksand upon which we are about to tread.
Suicide and assisted suicide were legal in the time of Hippocrates. Nevertheless he forbade his students and followers to be involved. The basic arguments for and against euthanasia haven’t changed since then – our profession has. We somehow think that we are immune from the ethical conflicts that Hippocrates foresaw so clearly. I think we will find, to our great cost, that we are not.
I am a retired physician and U of T teacher. I firmly believe that patients’ self-determination is the central issue here and, in case of doubt, the greater good. However active physician participation over and beyond making a referral should be voluntary.
A consent and capacity board should be available to deal with complex issues.
I have read the CPSO interim guidance on PAD document and I am very concerned about your position under Conscientious Objection.
Although PAD may no longer be illegal, the College should not consider it part of “health care” as it is clearly not health care but rather the end of health care. As such, being involved in the process in any way should not fall under the responsibilities or obligations of the physician.
Therefore the expectations for the physician as set out in the Colleges Professional Obligations and Human Rights policy should not apply.
This issue has elicited strong positions for and against PAD in our profession as it speaks to the very core of our beliefs and world views concerning life and death and the taking of another human life, whether requested or not. It also speaks to how we, as physicians, should define our vocation and responsibilities. As such the College should be very mindful to not force physicians (or other health care professionals) to participate in PAD in any way. Forced consultation would constitute forced active participation in the minds of many who object for any reason. In the era of readily obtainable information there is no need to force physicians, who object, to consult. Patients and their families would have no trouble accessing information on self-referral for PAD. This process should remain in the hands of the patient and their families to arrange, as is the case with any other non-health care related procedure. Information could be made readily available to them but the physician should not be the party obligated to provide it.
Lastly I believe that PAD should not take place in hospitals. Many health care providers may feel strongly against participating in this highly personal issue. Instead, the College should recommend that this take place in separate facilities outside of the hospital setting where all involved are voluntary participants.
This would ensure palliative care physicians, and nurses, would not be pressured to participate or potentially risk losing their jobs, as may soon be the case in Quebec. I fear that the hiring practices for palliative care physicians in the future may depend on their willingness to provide PAD. This would be highly discriminatory against our physician colleagues who may object to PAD. Will they be forced to choose between PAD and working in their desired vocation?
I understand that there is a balance that needs to be arrived at between a patients right to request PAD and physician right not to participate in PAD. I believe that both can be addressed without the need for forced consultation.
I have just reviewed the CPSO Interim Guidance on Physician-Assissted Death and I strongly disagree with the last point in the section on Conscientious Objection. The mandatory requirement to refer a patient makes the objecting physician a collaborator in the process of killing his or her patient. The refusal to provide a treatment that, in the opinion of the physician, is not in the patient’s best interest is not abandonment of the patient.
I believe the requirement of a mandatory referral is a violation of my constitutional rights. This requirement should be removed from the policy.
I would like to thank you for the opportunity to provide feedback on the CPSO interim guidance on physician-assisted death document.
It is not clear to me why we should restrict this to the Ontario residents covered by OHIP. I would suggest that this limitation being removed.
- i understand that there are terminal diseases that could be associated with long agony and pain, however there is a big difference between keeping the paients comfortable as much as possible till they die and giving them medications to kill them.
- there is also a big difference between holding treatment or support (e.g feeding tubes, ventilation ect.) that we know from the course of the disease and the condition of the patient that such intervention will not reverse the disease or change a hopeless condition ,and actively killing the patients by any method.
eusthenasia if allowed ,it will be abused at many levels and by parties involved.
- there is no other word that could be used -let us not fool ourselfes- to describe it except that we would be killing patients.
- we went to medicine to treat people,alleviate their pain,cure diseases not to kill people.
- why such burden should lie on our shoulders as physicians,? i am very sorry that some patients will suffer from a disease that is beyond control or releif,but i do not think that the answer is killing them.
All life is precious and no one should be killed by anyone that is clear to me.
College of Nurses of Ontario
Response in PDF format.
1. Judgement is spelled two different ways in the document.
2. Does grievous medical condition include mental illness?
3. Patient and doctor should have opportunity to meet alone, in order to avoid undue influence of family members.
4. Neither witness to the final document should be a beneficiary in any way.
5. There needs to be a legal definition within Canada of Physician-Assisted death as being equivalent to natural death to avoid financial repercussions or criminal charges.
6. It is important to protect anonymity of participants.
7. Address the possibility of the procedure being unsuccessful but leaving the patient further impaired. The patient might then become unable to rescind and by this document, the procedure would have to stop.
8. Address the concern of conflict of interest in medical literature for authors. Should they not be required to declare such conflict in published articles, such as religious affiliations which might alter their impartial status, much as they must do with respect to similar financial considerations.
9. Consider encouraging physician to advise the patient of the need for separate legal advice with respect to estate and insurance issues.
The focus should be on “reasonable accommodation”- ensuring that patients’ access is not affected by the conscience of the physician. Physicians are moral beings but our professional role requires us to take on a fiduciary responsibility that will occasionally make us step outside our circle of comfort. Hopefully these will be rare situations, and the requirement on the physician will be as minimal as possible. But we are kidding ourselves if we think that it is reasonable to hand the average patient or relative a phone number or website and expect them to navigate our system and find a willing provider. At the moment, this is hard enough for a member of the medical profession.
We need to get the ministry to make a common referral system with multiple points of entry- not just for PAD but for all EOL care because right now it is hard enough for most people to find palliative care. When that exists and is robust, the burden on the objector will be lessened dramatically- giving people this number would be as good as an “effective referral”. But until this exists, I think the mandate for an “effective referral” should remain. Simply giving a generic explanation that there are others out there is not a reasonable accommodation IMO.
Canadian Medical Protective Association
Response in PDF format.
Can the CPSO include some guidance about what would be recommended in cases of failed PAS.
Should such patients be sent into the ER and what treatments would be expected there?
If such patients are no longer able to swallow then it would be necessary to have other medications and other routes available for administration. This may necessitate the involvement of other team members such as visiting nurses to set up iv routes etc. This may be particularly important when assisting in a death at the patient’s home.
It has been my experience that visiting nursing agencies have NOT been willing to participate in withdrawal of life support in the home despite the fact that this has always been seen to be legal and ethically sound…
Medico-Legal Society of Toronto
Response in PDF format.
What Canada needs is NOT physician assisted suicide – but more money channelled to palliative care and end of life research. The answer to a person’s suffering is not to kill them, it is to alleviate their suffering, to demonstrate compassion through CARE not through killing.
I agree with MD assisted death..If someone is suffering and terminal and wishes to escape the pain of dying…why not allow the MD to help..My own mother literally rotted away in hospital..we were never offered a hospice…I didnt know hospice is free..so with no circulation she was given subcuticular dilodid which didnt do a thing as she had masses on her aorta and circulation had literally ceased…the palliative care she got was deplorable…I wished every day that I would get a call that she had died….thank god I got that call..I am sure she would have been happy to have not suffered the incredible pain she endured. There should be a provision for MDs to give medication to terminate life in the event that the patient is terminal and cannot be given pain medication that is effective..
MD assisted death…dont call it suicide..call it kind treatment of the terminally ill…my god my mothers slow painful death haunts me 6 years later…to watch her rot in an active patient treatment ward…instead of a hospice like environment..never offered hospice care..I was disappointed in the social workers and the doctors who never suggested terminal care. Yes to MD assisted death in cases of terminal illness…
I am a retired RN and am very concerned about this proposed legislation. Although the intent of such a law always starts with the purpose to be that the application be to palliative care patients, historically even in recent times, the line shifts. If you research how the line has shifted in Holland and Belgium for example, you will find that the legislation now applies to those who do not give consent and even to depression as in the following article. I have a lovely daughter with bipolar and I can tell you unequivocally that the harm done in such a case to the family would be equivalent to suicide. Not to mention the loss to the world. Each life has value, even to the end of life (and yes, I had a mom with Alzheimer’s and have watched dear friends die of cancer) We need good palliative care, not this, and God forbid that this law should ever be economically driven someday and be used to cut costs as an unforeseen consequence!
http://www.nydailynews.com/news/world/belgium-woman-24-granted-euthanasia-death-depression-article-1.2276577
To those who are conscientious objectors to the point of refusing to transfer a patient to another provider who is not, thereby obstructing the patient from accessing this service: such conscientious objection is a lifestyle choice which is physician focused care–not patient focused. You should not be placing yourself in this conflict of interest.
I think this is a dangerous slippery slope that we don’t want to attempt to navigate. Having the power of life and death should not be in our hands.
Life and death is God’s choice.
We have many choices in life. But life and death are not our choice, but is God’s choice only! For man to thick he has a choice in this matter is a great error on his behalf.
As a patient with multiple medical conditions this concerns me. I am concerned because this is a slippery slope, and it may be determined in the future that those with disabilities don’t know what is best and the decision to terminate their lives must be made by a more competent person.
If I were old and weak, I might lose my sense of having personal value. As I considered, or was led by others to consider, the inconvenience and expense that my life was causing, I might feel pressure to end this life. Great potential here for the ultimate elder abuse!
I am an RN and I truly believe palliative care is the way to go! If we do it right we do not need physician assisted death. I have been at the bedside of many people who have died and with compassion comfort medications it can be a time of letting go for for the person dying as well as family and friends. it need not be horrendous as some think it is.
I am a physician who practices palliative care. We have many tools to help patients to be comfortable in their last months/weeks/days/hours. I am sure many people have said that access to palliative care needs to be improved across Canada. I am often saddened when I hear of doctors who refuse to refer or implement suggestions from doctors who have experience with palliative care, whether or not they are officially a palliative care specialist. We all need to be humble enough to realize when we need help in caring for a patient’s needs.
I disagree with the mandate to referral for Physician assisted death (PAD). I think self referral for physician assisted death is the best way to ensure access for patients and to ensure that those who have consciencious objections to PAD will not have to violate their consciences. There is no other jurisdiction in the world where PAD is legal which requires referral. I’m not sure why the CPSO thinks they need to be different.
When people have opposing world views, people with a conflicting view can not really tell the people in disagreement with them what will or won’t violate their conscience. The CPSO is imposing their world view on doctors who oppose PAD on grounds of conscience. Not every one who opposes PAD actually do so on religious grounds though those who support PAD make such a claim.
I also don’t agree that the CPSO tells consiencious objectors to state that their objection is based solely on conscience or religious views rather than clinical criteria. As a physician, I don’t think PAD is clinically indicated for any patient because it is not a reversible “procedure” and it is very subjective to try to decide whether someone is truly suffering irremediably… often people’s perceptions of their condition change depending on what is going on in their world/family, etc.
I truly hope that the federal government will make a law about PAD and that they will protect conscience rights of physicians and other health care professionals. I don’t think that the CPSO has done a good job of this in this policy.
I have three concerns with this policy. Many of my points have already been posted on this forum, but I want to add my perspective as well.
First, how does one determine that a patient “clearly consents” to euthanasia? The Dutch experience clearly demonstrates that once the gates are open, both overt and subtle forms of coercion affect the choices of individuals. Patients who would never have chosen euthanasia for themselves – now that it is an option -feel they ought to choose this in order “not to be a burden”.
Second, in the Dutch experience euthanasia has been followed by “termination of life WITHOUT request”. As a pediatrician, I shudder at the possibility that in the future I may face the situation of parents asking me to terminate their child. In the Netherlands “grievious, irremediable and intolerable suffering” has been used as a rationale for euthanasia of children with spina bifida and Down syndrome, something my conscience would never allow me to be involved in.
Thirdly – and worst of all – I am very concerned that the College is planning to force physicians who have moral and ethical problems with euthanasia to participate in the process. The way the statement is worded, the objecting physician is given the reprieve of not having to actually administer the drug that kills the patient but must do everything in their power to make sure it happens, which is tantamount to the same thing. In short, the interim policy leaves ABSOULTELY NO ROOM for a physician to object to participating in the procedure on moral or ethical grounds. This completely contravenes the physician’s rights.
Suicide and attempted suicide has been a pattern in my generational family tree. This is something that has spiritual roots and cannot be undone by encouraging people to go ahead and kill themselves just because their suffering is unbearable. There are ways to alleviate suffering that go beyond medications and killing. And what gives anyone the right to decide their life has no value? Forcing doctors to kill their patients or be accomplices in their death is very harmful on a moral and spiritual level and doctors will leave the system.
The stipulations or restrictions on witnesses to requests for physician assisted death need to be more carefully examined and be less exclusive, in my opinion. There will be very few people who will be able to meet the non-family, non-caregiver-of-any-kind restrictions currently proposed.
many physicians are not ready to participate in assisting in the end of life request . we were trained to save and make life as comfortable as possible. now we are asked to do a things from which we were prohibited to even think! it will take a long time to put our thinking in this process. some of us will never be able to practice this medicine and need all the support from C.P.S.O.
The idea of suicide and assisted suicide go against my Catholic belief in the sanctity of life, but, in few and special cases, for the sake of mercy on the patient & family…with lots of thought & discussion perhaps it is acceptable. But, I believe that no physician should feel coerced to participate or even refer in such cases. Thank you.
As an anesthesiologist and a pain doctor who have seen the suffering of human beings everyday, I am a huge supporter of assistant suicide. In fact we are 2 anesthesiologist who are willing to provide this service.
I read comments and I believe many people have jump to conclusion that doctors will kill the patients. It can not be more far away from the truth.
I’m living in the world that people are greatly suffer everyday. For some chronic pain patients, we are providing a great deal of relief, for a long time. For example for a chronic back pain that is caused by the arthritis, we provide a few years relief at the time. I personally have a few patients who are over 80 years old. So the person who wrote we are planning to kill older people(!), has a wrong idea.
The other side of the spectrum is a patient with multiple health issues, multiple organ failure and severe nerve caused pain (neuropathic pain) that we can not help. She is crying day and night and her family has to observe her suffering and there is no treatment that anyone can offer. Remember neither of these conditions are killing her in the next few years. If one day she decides enough suffering and it’s time to pass through this painful life, who is to say she has to offer? This is the patient who I am willing to help.
Responding to the doctor who suggested a specialist has to be the one assisting the patients, I agree. In fact I believe anesthesiologist has the skill sets that could provide the most comfortable passing for any patient. We know “pain “and many different medications that could help this person stop suffering for the last hour of life, hugs and kisses the family, provides comfort to her family and say goodbye and calmly pass away.
For our religious reader, this notion is not acceptable, since in major religions, your life belongs to God. However we are living in the society that people can believe in autonomy, and the fact that you are the owner of your life. Therefore you can decide when it’s time to end it. In my opinion, I am willing to help, because I am respecting the human dignity.
It’s a very emotionally draining process. Therefore every one of the providers need to understand, by helping each person to end his/her life, a piece of you will die.
Your last line is very telling.
Will there be adequate supports established for those who assist other people with their deaths.
One should not minimize the effect this will have on them.
I am a physician in London, Ontario. I just completed the consultation survey online. Thanks for the opportunity to respond. Here is a summary of my thoughts on this important issue. In the survey I indicated my general support for a well written draft guidance document. However you will see from my comments both on the survey and below that I think that unless the College highlights the social nature of this policy, and lobbies government for access to a separate process independent of physicians, the (currently entirely unnecessary) conscientious objection element you have described will become reality. This will significantly impact physicians’ thinking and practice, with implications for Ontario healthcare.
Implementing Physician Assisted Death in Canada is a government policy, the response of the government to a need expressed by some members of their voting public. Of course this includes some individual physicians or physician lobbyists.
There are many components that impact this complex issue. However key elements of the government’s proposal/the Supreme Court’s decision that this response will discuss are:
• Inducing the death of patients by the administration of drugs, other agents, or the performance or withholding of medical procedures (whether intentionally to cause death, or allegedly to alleviate
suffering) has never been a policy that has enjoyed widespread physician support in history.
• Physicians have occasionally engaged in such activities under instruction from oppressive regimes, and occasionally individual physicians have killed patients for psychopathic reasons or ulterior motives. However history has revealed that these actions have been universally condemned by physician regulatory bodies, and have been recognized as criminal by the courts and the general public. It is acknowledged that the demise of many patients has perhaps been hastened or indeed directly caused by physician error, however this is deemed by physician bodies to be highly regrettable and indeed such actions may result in criminal prosecution for negligence when appropriate.
• Physicians in general affirm or swear to uphold health and affirm life, rather than assist in its withdrawal. Similarly, healthcare facilities, such as hospitals and palliative care centres, in Canada are perceived to be, and indeed are, places where healing occurs, or for those in whom healing is impossible, suffering is alleviated.
• Physicians recognize the inevitability of death and work daily to support the alleviation of suffering. Medical and technological advances have led to extremely effective measures to alleviate suffering, and the administration of this important service through palliative care programs has universal physician support. In particular those health care professionals and volunteers who work in hospice and end of life care centres have first hand experience of the benefits of palliative care and are frequently among the most ardent advocates against the premature termination of life in favour of the alleviation of suffering. It is noted that while palliative care programs have received unanimous enthusiastic endorsement for their existence from physicians, this has not been shared by government, which has continually underfunded these critical health care services.
• Physicians assisting with death as proposed is a social policy and has had no place in conventional physician practice, ever.
• Under the Supreme Court decision/government law, physicians will be required by law to assist any of their patients who request assisted dying, or if they are unwilling to do so personally, to refer such individuals to their colleagues who are prepared to undertake this action. The law will include penalties for physicians who refuse to comply with this law.
Bearing these universally acknowledged facts in mind, it is proposed that if the government wish to implement a program of Assisted Death the following process modifications be made.
• The action of assisting death should not be performed in hospitals nor should it be performed in hospices or other end of life care locations. These institutions have universally acknowledged roles that include the affirmation of life and alleviation of suffering.
• Separate facilities in which to conduct actions to assist death should be established. The funding for such facilities should not be obtained from the health care budget and they should be unambiguously named in such a way that they cannot be confused with facilities for health care, since these facilities will not promote healthy life but rather death.
• Performance of the action of assisting death is not a physician duty and the government should identify and train a separate group of individuals who wish to do this. It is acknowledged that some physicians may wish to apply for this role.
• Physicians may diagnose (and it is noted that this is occasionally or even frequently inaccurate) terminal or irrecoverable illness, and physicians or health care facilities can be reimbursed to provide the information forming the basis for their diagnosis and expected disease course to the patient or their representative.
• The patient or their representative may then do whatever they wish with information provided by their healthcare provider or institution. If a patient wishes to be assisted in dying, they should access the appropriate government designed pathway to request this. The physicians or institution responsible for their health care should not be required by law to access the system on the patient’s behalf. It is the patient or their representative, not those responsible for their health care, who should pass the information to decision makers within the system and interact with them while they are processing the patient’s request.
• If the patient is physically present in a hospital or health care facility at a time when the appointment for assisted dying is scheduled, the patient must first leave the health care facility. It is of course anticipated that this will be against medical advice (this usually being to remain in the facility for observation and treatment, in many cases to alleviate suffering) and the patient or their representative should take responsibility for this, completing the appropriate paperwork. Transport from the hospital to the facility for assisted dying should be the responsibility of the patient or their representative, and not the health care facility or ambulance service, which does not receive funding for transportation of patients who leave the institution against medical advice.
This response has not discussed the ethics of assisted dying, or specific process issues, protocols and safeguards. It is intended to demonstrate that as long as Canada has facilities and personnel whose roles are to promote health, affirm life, and alleviate suffering, that these facilities and personnel should be clearly separated from those that will be responsible for implementing a social policy with entirely different objectives.
The draft guidance is very well written however if the College, as the representative body of all Ontario physicians cannot highlight these fundamental guiding principles, no one else has the authority to, and many physicians will find themselves in a position where conscience directly conflicts not only with officially issued advice, but with the law of the land. Some will find it impossible to reconcile and will leave their practice or the country, while others may comply and will carry the burden of government/College imposed moral bankruptcy, when this could have been avoided by ensuring that access to the “service”
was independent of the physician, whose only role was to give the patient their health records, before others took over in administering the process.
In conclusion, the government/Supreme Court should not persist in asking physicians to implement social agendas for which the government is responsible. If the government/Supreme Court imposes legal obligations on doctors to assist death or directly refer to those who will, they should be strongly advised that the College anticipates physicians leaving the country. Many physicians have conscientious objections against assisting death and if they are compelled to do this, or to refer to others who carry out this action, there will be a vehement and predictable reaction. Specifically they will leave their profession prematurely if they are financially able to do so, or leave the country to seek employment elsewhere rather than become morally bankrupt in their own eyes, and the eyes of physician colleagues around the world, both at present and in the future.
I am a physician who practices palliative care. We have many tools to help patients to be comfortable in their last months/weeks/days/hours. I am sure many people have said that access to palliative care needs to be improved across Canada. I am often saddened when I hear of doctors who refuse to refer or implement suggestions from doctors who have experience with palliative care, whether or not they are officially a palliative care specialist. We all need to be humble enough to realize when we need help in caring for a patient’s needs. I also work in Emergency Medicine. I often have to admit patients on a form 1 against their will for psychiatric assessment in regards to suicide. I have serious concerns about the validity of a form 1 once Physician assisted death becomes common practice in Ontario. In the Emergency Department, I often have discussion with patients about what treatments they do and they don’t want for their medical conditions. We are able to help people be comfortable often and alleviate suffering. I wonder how we will be expected to care for patients in the Emergency Department if they come in requesting physician assisted death. This document is not clear in this regard.
I disagree with the mandate to referral for Physician assisted death (PAD). I think self referral for physician assisted death is the best way to ensure access for patients and to ensure that those who have conscientious objections to PAD will not have to violate their consciences. There is no other jurisdiction in the world where PAD is legal which requires referral. I’m not sure why the CPSO thinks they need to be different.
When people have opposing world views, people with a conflicting view can not really tell the people in disagreement with them what will or won’t violate their conscience. The CPSO is imposing their world view on doctors who oppose PAD on grounds of conscience. Not every one who opposes PAD actually do so on religious grounds though those who support PAD make such a claim.
I also don’t agree that the CPSO tells conscientious objectors to state that their objection is based solely on conscience or religious views rather than clinical criteria. As a physician, I don’t think PAD is clinically indicated for any patient because it is not a reversible “procedure” and it is very subjective to try to decide whether someone is truly suffering irremediably… often people’s perceptions of their condition change depending on what is going on in their world/family, etc.
I truly hope that the federal government will make a law about PAD and that they will protect conscience rights of physicians and other health care professionals. I don’t think that the CPSO has done a good job of this in this policy.
I am very disturbed and disappointed by what seems to be the thinking of the CPSO regarding the role of doctors in doctor assisted suicide. I know that the Supreme Court decided some time ago that suicide was not illegal and has now said that a person has the right to have someone else facilitate his or her death if he or she is unable to commit suicide. If someone wants to kill himself or herself, that is a decision that is his or hers. For whatever time a person has left, he or she lives with that decision and his or her conscience. Nobody has the right to demand that someone else help kill him or her, either by actually doing it or by being an accomplice to the act. The word accomplice is not original with me. It was the term used by a professional, an accountant, in Toronto this week to describe the position of a doctor who is forced to refer a patient to someone who is willing to perform assisted suicide. His response, when the situation was explained to him, was “So the CPSO wants doctors to be accomplices.” It gave him a whole new understanding. He, and most of the general public, judging by the percentage of the people with whom I have talked, do not understand the significance of the decision that is to be made. What the public hears is how great this new law will be for the minute section of the population who actually have a reason for their decision to commit suicide.
I understand that in legal matters, a person who arranges for something to be carried out can be held responsible for that particular act, not because they committed the act but because they arranged for it to be committed. This is exactly the same thing that doctors may be asked to do. Many doctors have certain convictions based on their religious beliefs. What kind of emotional and mental pressure does this put on them? I know of one doctor who has stopped practicing in Ontario for two reasons. One is the position on assisted suicide and euthanasia. The other is the abortion pill that doctors are now required to dispense if it is requested. This doctor does not support the ending of life, either at the beginning or the end, and is starting to work in Alberta next week. Another doctor is planning early retirement if the CPSO says that doctors must either “do or refer”.
A doctor in Alberta sent this comment when we were discussing this situation. “It seems stupid that they don’t have an open door policy in specially run clinics by physicians specially trained to kill. I frankly don’t understand why a referral is even needed.” This is from someone younger and much closer to the problem than I am. “Out of the mouths of babes.” (My comment)
Ontario is already short of physicians. If forced to be an accomplice to assisted suicide by having to actually find someone to commit it, or as previously mentioned to provide an abortion on demand, we will lose many fine, qualified doctors to places like Alberta and Manitoba or to early retirement. Please, please consider carefully and prayerfully the fate of many doctors and the future of the patients in Ontario, whom we all will be at some point. Personally, I would be afraid to have to be treated by a physician who has been forced to compromise his or her beliefs or convictions. Please follow the example set by Manitoba and Alberta in their policies to support doctors’ conscience rights. Doctors fall under the purview of the Charter of Rights and Freedoms, just like the people for whom they are caring. How can they be discriminated against because of their beliefs? The provinces of Alberta and Manitoba are to be commended for their stands and policies. Will Ontario now stand up and support its doctors’ conscience rights in both the abortion issue and the assisted suicide issue? Will Ontario even lead the way in Canada and create an independent board with well-publicized, publicly available contact information staffed by specially-trained, voluntarily participating physicians where the public can self-refer to obtain whatever information and treatment they desire? This way nobody has to go through a middleman. To me, this is an issue where everyone can be a winner – doctors, patients, the public, and the CPSO.
The CPSO can show the rest of Canada that, as well as valuing the public and their rights, they also value their exceptional doctors and their rights.
I would like to provide feedback regarding the proposed policy “CPSO Interim Guidance on Physician-Assisted Death. My thoughts are as follows:
III – Guiding Principles of Professionalism
One of the key values listed is trustworthiness. I do not see how a policy that forces some doctors to break their word, for example as expressed in the Hippocratic Oath, enhances the trustworthiness of the profession. (This relates to section VI (C) Conscience Objection, which I address in order below.)
I would also note that patient autonomy means patients can decide what treatments they want, but it does not mean they can receive any treatment they want – if a patient requests an inappropriate treatment for his or her medical issue, and continues to insist on it despite appropriate discussion and explanation, I, as a physician, am not obligated to provide or arrange for it – professionally I have a higher obligation to refuse it. Autonomy is not an absolute.
IV – Interim Guidance on Physician-Assisted Death
A. Criteria
1. Competent adult
You acknowledge that the SCC’s decision limits PAD to competent adults, but decline to define ‘adult’ since the SCC did not define it. However, you proceed to define ‘competence’ in the next part, though the SCC did not define it either. You have designed a policy that does not even address the most basic criteria for the population it is supposed to affect. I would think it reasonable to assume that a legal institution, such as the SCC, intended basic legal definitions for terms such as adult unless otherwise specified. If you do not feel that was their intent, you should be stating so directly rather than dodging the issue.
2. Clearly consents to the termination of life
“[T]he College advises physicians to decline requests for physician-assisted death when made through an advance directive, or the patient’s substitute decision maker.” This is not a definitive statement. If your intent is to leave the door open for non-competent patients to undergo PAD or euthanasia, it would be more honest if you would state so. Otherwise, requiring physicians to decline would be more appropriate. This would also be more consistent with the final point of section IV – Sample Process Map for Physician-Assisted Death, Stage 2 – Capacity Assessment and Second opinion.
4. Enduring suffering that is intolerable.
Your suggestion that sincerely inquiring about PAD suggests ‘enduring suffering that is intolerable’, thereby qualifying the patient for PAD, seems rather circular in reasoning. I believe this would benefit from some revision.
B. Fees
“The activities involved in both assessing whether a patient meets the criteria… and providing [PAD], are currently insured services. [...] Accordingly, physicians may not charge patients.” I have no issue with the conclusion. However, in section IV – Sample Process Map for Physician-Assisted Death, Stage 3 indicates you consider this policy to apply to both assisted suicide and euthanasia. I have not read the OHIP Schedule of Benefits in its entirety in the last few months, but I don’t think they have an entry yet for ‘deliberate administration of medication by physician to cause cessation of life’, especially considering it is still illegal until next month. Therefore, I think it is inaccurate to state that these are entirely insured services and you should consider this when revising the policy.
C. Conscientious Objection
Section 132 of the SCC decision stated, “Rather, we underline that the Charter rights of patients and physicians will need to be reconciled.” You acknowledge this in your policy. You then proceed to reiterate your Professional Obligations and Human Rights policy and completely ignore physicians’ Charter rights to conscience and religious beliefs by forcing objecting physicians to be accomplices in PAD. In fact, you make it impossible for a physician to even express objection – he or she “must communicate his/her objection directly… and inform the patient that the objection is due to personal and not clinical reasons” while at the same time “not express[ing] personal moral judgements about the beliefs [...] of the patient.” If the patient is requesting PAD, he or she can be assumed to believe PAD is moral. For a physician to then directly state he or she objects for personal reasons, that can easily be interpreted as a ‘personal moral judgement’ about the patient’s belief regarding PAD. You have physicians who have concerns regarding PAD in a position where they both cannot object and cannot avoid participation. This section is flawed and needs revision to actually reconcile Charter rights, not eliminating them for one party (the physician).
I appreciate that the college is trying to provide some direction about this very difficult and contentious subject.
I share some of the concerns about who would be the 2nd witness , as those who have written on the forum
I also have concern about the lack of direction in regards to the medications used to end life. The articles that are given as references are more than 4 years old and I would worry that without expert recommendations that there would be little standardization, possible ineffective doses; causing further suffering and trauma to the patient , family and physician. I think that research needs to be done and there need to be clear guidelines on what is known to be effective. It may also be useful to draft standardized documents to be used, again as the more standardization in such a process likely the better.
I wish to express my feedback regarding the draft policy of the CPSO on Physician-assisted death.
In the first place, as a physician, I must say that the notion of physicians directly aiding in the death of patients is an absolutely sickening and abominable action. I understand that the morality of this concept is not the main purpose of this consultation/feedback. However, I wish to stress that euthanasia, euphemistically phrased as physician-assisted death, does represent a significant change. Since the beginning of medicine in all societies, the role of the physician has been one of healer and comforter, not abettor of suicide.
I do not have the impression that those in authority at the College really understand that for those physicians who are conscientiously opposed to any form of participation in physician-assisted death, the matter is of supreme importance. To me, referring a patient for physician-assisted death is morally the same as directly assisting a patient to commit suicide. To put it plainly, participation in a process which results in the killing of a patient is no different than for me to kill the patient directly. I think that the College has to find another way to allow the many physicians who are conscientiously opposed to physician-assisted death to be able to refuse to participate in this despicable process.
With all due respect, I think that the College has to find another solution without forcing physicians to act against their own conscience. I do not think that the proposed policy will work at all. I think that many physicians will follow their own conscience in the end as they should. However, I am extremely upset that the College has already drafted this policy without consulting its members first. One gets the impression that everything has already been decided already. I really hope that the current consultative process is not a sham.
I think that it is also very dangerous that under the draft policy any patient who feels that their chronic condition is intolerable would have the right to assisted suicide, and by extension the policy would compel a physician to refer this patient for this purpose. Who decides what is intolerable or grievous suffering? I am very concerned that over time our society will gradually find it acceptable to terminate the lives of individuals with various disabilities who may not have the capacity to really understand all the issues.
I hope that the College understands that the proposed changes are extremely disconcerting for many physicians like myself. It is not like a draft policy on confidentiality or recordkeeping. I hope that the College will continue to engage its members to find a solution which is morally acceptable to those with conscientious objections to physician-assisted suicide. I must stress that physicians like myself who are conscientiously opposed to any form of active participation in physician-assisted suicide wish to respect the College. However, the College has to respect our rights as well. Only in totalitarian countries are people forced to act against their will.
Thank you very much for your consideration.
Your draft policy states that physicians must either provide physician-assisted death or give an “effective referral” to a physician who will do so. This requires that physicians have access to a list of physicians who are willing to provide physician-assisted death (in order that the referral they provide can be “effective”).
Since such a registry of physicians must be created, why not simply make it available to the public, so that the “effective referral” requirement can be removed? This would be a simple way to ensure that patients have access to this “service” while simultaneously protecting physicians who, in good faith and quite reasonably, object to being compelled to cause or facilitate the deaths of their patients.
Thank you for your efforts to offer guidance on the provision of physician assisted death (PAD).
Given the finality of PAD, however, I am concerned that the processes suggested by the CPSO in the draft document are inadequate to protect vulnerable populations and prevent the misapplication of these services. Additional steps that I believe should be taken to enhance patient safety without unduly impeding access include the following:
• Advocate for the development of rigorous training and certification standards for physicians who wish to provide PAD services and make participation mandatory
• Limit provision of PAD to novel, ideally purpose-built facilities that are entirely separate from all current healthcare institutions physically, administratively, and otherwise to clearly distinguish life terminating services from other healthcare vehicles and maintain public trust in the latter
• Exclude physicians who have provided disease modifying and palliative treatment for a given patient from participation in the administration of PAD services to that patient to avoid undue influence on the patient’s decision to undergo PAD and other potential conflicts of interest
• Create strict, unambiguous guidelines on acceptable indications for PAD that include objective disease measures in addition to the subjective experience of patient suffering and exclude all conditions with difficult to predict natural histories that may include periods of relative improvement
• Mandate that a minimum of two specialists perform separate detailed assessments and come to the conclusion that all alternative therapies have been exhausted before a patient is deemed eligible for PAD
• Require completion of a formal capacity assessment
• Extend the general minimum period between requests for PAD and administration to a period of months during which the desire for PAD must be formally confirmed several times in writing by the patient (exceptions could be made under extenuating circumstances)
• Develop a formal system for documenting and processing PAD requests with multiple safety check points and quality assurance measures that is overseen by an independent body created for this purpose
• Restrict organ donation by PAD patients to those who formally documented such wishes in the event of their death well in advance (>1yr) of their request for PAD
In addition to protecting patients, PAD policies must safeguard the rights of physicians and other healthcare providers, including the Charter right to freedom of conscience and religion. Many consider facilitation of an action morally equivalent to directly performing the action. The act of referring for PAD would violate some of the most important precepts an individual may hold true and is no trivial matter. Such a major human rights violation would only be justifiable under extreme circumstances. In contrast, such a violation is easily avoided when services are readily available by self-referral for patients who desire them. Direct transfers of care as outlined in the Provincial/Territorial Expert Advisory Group on PAD recommendations could be another alternative until such a self-referral system has been developed. This seems like a win-win solution in a pluralistic, tolerant society such as our own and would avoid any compromise to the integrity and wellbeing of physicians without interfering with patient access to care. Moreover, I would suggest that physicians not be obligated to volunteer PAD as a potential treatment option in the same way that informed consent requires the discussion of other non-life ending therapeutic alternatives. The decriminalization of PAD does not create a duty to inform as suggested in the CPSO document. Accordingly, I urge the CPSO to drop the third and fourth points in section C on conscientious objection.
Although I do not have their commitment in writing, when I met with my CPSO council representative at the time that the Professional Obligations and Human Rights policy was being considered I was reassured that my concerns that it would be applied to PAD were misplaced given the unique nature of life ending procedures. I hope that my trust in their counsel will not prove ill founded.
I would like to express concerns with the fourth bullet point under “C. Conscientious Objection” in the draft interim guidance document (lines 184-189). Specifically, I am concerned that physicians who decline to provide physician assisted death will be forced to provide an effective referral. To provide an effective referral in such a case constitutes a level of cooperation in physician assisted death which, although not equivalent to providing such “care” itself, nevertheless will be equally objectionable for reasons of conscience to the vast majority of physicians who decline to provide physician assisted death for reasons of conscience in the first place.
The wording of this section also implies that if a physician who declines for reasons of conscience were not to provide an effective referral, he would be abandoning his patient. It is precisely the opposite–the physician who objects for reasons of conscience is precisely convinced that to provide physician assisted death would be to abandon the patient. And similarly, to give an effective referral would also constitute abandoning the patient for the majority of physicians who decline for reasons of conscience. What effect will this have on physicians–that they be asked to participate in what their conscience tells them is causing serious harm to their patients? For the good of the medical profession, physicians must not be asked to do to what they are convinced does serious harm to their patients, as this undermines the entire profession. I, for one, will trust a physician less whom I know has willingly done harm to, or participated in doing harm to, his patients, even if the harm done was not an objective harm, but nevertheless a perceived harm, a harm in the eyes of the physician himself.
A physician should never be placed in a position that requires their active participation in the death of a patient which would include a referral to a death-dealing doctor or service. Should a patient wish to end their life and the majority of the populace want to allow them this “right” they should provide non-physicians to do the deed. It takes little or no training to kill via lethal injection. To require physician to add death-dealing to their scope of practice undermines the relationship of trust the needs to remain sacrosanct in the doctor-patient relationship. The patient’s best interest has to underpin every action the doctor is willing to provide. The doctor must be free to follow his conscience or the patient cannot be sure that his actions are not suborned by a different vested interest-eg a government that wants to save the cost of care at end of life for a particular person. A doctor who deals both in death and in life cannot remain unaffected by the ease at which an apparent life problem can be removed simply by removing the patient. Doctors that can either bless or curse have been traditionally known as witch doctors. Please reconsider allowing any physician in the tradition of the Hippocratic Oath which ensured that patients could trust their physicians in the first place, from participating in any way with euthanasia. If society truly wants this as an option available to people, a different profession needs to be set up to deal with it. My Class of 1977 had the dubious distinction of being the first U of Toronto Medical Class not to publicly take the Oath so I took it privately some years later to help remind me of my duty towards my patients and society at large.
Assisted suicide and euthanasia are directly opposed to God’s commandment NOT TO KILL. The bible, the Word of GOD says there is an appointed time for all of humanity to die, not when anyone person or persons decide.
May God have mercy on us all!!!
I have many concerns which are: there is no proper definition of the term adult, the definition of grievous and irremediable condition is not clearly defined, close family members should be consulted to ensure that the patient is in a clear state of mind, the term referral to another physician states that the referred physician should be willing to approve the suicide, the term suffering can be used to describe anything that the patient considers enough pain to ask for suicide help. The process does not include consultation for other methods of treatment… just a referral for suicide! The policy for doctor assisted suicide should be turned down and made totally illegal. It is just providing a convenient way to legally commit suicide.
As a Christian, I would not want to be treated by any physician who does not respect/value the sacredness of human life, from the moment of conception to natural death. God is the Author of life and only God has the right to take human life. No Christian or God fearing physician should be forced against their conscience to refer a patient to another person who would kill a human life. As a daughter of two Nazi holocaust survivors, I am completely opposed to euthanasia / physician assisted death. This is nothing short of Evil.
I have been a small town family doctor for nearly 30 years. I come to this issue with those sensibilities and a very patient-centred approach. I thought the document was quite good, and well-thought out. As I read it, most of the questions that arose in my head were addressed in the ensuing paragraphs. Lots of good comments too.
The outstanding issues in my mind are:
1. I agree that the requirement for multiple signatures seems burdensome, and potentially restrictive. I have many widowed aging patients who are remarkably alone in this world
2. I think we should consider the plight of patients who may not yet be suffering unbearably, but will be at some point in the near future. They should be granted the right of self-determination.
3. I absolutely believe that a competent patient should be allowed to clearly state their wishes for PAD should they become incompetent. This wish has been stated to me many many times over the years. Who among us hasn’t heard a reasonable patient say that they don’t ever want to be drooling in the corner of a LTC facility. (I write those words with the utmost respect for the care patients get in LTC).
4. I echo the comments regarding ensuring that nothing in the policy should require a specialist consult. Rural and small town FPs are de facto experts in palliative care.
Thank you for this opportunity to provide feedback.
As a psychiatrist, my comments will be framed in the context of the contradictions that physician-assisted dying poses for mental health care professionals working with suicidal patients and within a suicide-prevention model of healthcare.
Section C: Conscientious Objection:
In regards to “impeding access to care”: Normally, when a patient presents to care with suicidal intent, physicians can place them on a Form 1 for a psychiatric assessment lasting up to 72 hours. During this time, the patient is prevented from obtaining the means to kill themselves. This could be seen as “impeding access to care” under these guidelines if the patient is found to meet eligibility criteria for physician-assisted death. However, the physician who issued the form 1, or the psychiatrist treating the patient on the inpatient unit, is simply doing their job. It should be recognized that those physicians who are treating suicidal patients be supported in doing their work in suicide prevention and not penalized for doing so.
Line 173-174: Conscientious reasons for objections to physician-assisted dying are not mutually exclusive of clinical reasons. A physician may have conscientious reasons for objecting to physician-assisted dying that are both on grounds of conscience AND clinical reasons. For example, a physician may have no conscientious objections for a terminally ill cancer patient in receiving physician-assisted dying, but be opposed to the termination of life of an 18 year old individual with psychological problems from substance abuse issues who finds addictions treatment “unacceptable” (as the Supreme Court has allowed), and who wishes to terminate his life for “intolerable” psychological suffering (psychological not being an exclusion criteria currently) secondary to substance abuse that has been exacerbated by the recent death of an intimate partner. Since the criteria for suffering is purely subjective, and the cause of his suffering is irremediable (death of partner, and addiction not likely to remit without addictions treatment), it would appear that this individual would meet eligibility criteria for physician-assisted death if he also fulfills the “competency” criteria (i.e. if he can understand and appreciate that he will die after being given a lethal injection or overdose, and also be able to understand the risks and benefits of any and all other treatments/counselling available that the Supreme Court has given him a right to refuse.) The criteria given are so subjective and broad, that nearly any condition could be made to fit the criteria if a suicidal patient states that the suffering it causes is intolerable to them. I would assume that most clinicians would be uncomfortable with offering “death” as their first line of treatment simply because a patient requests it, without trying other ways of alleviating their suffering first. Unfortunately, there is no requirement that the patient take any of these other suggestions before opting for death.
In the past, we have treated suicidal patients with care and with great efforts to help them find reasons to continue living, even when they themselves have given up all hope of a better future. To do otherwise, and to acquiese to a request for physician-assisted death in such patients would be, from my perspective as a mental health clinician, the ultimate form of abandonment and betrayal of a patient who has come to the attention of health-care professionals either of their own accord, or through concerns of their loved ones. If family members knew that their seriously ill and actively suicidal loved one could be put on a pathway to receiving a lethal injection because they expressed a desire to die (definition of actively suicidal), would they be so comfortable in sending their loved ones to a hospital where physician-assisted death is practiced? If not, this would be a serious injustice to all those with mental health issues who could have benefitted from available treatments, but who never did, SOLELY because of newfound distrust in a medical system that, as a result of the Supreme Court’s ruling on Carter vs Canada, allows for assisted death. [The same could be said of family members/patients who become wary of palliative care centres where assisted-death is offered, if there is no clear delineation of services provided within and outside their walls.]
Suicide prevention and assisted death cannot be made to mix in a suicide prevention model of healthcare, as oil cannot be mixed with water. The two must remain separate to protect the integrity of the mental health profession, and for the protection of vulnerable patients who come to our attention for help. There are truly vulnerable patients treated in this sector whom I fear could fall through the cracks without scrupulous scrutiny of each case – which requires sufficient time for assessment – that is contradictory to the stipulations of [lines 187-189 in the policy] below.
Lines 178-182: It is not clearly stated anywhere in the document that provision of information on physician-assisted death should be triggered/initiated by the patient. Providing physician-assisted dying as a possible “treatment” runs the risk of sending a clearly negative message to the patient who may feel undue pressure from the physician to pursue this procedure, or see in the offer of this procedure, the withdrawal of any hope for a life worth living.
Lines 184-189 and 216-218: The requirement to make “an effective referral to another health-care provider”, defined as “a referral made in good faith, to a non-objecting, available, and accessible physician or agency” is taken directly from the policy on Professional Obligations and the Human Rights Code. This requirement strips physicians of any true and meaningful conscientious objection, as many conscientious objectors view the act of making such an “effective referral” an act of complicity in the objectionable act itself. Instead, the College should be advocating for, as the majority of the Canadian Medical Association Members had voted at their 2015 General Council Meeting, the establishment of a third party, external agency to which patients can SELF-refer, that would provide information, counselling, and if deemed appropriate, access to physician-assisted dying. Not only would this arrangement solve the problem of access to care, and in fact, would facilitates patients’ access to care, it would at the same time respect the conscience rights of physicians who object to the intentional infliction of death upon another human being. The Charter rights of an individual, of which freedom of conscience is one, can only be restricted in so far as no other reasonable alternative can be made, and in this case, a less restrictive alternative DOES exist that would respect the freedoms of BOTH parties. This avenue should thus be pursued, and the requirement for an “effective referral” be struck from this guideline. As a fundamental human right protected by the Canadian Charter, the rights of an individuals’ freedom of conscience is not an issue that can be taken lightly, nor be decided upon through public opinion polls.
Lines 187-189 stipulate that ‘the referral must be made in a “timely manner” to allow patients to access care. Patients must not be exposed to adverse clinical outcomes due to a delayed referral.’ This stipulation is problematic because if physicians are expected to do an assessment to ensure that the request is non-ambivalent, made freely and without undue pressure from others, what is meant by “timely”? The guidelines are setting impossible and contradictory expectations if a thorough assessment is to be done; there needs to be sufficient passage of time to make this assessment. Secondly, during the course of the assessment, the patient could experience an adverse event as a result of their underlying illness. Are the physicians who are simply doing due diligence to ensure that all criteria have been met to be penalized for this? There is not protection explicitly stated in the guidelines for physicians who are doing their job in good faith to ensure that vulnerable patients are not put to death unnecessarily but exercising due diligence.
Further along the lines of treating suicidal patients, normally, when a person expresses suicidal ideation and a wish to die, physicians try to obtain assistance for that person, in following a suicide prevention model. Would this then be interpreted to be a “delay” in providing physician-assisted death if the patient continues later to request physician-assisted dying? Again, this is not clear in the guidelines.
Thank you for your attention to this important matter.
The main weakness of the Interim Guidance document is section C bullet 4. Given that Canadian Charter of Rights and Freedoms section 2 established the freedom of conscience and religion as the first of fundamental freedoms and that the CSC in the Carter decision confirmed that “nothing in this declaration would compel physicians to provide assistance in dying” it is incomprehensible why CPSO would want to compel them. Also, such attempt to compel “effective referral’ may not withstand legal challenge based on the Charter. There are also serious operational issues involved, because physicians may not advertise if the are “non-objecting” or “objecting” and a practitioner wishing to refer would have to actually run a large scale survey of medical professionals to determine that. In addition, a physician may find it compatible with their professional integrity to provide assisted death to one patient (e.g. rapidly progressive condition, patient close to death) and not to other patients (e.g. schizophrenia or depression). I would like to suggest that the bullet 4 be replaced with the following: “Where a physician declines to provide physician-assisted death for reason of conscience or religion, the physician must not abandon the patient and should provide best possible care that is compatible with physician’s professional integrity. Such physician may refer or transfer the patient care to another practitioner aiming for continuity of care.”
CPSO may wish to consider to operate a referral service for patient interested in physician assisted death. Such service could be be accessed through existing services, such as Telehealth Ontario and would connect the patient with a nearest practitioner on the list of those who provide physician-assisted death.
Please be advised that I am absolutely against any law or regulation that would force any doctor to kill a human being because the human being asked to be killed.
A doctor did not enter his or her profession to kill people but to make every effort to save lives.
I would like to give some detailed feedback regarding your draft Interim Guidance Document for end of life choice.
Firstly, overall, I think you have done a commendable job of following the direction given us all by the Supreme Court of Canada.
I do wish, however, to point out a few areas of concern, and also explain why I feel it is so important for the CPSO to resist pressure from a very vocal minority to make discrimination against identifiable groups within our society part of any document revisions.
As the draft document stands at the moment the most worrying stipulation is that, after initiating or completing the application process while competent, any person who does not retain this competence until the actual time of PAD is disqualified.
What on earth is your reasoning here?? If a competent individual has already made their wishes clear in writing, and then falls unconscious or experiences some other event which renders them unable to competently express themselves, how can you possibly justify denying them what has now been determined a Charter Right?
I suspect if the College elects not to change this aspect of the document, and a person is denied their rights under such circumstances, you shall find yourselves very swiftly in a court of law as this restriction is unreasonable and violates the spirit of the SCC’s decision if not it’s specific instruction. It must be changed…it is legally and morally incorrect.
Secondly, though of less obvious concern, are the restrictions placed on the two witnesses who must attest to the patient’s signature. While I realize that this is probably a well intentioned effort to avoid any type of coercion, and I appreciate it as such, it is so restrictive that I am afraid it will constitute an unreasonable barrier, particularly for those in institutional care. I believe, at the very least, the restriction should be removed for employees of the institution where the client resides or has been admitted, especially if the employee is not involved directly with the applicant’s care. I hope the CPSO will consider a little ‘fine tuning’ in this regard so as to better balance safeguards with access.
As studies in other jurisdictions have already shown, when coercion occurs it is almost always opposite in nature to the kind you are trying to protect against here. In other words, family or health professionals try to influence the applicant to continue suffering (often to satisfy their personal religious beliefs) rather than attempting to influence the applicant to move forward with PAD against the patient’s wishes. The second scenario, while it must be considered, is rather statistically unlikely.
Now I would like to discuss the ugly spectre of discrimination, which your document has so far managed to avoid. However, due to the lack of definition of the term ‘adult’, I am concerned that mature minors will be unfairly excluded regardless of their particular circumstances. Also, pressure from some quarters will seek to change your document so that entire groups of Canadians either are denied access to their rights completely, or are to be subject to additional requirements to which no other citizens are subjected.
I was very happy to see the nuanced approach that The Provincial and Territorial Advisory Group took regarding the definition of who precisely qualifies as an adult: they based it on competence level, as should be done for all applicants. If a young person is mature enough to understand the consequences of their decision, to comprehend all their medical options, and the risks and benefits of each, then obviously their choice regarding PAD should be respected if they meet all other criteria.
The concept of mature minors making their own health care decisions has a long history in Ontario. It is also important to note that those under the age of majority often testify in court, and are asked to contribute their opinion in legal situations where the outcome will effect their lives.
Some will argue that society protects minors from possible harm by, for instance, preventing them from purchasing alcohol and tobacco until they reach a predetermined age, and therefore we should follow the same path with PAD. Firstly, this position assumes that PAD causes harm, whereas I would argue that refusing to assist a person with a humane passing when they are competent enough to request one causes harm because they will continue to suffer and their human rights are denied.
Secondly, while it is true that society does make somewhat arbitrary decisions using age as the only guide when it comes to certain rights, when dealing with something as important as PAD, surely arbitrary rules are precisely what we do not want to see. Although we cannot reasonably assess every Canadian youth to determine whether they have the maturity to purchase alcohol, we do have the capacity to do such an assessment for those few youth who are suffering in agony and are requesting PAD. We not only have the capacity to do this, I would also maintain that we have the moral responsibility to do it: any other attitude would indicate that we are comfortable allowing ‘children’ to suffer and die in torment against their wishes, while we protect adults from the same horrible fate. What kind of society would endorse that?
Now I would like to address the pressure, often exerted by religious organizations, to discriminate against those with disabilities, or mental rather than physical health concerns.
While it is very important to ensure that those with disabilities are given the best support possible, unless there is a question of mental disability which renders the applicant incapable of informed consent, denying disabled people access to PAD services if they meet the other requirements set out by the court would directly contravene it’s ruling. Being physically disabled does not in any way degrade one’s ability to reason and think, and to suggest otherwise is highly offensive.
Lastly, I have been disgusted by the suggestion made by some opponents that every citizen with mental health issues should be treated differently in regards to their access to this essential health service. Again, in the interest of justice, what must be focussed on is the ability to provide informed consent. As you are no doubt aware, the vast majority of those suffering from depression are perfectly able to consent to all medical procedures, including the withdrawal of life extending treatment, and PAD should be approached no differently. To do so would be to tantamount to hijacking the autonomy of an entire group of citizens who are already stigmatized in our society because people erroneously believe that they are incapable of deciding for themselves.
I also think, where mental illness is concerned, the ignorant view that it is somehow less agonizing than physical illness still exists. This false belief feeds the notion that those who endure long standing mental health issues are not suffering ‘enough’ to qualify for PAD. While this attitude is ill-informed, it is also contrary to the SCC ruling. It has been made quite clear therein that one’s level of suffering, and at what point it becomes intolerable, can only be assessed by the individual as each person is unique in this regard.
The other myth regarding mental illness is that it is somehow more treatable than many physical illnesses. While this belief is actively encouraged by many pharmaceutical companies, and shamefully by many physicians who promote their products, it is entirely inaccurate. In the case of depression, whether treated with drugs or some type of ‘talk therapy’ recent research done independently from commercial interests indicates that the vast majority of patients do not remit. If remission is achieved it is almost never permanent. Depression is usually a recurrent, chronic illness which causes untold agony. Many experience such torment that they decide to end their own lives, but are presently forced to use unsafe and inhumane methods.
Most Canadians who die by suicide presently employ a firearm or a ligature. Using a gun is horrific for both the patient and those who discover their remains. Hanging often entails unspeakable suffering for the victim prior to death and sometimes results in terrible injury instead of the desired release from life.
Please resist entreaties to discriminate against those who suffer mental horrors rather than physical ones, provided they are competent to choose. To do otherwise would be to devalue their experience, their illness, and their right to decide for themselves when they have had enough. It would also be the very essence of discrimination against an identifiable group, and no doubt would be challenged in the courts.
The Supreme Court of Canada made no differentiation between mental and physical suffering, and neither should you.
While I believe this consultation is probably just window dressing designed to cover up pre-determined conclusions I will offer my views anyway.
Euthanasia and assisted-suicide are simply euphemisms for murder. Death is never the answer to personal difficulties and suffering.
Another problem is that euthanasia and assisted-suicide that is voluntary on the part of the patient quickly become involuntary. It is a slippery slope. Once you start killing people there is no end to it.
Doctors should never be forced to participate in euthanasia/assisted-suicide “services” against their consciences. They should never be forced to refer to other doctors that are willing to provide these “services” because this would still involve participation in euthanasia/assisted-suicide.
How about we get some real palliative care in this country. How about we use heroin in the treatment of severe pain.
As a disabled person I fear that it is just a matter of time before I am euthanized against my will.
The criterion for one to be considered a candidate for physician assisted death indicates that the patient must be competent. I would submit that we need also to consider those who request physician assisted death while he/she is competent but to be carried out when the patient is no longer competent to make that decision. For example, a patient who has early alzheimers disease and requests assisted suicide when he/she is no longer competent to carry on life activities or recognize family. Such individuals have an illness that is both destructive to the patient and family.If the patient has recorded his wishes while competent, signed in front of 2 physicians and not under duress, and sets out the criteria upon which assisted death is requested, such individuals should be able to be assisted in death by a physician. This is how I would like to be managed should dementia develop and progress while I am still capable of making the decision for assistance in ending my life. I am sure that there are many others who would wish the same merciful end of life.
The Chinese Pastoral Council of the Archdiocese of Toronto
PETITION TO THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO (CPSO)
for physicians’ conscience rights and for patient protection against physician assisted suicide
Recently, the Supreme Court of Canada has instructed for legislation of Euthanasia, and the College of Physicians and Surgeons of Ontario (CPSO) has proposed a policy obliging doctors to refer for, and in some cases actually perform, procedures like birth control; abortion and even euthanasia; physician-assisted suicide.
This policy will seriously infringe physicians’ conscience rights and especially on Catholic and Christian doctors’ freedom of religious and moral conscience. Furthermore, this is against the Church’s principles in saving instead of killing lives; and is in danger of taking away the religious and moral freedom of Catholic doctors. His Eminence Thomas Cardinal Collins has stated against this and asked all Ontarians to express to the government.
The Chinese Pastoral Council of the Archdiocese of Toronto (CPC) supports the standing His Eminence and the Catholic Church on this issue, and urge the College and the Government of Ontario not to go through with this proposed policy, but to provide all who are suffering with the best medical assistance and effective palliative care that can offer.
Catholic Health Sponsors of Ontario
Response in PDF format.
Protection of Conscience Project
Response in PDF format.
Please allow conscience rights for all physicians. Our province, our country, our world needs this freedom.
On reviewing your draft policy, in addition to feedback provided by survey earlier, I wonder if thought can be given as to how the average community health care provider can (a) access ethics consultation when needed, and (b) find out who would be an appropriate ‘willing’ alternate provider in the case where an apparently suitable candidate is requesting physician-assisted death and the practitioner approached is not ethically comfortable assisting.
I also wonder how ‘grievous suffering’ and ‘irremediable condition’ will be applied to conditions such as treatment-resistant depression or other mental disorders. I have already had one patient with chronic mood difficulties and periodic suicidal ideation / attempts (in the context of personality factors) indicate that, once physician-assisted dying is legal, he will want to request it. While he would be considered ‘capable’, it is difficult to separate this kind of a request from a variant of the very suicidal behaviour that we diligently attempt to prevent in psychiatry! This would be an area requiring special attention & further guidance.
I am writing you to express my concerns about the protection of conscience rights for Canadian physicians who refuse to participate in controversial procedures like euthanasia. It has come to my attention that legislation may be drafted that will legalize euthanasia in Canada as a result of the recent Supreme Court decision in the Carter case. My concern is that physicians’ conscience rights be protected so that they are not required to participate in these and other procedures despite their moral convictions to the contrary. I consider referral, even to a third party to be a type of participation. I request that whatever legislation is developed respects and protects the conscience rights of Canadian physicians and other health care providers.
I believe that the Canadian Charter of Rights and Freedoms protects Canadian citizens against being forced by the state to do things against their moral or religious convictions. There are undoubtedly other ways to ensure that the autonomy of the patients who choose these procedures is respected. It is not necessary to make dedicated physicians put their careers on the line and open themselves to professional disciplinary action simply because they wish to follow their conscience.
If all of these physicians are forced to leave the practice of medicine because of short-sighted policies, then patients like me will be unable to find the kind of doctor that I would like to have. The role of the government is to uphold the interests of the public. Please consider my interests as these policy deliberations are conducted.
Thank you for the opportunity to provide feedback to this draft proposal regarding a very difficult issue for our society following the Supreme Court’s ruling which overturned the prohibition of physician assisted/induced death. This represents a paradigm shift of profound significance to both patient and physician alike: one moment the killing of someone is criminal and the next, it is okay.
One surely must admit that the law of the land and the technical aspects of the issue are sterile and devoid of some critical human and moral components in the discussion apart from a token reference to conscience considerations. As a general surgeon for 36 years I have participated in innumerable life and death situations. The drive to preserve life and to make it liveable are an inseparable part of most physicians’ intention for their patients. I have wept at the bedside of patients who died. I have turned down requests for death and seen people grateful for the life that they then had. I have also killed an animal driving on the road and felt sick about the event. The emotional and mental effect on physicians providing death to a human being has not been calculated in the sterility of the law. Without doubt, the foundations for good health care to date have been premised on a commitment to life and not death.
The Supreme Court’s decision does not address the moral issues of killing. The judiciary bases its statements solely on the law as touching the necessity of autonomy, self-determination. However, the endorsement of autonomy alone, although appropriate, is insufficient to determine the morality of any given act. If that were the case, then female circumcision, as an example, would not have been proscribed in Canada. Although I support autonomy and the allowance for people to choose their own trajectory, I do not support the mandated involvement of all others to participate in something that would be considered by a large number of people to be morally offensive. Autonomy cannot overturn the morality of millennia basing our orderly society on the foundational statement “You shall not kill innocent life” as articulated in the biblical commandments and embraced by all the major religions.
Without doubt, a pluralistic society supports the marked polarization of opinion. Various lobby groups attest to that. The provision for accommodating a variance of opinion is the basis of Canadian culture and it is quite appropriate, indeed essential. However, to embrace only the secular point of view in governing societal activity is to disenfranchise those who hold a transcendent perspective on life, physicians included. There are physicians who consider the compulsion to even refer a patient for death to be morally reprehensible.
It is paradoxical that physicians who hold a strong moral perspective keeping them from administering or facilitating death and who refuse to participate in the referral process will now be in a position of being disciplined by the provincial licensing Colleges and potentially lose their licenses to practice. Their inability to refer would be considered unprofessional and a matter of malpractice should they remain non-compliant in the matter of making death referrals! For a pluralistic society, not to accommodate such conscientious objectors beggars the very concept of acceptable pluralism. There is also the risk of highly conscientious young people thinking twice about entering a profession which is compelled to provide what they feel is a morally unacceptable treatment.
The whole discussion, of course, is vastly more complex than a short response can encompass. There needs to be a more careful definition of terms including: grievous, chronic, suffering, depression. There also must be better safeguards for the patient who think that they have exhausted non-death options but have not really done so. Then there is the matter of young people who in various sectors of society already have a huge suicide rate and who might seek death through medical channels. The list of issues to explore goes on and on.
However, the core of this particular feedback is to ask that the College consider the transcendent issues beyond the sterility of the law in order to safeguard very large numbers of physicians who find killing another human being, regardless of context, as repugnant. Will the College recognize the altruism of such individuals in any way? Will the College recognize that refusal to refer is by no means equivalent to abandoning the doctor-patient relationship? The current obligation to refer, as stated in the draft, does not adequately do so. In drawing up the current “Interim Guidelines” the College is assuming that it will be physicians at large who participate in the facilitation of death for those so requesting it. This may not necessarily be the case. Here is a viable and perhaps even better option:
If our society is bent on expanding the provision of euthanasia, why cannot Dying Centers/Clinics be set up that can accommodate individuals by self-referral? This would enable a variety of things: the accessibility for patients choosing the route of death in a timely fashion, the skill of individuals to provide death, a multi professional team to provide support to families….all of which can be done while at the same time preserving the integrity of the medical profession at large and avoiding the stressful coercion of otherwise altruistic physicians.
It is astounding that medical associations have embraced the notion of physician assisted death and have put teaching in place without a new law even being on the table. The assumption has been made that it will be physicians at large who dispense death assistance either by referral or by so doing with training. Provincial licensing Colleges like the CPSO are charged with the obligation of preventing harm or injury coming to patients. Causing the death of another human being would seem to be the ultimate harm! And yet, without much ado, the leap has been made to allow physicians to bring death to their patients. This may be overstating the case somewhat but the endorsement of a death culture as compatible with the physician motivation to save and assist life seems like a disconnect. With due respect to the “expert” panels that have been put in place, the matter of mercy killing must have a much more comprehensive analysis and I would support the request of the government to have more time to draw up a critical piece of legislation that goes beyond the sterility of law and technology and recognizes the human dilemmas that prevail as touching the transcendent issues of life.
I am someone who has acquired considerable expertise and understanding about death, not only through reading but also through many conversations and consultations with people who were thinking about their own dying or about a dying they witnessed.
The points I want to make concern
A) lines 119- 121 on page 3 ([interim] unacceptability of requests made through an advance directive or by a substitute decision-maker),
B) lines 153 – 154 on page 4 (government to bear costs of assisted-dying process), and
C) line 220 on page 7, last bullet (“If at any time the patient loses the mental capacity to rescind his/her decision, physician-assisted death ceases to be an option”).
A) (Advance directives, substitute decision-makers)
There are at least two things which an advance directive can be in advance of: (1) diagnosis, and (2) suffering.
Regarding (1), the report of the Provincial-Territorial Expert Advisory Group suggests (in Recommendation 13, at the top of p. 7) “Within one year, provinces and territories, in collaboration with the federal government, should study whether patient declaration forms completed prior to the diagnosis of a grievous and irremediable medical condition might also be considered valid.”
I am not sure if this refers to an ordinary Living Will in which people try to “cover all bases” and outline the circumstances in which they would want to receive death assistance. Certainly most people who draft a Living Will do not know what conditions might afflict them in the years to come, so they attempt general descriptions of future situations from which they would want to be released. They may do this in “doctor language” – “If I have X, do Y but not Z” – and/or in “patient language”, as I do at the start of my “Guidance” document. Such documents are not legally binding at present, as far as I know, but perhaps Recommendation 13 is the Advisory Group’s way of saying that they should be made legally binding. If they are, there would need to be standardization of the forms involved, and high levels of precision would have to be required.
Regarding (2), the language chosen by the Supreme Court appears to suggest that people should not be given release until they have begun to suffer. Several points can be made with respect to this idea:
(a) Some people do not want to “get that close to the fire”. Especially if they are content with the life they have had, they may want to quit while they’re ahead, die with a good taste in their mouth, etc.
(b) Anticipatory suffering can be quite intense. Imagine a maiden who has been tied up by a villain and placed on railway tracks. Her eventual suffering may not last long if the villain has had the grace to position her so that the train’s wheels will roll over the centre of her head. But she will suffer dreadfully in advance, from the moment she hears the train’s whistle in the distance and feels the rails begin to vibrate beneath her.
(c) If current suffering does get established as a prerequisite for release, loss of competence could perversely serve as a qualifying condition rather than a disqualifying one (though the requirement of clear consent would have to be suspended). It is true that in the early stages of dementia people are often happy in a “loopy” kind of way, but usually they do not stay that way. As their disease progresses they come to suffer constantly in the grip of negative emotions like rage or fear or guilt or sorrow or bewilderment. Of course I am not suggesting that we should build Canada’s policy on this sad fact, at least not anytime soon. But perhaps someday we will have technology capable of monitoring and recording a person’s interior emotional “movie”, and a large random sample of “stills” from this movie might in some cases be seen to establish suffering of such magnitude and immutability that euthanasia without consent (which would not be possible anyhow) is judged to be warranted.
Concerning (a) and (b), it is worth noting that in jurisdictions where assisted suicide is legal (Oregon, Switzerland, etc.) there is no requirement that the person wait until suffering has begun (Brittany Maynard did not have to wait until her brain tumour made her life unbearable). All that is required is a firm diagnosis of a condition which will lead to suffering in the future, although American jurisdictions currently require a rather compressed future (6 months). However, the only release that is permitted in these jurisdictions is self-release – assisted suicide. The Supreme Court may have been thinking mainly about euthanasia, which Canada will permit. Human beings (except for psychopaths) have an instinctive revulsion from the act of ending another person’s life. Maybe a perception of suffering is necessary in order for a doctor to overcome this revulsion and end a patient’s life. If so, laws and policies might distinguish between self-provided release (suicide) and other-provided release (euthanasia), with more stringent requirements being applied to the latter. Regarding self-provided release, our main concern should be to help the person avoid making a mistake, by which we mean an act that would be regarded as a mistake even by its enactor, upon reflection. Regarding “how close to the fire to get”, the decision could be left up to the individual.
If our policies do decree, at least initially, that release (except via non-treatment) cannot be requested via an advance directive, then every possible step should be taken to make people aware of this fact. Printed or downloadable forms should begin with a bolded large-print WARNING. Seminars or workshops should mention it at their start, and mention it again if there are latecomers. Many people who create an advance care directive are doing it right after making a will, in which they issued commands about future actions involving their property, in full confidence that their commands would be obeyed. It is not to be wondered at if their confidence “runs over” into the drafting of their care directive.
Concerning requests made by a substitute decision-maker, a blanket prohibition may not be the best or only way to proceed. When I drafted my own living will, I included a list of powers my proxy should have, copying it from Sidney Wanzer’s living will, which he included in a pamphlet he wrote and later enlarged into his book To Die Well (co-authored with Joseph Glenmullen). Here is the list:
“- My proxy has the authority to withhold or stop any form of care or treatment for me (including nutrition and hydration, supplied by any method), even if such withholding or stopping will bring about my death.
- My proxy has the authority to request euthanasia for me (emphasis added), if it is legal in my jurisdiction of residence at the time I need it.
- My proxy has the same rights I would have with respect to my medical records (e.g. may see them, may obtain copies of them, may consent to disclosure of them).
- My proxy has the authority to engage in the following activities with respect to healthcare and personal-care professionals or institutions:
• requisitioning information
• signing contracts, waivers and other empowering documents
• hiring and firing (of professionals)
• admitting and discharging (to/from institutions)
• pursuing any legal action in my name, and at the expense of my estate, to force compliance with my wishes as determined by my proxy or to seek actual or punitive damages for failure to comply”
In the book, Wanzer has a slimmed-down version, ending with “My agent is then to have the same authority to make health-care decisions as I would if I had the capacity to make them, EXCEPT (list here the limitations, if any, you wish to place on your agent’s authority).”
Something like this might be good to build into Ontario’s system. It would allow fortunate people like me (whose proxies are a brother and a nephew whom I trust completely) to feel insured against just about everything, but it would allow less fortunate people to withhold certain powers from some or all of their proxies.
B) (Costs of assisted-dying process)
Here I only want to pass on some information, just in case you don’t have it already.
In the American jurisdictions where assisted suicide is legal, price-gouging is going on, for the barbiturates which are normally used in assisted dying. Instead of the $400 or $500 which had been the cost until recently, and which is still the cost in the relevant European jurisdictions, 4-digit or even 5-digit amounts are being demanded. I have not heard if anyone has discovered at what point in the supply chain the price increase is being made. I would say that it could not be the individual retail pharmacies, so I guess it has to be the wholesalers or people even further back. Explanations heard include that the drug manufacturers don’t like shipping pentobarbital and secobarbital to the USA because capital punishment is still practised there, with barbiturates. If this is the problem, prices in Canada might be normal, but it is also possible that the price-setters might think, “What if some dodgy Canadian importer decides to cut a deal with some American firms, and undercut us? Better shaft the Canadians too.” American insurance companies are refusing to pay the inflated amounts, and Canadian “insurers” (governments) might feel driven to do likewise. They could avoid the situation by doing what Americans are doing – a second-best drug cocktail, involving chloral hydrate and phenobarbital and morphine, is being used.
C) (Loss of competence means no assistance)
This is a harsh and frightening policy. Gentler policies are suggested in the report of the Provincial-Territorial Expert Advisory Group:
“The second situation involves a patient who, although competent and having a grievous and irremediable condition and experiencing intolerable suffering at the time of the completion of the declaration form, loses competency between the completion of the form and the provision. In this case, we believe that the person should be eligible for physician-assisted dying.
The third situation is more complex. It may occur when a patient has been diagnosed with a condition that will remove competency, such as dementia, and has concerns about the quality of his or her end-of-life in that future. The patient is not experiencing intolerable suffering but has been diagnosed with a grievous and ir remediable medical condition. Should this patient be permitted to complete a patient declaration indicating that he or she would like to receive physician-assisted dying when certain conditions that the patient believes would constitute enduring intolerable suffering are met, even if the patient will no longer be competent when those conditions are met? Our answer is yes.” (p. 31)
If the currently-suggested policy is retained, people must be warned about it. Anyone who is at serious risk of losing competence during the 15-day waiting period (e.g. by having another and more serious stroke) must be asked if they want to leave before the 15 days are up, and a situation like this should be included among the reasons for shortening the waiting period, as is mentioned in the middle of the box labelled Line 219 (p. 6).
Ontario Long Term Care Physicians
Response in PDF format.
There are several aspects of the interim guidance of PAD. One is the use of the term physician-assisted dying. As a physician, I have assisted (provided comfort, palliation) several patients at their death. What this interim guidance addresses is physician-assisted killing or euthanasia.
I am also concerned about the lack of clear definitions of ‘grievous’ and ‘irremediable’ – the majority of conditions that we treat have significant impact on patients’ well-being and cannot be cured. This essential makes euthanasia available to almost anyone.
The requirement for individual physicians and institutions to provide “effective referral” based on the Professional Obligation and Human Rights policy of the CPSO is flawed in several ways. Most notably is the fact that this policy was pushed through by an activist minority when the majority of physicians and the public were opposed to it. The requirement of effective referral essentially tramples on physician rights – it does NOT reconcile them with patient rights.
What patients do have a right to is good palliative care. Nowhere in this document does the CPSO call for more access and funding so that 100% of all patient in Ontario have access to palliative care, rather than the approximately 20% that currently do.
I am very concerned that Physicians will be required to either provide assisted suicide or recommend a physician who will to a patient who has requested this procedure. I am also concerned that a physician who refuses to provide or recommend this procedure will be prevented from being employed in various hospitals across the country.
Our country is becoming far too liberal, the Supreme Court system smacks in the face of a democracy, 12 unelected individuals deciding laws for the population by their determinations.
This is going to be another procedure that is financed by the taxpayer against many of their wishes and religious values, it will become washed out and performed will little forethought once it becomes the norm. We as a country should not be allowing murder in our institutions, the Supreme Court needs to be challenged vigorously on this decision.
It seems to me that this option:
o If at any time the patient loses the mental capacity to rescind his/her decision, physician assisted death ceases to be an option.
Located in;
Sample Process Map for Physician-Assisted Death
Stage 2: Prior to the provision of physician-assisted death
Is a loop hole that can be used be physician and or others to stop the termination of life should the patient laps into an unconscious/non communicative state before the
Process is completed.
The Canadian Charter of Rights and Freedom guarantees the freedom of conscience and religion. Physicians whose faith or conscience objects PAD should not be forced to refer patients directly for PAD. This violates their freedom of conscience. A list of physicians willing to perform PAD can be published for those who want PAD to access it.
Even if the Canadian Criminal Code allows for euthanasia or assisted suicide under certain conditions, you must remember that forcing physicians to refer— even as far as to threaten them—is only going to cause unnecessary and damaging battles for all, to divide the profession and spoil the collegial relationships in our hospitals.
A true compromise—one that would respect everyone’s autonomy — would be to make the service easy to access, universally available, with a direct route to the euthanasia practitioner. Don’t require a referral. Don’t involve other physicians. Do not force participants to act against their will —neither doctors nor anyone else involved.
I disagree with the current guidelines for physician assisted death. We must respect human life and this is a slippery slope. In no time we will see old people and those who maybe a financial burden on the health care system and society be given an over dose of meds to end their life where is may not be their wish at all.
In my long experience as a physician I have not encountered a situation where patient’s suffering could not be alleviated by a proper psychological or medical treatment.
I strongly believe that by allowing physician-assisted death we would be opening a Pandora’s box (legal, cultural, psychological problems):
- Patient-physician relationship would be poisoned.
- Given the subjective nature of assessing the level of suffering, we would be introducing a death-on-demand system.
- Causing death goes against the very nature of the medical profession.
- Wouldn’t doctors who do not conform with the patient’s request based on their professional opinion and expertise be routinely sued by the patient’s family?
- For many physicians, including myself, terminating somebody’s life would be a traumatic experience. To add insult to injury, I would be enforced to provide this kind of “service”.
I have no objection to lines to 167 to 182 in the proposal.
I do object to mandatory referral expectation. Other jurisdictions in Canada do NOT have this expectation. I contend that mandatory referral is participation in an act that is against my conscience (a violation of the Charter of Human Rights and freedoms Section two).
Refusal of referral is not to be equated with “abandoning a patient”. Patients can still access services they wish without active participation of a particular physician as is done in other jurisdictions (e.g. BC) and has been done in Ontario for other indications (e.g. Abortions). Every conscientious objector I have ever spoken with does not want to abandon their patients. We have a strong and lasting commitment to them. Gutting a clinicians moral compass can only lead to a loss of integrity, honestly, transparency, and faithfulness in the delivery of healthcare. Annulling conscientious objection is a massive threat to patient and public safety.
I have serious concerns with the CPSO Interim Guidance on Physician Assisted Death.
First, I believe that forcing doctors to hasten patient’s death is violating the latter fundamental freedom to act according to one’s moral beliefs, religious values and best medical judgement and should be rejected. This includes the act of referral as well.
Second, definitions to describe ‘irremediable conditions’ should be explicit because they will be a source of abuse as it has happened in other jurisdictions where euthanasia or assisted suicide is available.
Third, adult should include only competent patients over the legal age of 18.
Thank you.
There are a couple of issues I would like to raise with regard to the draft policy under discussion which I am not sure have been addressed.
1) The introduction to the policy rightly points out that in Canada anyone (physician or other) assisting another person to end his/her own life historically has committed a crime. In both the Judeo-Christian worldview and the Hippocratic Medical Tradition, which have roots going back at least 2,000 or 3,000 years, human life is precious and physicians are accountable to a Supreme Being who prohibits killing for non-criminal offences. For the CPSO or any law-making body in the country to assume that they can override with impunity these deeply held beliefs is naïve at the very least. The Supreme Court of Canada recognized this in the ruling on Carter, but the CPSO does not recognize this in their section on conscientious objection (lines 185-189). Both the act of assisting a person to die and of referring a person for assistance to die are abhorrent to many physicians with conscientious objections because in both cases the physician is an accomplice in the death of the person. Just as in the legal system the driver of the get-away car is considered an accomplice to a crime, so also doing a referral for physician-assisted death is to be an accomplice to the act of assisted death.
2) Why not ensure that patients who request physician-assisted death are referred first to a physician having conscientious objections who also has access to community resources? That physician could assess if there are patient issues that need to be addressed. Do people fear that doing this would lead to fewer requests for physician-assisted death? Is that a problem? In the draft policy, I did not see any section outlining how to ensure that all aspects of patient medical and psychological care had been addressed properly prior to considering requests for death. This is a huge omission and surely indicates a bias towards promoting physician-assisted death on the part of the CPSO. If the CPSO truly has a mandate to protect the public, as they say they do, then why such a glaring omission? To put it very bluntly, how can anyone protect a dead person?
I think the CPSO draft policy demonstrates a lack of understanding about conscientious objections and the CPSO mandate as a protector of the public. It makes one wonder if the pendulum has swung so far that now the physicians who hold to the sanctity of human life are considered the guilty ones?
This response to the CPSO Interim Guiding Document on physician-assisted suicide (PAS) has been drafted by 9 concerned Ontario medical students, who believe that the draft policy will have a negative impact on patient care in Ontario.
As future physicians, we agree with the CPSO that our first and most important duty will always be to care for our patients. However, we do not believe that PAS ever constitutes valid, compassionate medical care, for a number of reasons. Firstly, it violates the most central principle of medical ethics, which is to “first, do no harm,” by deliberately and actively hastening the death of the patient. Moreover, it fails to uphold the dignity of patients by validating the idea that death is preferable to living with a certain illness or disability. For many patients, a request for PAS can represent a cry for help rather than a sincere wish for death. Our duty as physicians, in our role as healers, should be to help alleviate the physical and psychological symptoms leading to this distress.
We are also concerned by the serious lack of evidence supporting the clinical protocols recommended for PAS. In providing guidance to practitioners on how to perform PAS, the CPSO provides only two, highly outdated research articles. They are based on a handful of case series, and the authors themselves stress the paucity of available evidence on the potential risks of PAS. This lack of evidence means that patients undergoing PAS are being exposed to potentially serious harms.
Of additional concern to us is the requirement that physicians who oppose PAS on moral grounds must nevertheless refer for this procedure. Of all the values which are important within the medical profession, perhaps the most important is integrity. As medical students, we are taught that it is important for physicians to always act in the highest ethical manner, because of the immense trust which is placed in their hands by their patients. Unfortunately, the CPSO is asking objecting physicians to violate their integrity, by requiring them to provide an “effective referral” to any patients in their care who are seeking PAS, regardless of whether they hold deep moral opposition to this procedure. By expecting physicians to violate their moral principles in this way, the policy risks eroding public trust in the medical profession – if we can put our integrity aside in this circumstance, how can the public trust us not to do so in other cases as well?
Furthermore, our belief that PAS does not represent compassionate medical care is shared by many patients across the province, including members of vulnerable populations such as the elderly and those with disabilities, who fear that they will be pressured into accepting PAS by family members, healthcare practitioners or society as a whole. For these patients, having a healthcare relationship with a physician who shares their opposition to PAS is dearly important, as they feel safer in the knowledge that this will not be encouraged for them or their family members. By enforcing a mandatory referral policy, the CPSO Document takes away this important freedom of choice from patients who oppose or are fearful of PAS.
Finally, we do not believe that mandatory referral strikes a fair balance between the rights of physicians and patients. Consider the example of a patient requesting a prescription for powerful opioids without any medical indication for them. It would be inappropriate for the physician to write that prescription, but it would also be inappropriate for the physician to refer that patient to somebody else who would provide them with those pills. In both cases the physician is actively assisting the patient to achieve their desired, but dangerous, goal. We believe that the same holds true for PAS; there is little moral distinction between actively providing PAS and helping patients to receive it from another practitioner.
In closing, we would urge the CPSO to take into account the legitimate concerns of physicians and trainees who believe that PAS is incompatible with compassionate end-of-life care, so that we can practice with integrity and retain the trust of our patients.
I recently attended the Government of Ontario event facilitated by IPSOS-Reid in Ottawa on physician-assisted dying (January 7, 2016, Sheraton Hotel). It was at that venue that I learned CPSO had invited “public” input on your interim guidelines by January 13; hence this email.
Regrettably, although billed as a consultation, the Ontario Government’s meeting format did not provide adequate opportunity for participants to express and explore divergent views nor to identify substantive negative impacts that could result if PAD is implemented without provision for identifying and safeguarding medical practices that are dedicated to the care of patients and families who, when faced with the reality that they are dying, wish to have a natural end of life at home, with medical support and services adequate to enable them to achieve this goal.
Physician-hastened death (PAD) is antithetical to the philosophy and delivery of care provided by such a physician or team. An exemplar of this type of practice is the community based palliative care network with which I work. I do the initial assessment and triage of patients referred to our care by another physician active in the patient’s care. A physician then provides the patient and family with compassionate, expert end of life care, 24/7, in the patient’s home (place of residence). Duration of care can range from days to months; the practice includes patients with a variety of life limiting illnesses, including ALS.
In recent weeks I have had a number of heart-breaking conversations with patients and/or family members who have been referred to our practice for end of life care. Often the callers, of divergent ethnicity and religion (or of no religion), are not only wrestling with a diagnosis/prognosis they hoped not to have, but in light of recent media coverage of PAD, now have the added dimension of anxiety. Bluntly, as they don’t fully understand the evolving situation, they fear that if they are accommodated in our practice, there is now a new threat to their very life and well-being: callers are terrified that our palliative care Doctor might/could kill them within the context of the anticipated roll-out of PAD in early February or thereafter. I assure such callers that our practice has never, nor would our MD participate in PAD. I would like assurance from CPSO that in the implementation of PAD, there will be provision for practices such as ours to continue to so self-identify and deliver care accordingly.
Our practice is a tiny but extremely effective community-resource. Our physician has cared for more than 2000 patients over her dedicated palliative care practice, with very few not able to achieve their goal of a natural death at home, but instead opting for an institutional death in hospital or palliative care unit. As a result, there are generations of families now equipped via their lived experience and hard earned confidence to lend their support to others who wish to embark on this journey of a natural death at home. Our physician has also mentored many others over the years and continues to provide nursing and allied health care providers, as well as community-based groups with education and resources to better equip all in understanding the dying process vis-a-vis the care of the dying.
We have a specific focus of care that provides those who wish a natural end of life, when at that juncture, not only with the option to receive such care but with the confidence and assurance that that’s what we do, and do extremely well. The practice is solely funded through our physician’s OHIP billings for care delivered to patients.
If there is provision in the PAD implementation framework for services/practices such as ours to clearly identify, upfront, that we do not/would not engage in PAD, it would save patients and referring physicians, and staff here and in like-minded practices, a tremendous amount of time and energy and emotion. Most importantly, such a provision would afford a level of solace and comfort to those who wish a natural end of life at home by providing them with the assurance of the clarity of the match between their hopes and our focus of care.
In summary then, I am asking that PAD implementation include a mechanism to identify and safeguard the autonomy of practices such as ours within the context of conscientious objection and patient confidence/well being. Those patients who wish care to permit them a natural end of life, at that juncture, deserve to continue to have their rights and needs met.
Given the SCC ruling, I believe that patients who wish PAD should have adequate and appropriate resources to support them. As such, I hope that there will be dedicated practices/locations to meet their needs. But not at the cost/potential dissolution or diminishment of medical practices that have a different focus and are currently serving a different set of needs in the community.
Health care is for healing. When my family members who suffer from grievous and irremediable conditions need health care, we also need transparency about what professionals and facilities refer for or provide hastened death so that we can avoid them. CPSO documents are coercive regarding conscientious objection. They ignore submissions to the consultation on Professional Obligations and Human Rights that effective referral is unethical for conscientious objectors.
I thought prescribers were responsible for monitoring the effects of medication they prescribe. Since there is no requirement for physicians to attend physician-prescribed, pharmacist-dispensed ingestion of lethal doses, how will physicians report on these deaths, and how will unused, dispensed lethal doses be accounted for? What about medication safety practices?
Since there is no requirement to document factors underlying a request for assisted suicide, how can coercion be determined?
Dear Colleagues at the CPSO
Thank you for the opportunity to comment on the CPSO’s interim guidance on Physician Assisted Suicide or Death (PAD).
The comments on the CPSO website reflects the many and diverse concerns and issues that this important proposed change in practise raises amongst both the general public and physicians.
As a member of the College of Physicians and Surgeons of Ontario, these are my two major concerns: 1) protection of the vulnerable and 2) protection of conscience for both physicians and other health workers.
As health providers, the patient’s interests are our first priority. Of course, those interests are often diverse and are influenced by many factors including social issues, the patient’s worldview and education. But the common foundation for our intervention/interaction is rooted in the ethical requirement not to harm the patient. Early in my career, I became interested in bioethics and completed extra training at an academic centre renown for its focus on bioethics especially as it relates to the delivery of health care.
It is the intersection of clinical practise, compassionate care and bioethics that we are currently facing as a profession today, especially with respect to PAD. The overarching principle is to do no harm—harm to our current patient, to future patients as well as to health workers themselves.
Randomized control trials are carried out to ensure patient safety. Procedures/drugs are not introduced into practise until safety has been proven—and that safety is heightened in situations where the patient is more vulnerable or at risk. Medications for pregnancy undergo much more scrutiny than drugs for non-pregnant women because safety is of utmost concern.
THE WHO (of the CPSO interim guidance on PAD):
Many physicians have raised this essential issue of safety with respect to vulnerable individuals and the proposed service of physician assisted suicide. Psychiatrists are asking the question how individuals with significant mental illness, have few social supports and have an irremediable medical condition with intolerable suffering, will be managed with this new clinical option of physician assisted suicide or death. Referring to the CPSO online discussion forum (eg. Physician comments # 16, 18, 19, 20, 22 etc), it is clear that there are many physicians, albeit not all, who are extremely concerned about the safety and security that will result from the proposed policy—safety for both their patients as well as their health care team.
If the very professionals who know and care most for these individual patients are so concerned about the implementation of physician assisted suicide, the College needs to take appropriate action to address these concerns and not merely to hear them. The health system is only as good as the individuals who are able to implement the ‘system’ and its protections. Clearly, there are many physicians who feel very unsettled in their new proposed role—that is either hastening death or being required to refer their patients for the same.
Many supporters of PAD claim that all individuals will be protected from coercion or pressure to undergo PAD. My experience and that of others working with marginalized individuals differs. I have worked with vulnerable mothers in East Africa and Yemen for over 15 years and was awarded the Order of Canada for my work in these challenging places. From my experience abroad, I am reminded daily that vulnerable people do not have the real freedom to choose. They are subject to many seen and unseen influences which determine their decision making and outcomes. Family and cultural pressures dictate personal choices about care. In one study in Yemen, 100% of the women stated that they are not the decision makers for their own care (See Women’s perception of self-worth and access to health care
International Journal of Gynecology & Obstetrics Volume 98, Issue 1, July 2007, Pages 75–79). Refugee and immigrant women in Canada carry and maintain this paradigm with them. The same lack of decision making power is true for vulnerable people in Canada – especially those who are vulnerable due to socio-economic reasons, cultural/ethnic background etc.
The Supreme Court of Canada may have struck down the prohibition of PAD as unconstitutional but that is not the same as demanding that it be carried out in Ontario. We recognize the limitation of studies carried out in other countries—both for their relevance to the situation in Canada as well as to their sufficiency in terms of ensuring the safety and protection of vulnerable people (specifically the mentally and physically disabled). Yet it seems that the policy is being presented in a context that sufficient evidence for all of these vital questions are in place—when in reality, they are not. I was surprised to see that the medical references for the CPSO draft (for the lethal doses for PAD) were being quoted from studies in 1999 and 2001—the second one being from a journal in obstetrics. There seems to be a disconnect between the rigorous science required for this kind of procedure. There is no recourse the next day after PAD. In any other clinical decision, the patient can always go on to make another decision (that may end in reversing the bad outcome of a previous decision), but in the case of physician assisted suicide, there is no recourse—the patient is dead. Morning rounds at many teaching hospitals provide an opportunity to review the cases from the day before—a chance to review how they could/should have been managed. There is a chance to regroup and learn from clinical errors or mistakes. With PAD, there’s no reversal of decisions made.
Other well written studies document PAD without patient consent or written request in numerous countries. Despite having a policy in place, nearly half of the PAD cases were not even reported in Flanders, Belgium and half did not have the required written consent (BMJ 2010;341:c5174 doi:10.1136/bmj.c5174). This example of PAD being practised in an affluent country with a well established health system like Belgium should raise a level of concern about the protection of vulnerable patients and urge the College to seriously reconsider its approach to physician assisted suicide/death.
THE WHY:
Stepping back to look at the bigger picture, “The trial judge found that the prohibition against physician-assisted dying violates the s. 7 rights of competent adults who are suffering intolerably as a result of a grievous and irremediable medical condition and concluded that this infringement is not justified under s. 1 of the Charter .” (SCC docket 35591) It seems that the once this ruling has been made, that the medical profession is then being forced into providing the service. The point that should be taken from the Court’s ruling is that according to their interpretation, it is not constitutional to deny the service—but the question quickly follows is how this ruling then leads to insisting that all physicians be required to either provide the service or make a quick referral to another one who will.
I do a considerable amount of work in East Africa, where Female Genital Mutilation (FGM) is practised all too commonly. In countries like Ethiopia and S Sudan, close to 90% of women have experienced this torture and violation of human rights. There are many reasons for the ongoing practise of FGM and they are complex—a large majority support the ongoing practise. One recent shift has been to try and medicalize the procedure—such that girls and young women are taken into the hospital where the procedure is carried out under more sterile conditions. I recently organized a debate with my East African students focusing on this shift in this practise—half the class had to support the argument (to medicalize FGM) while the other half were to argue against it. An interesting debate ensued and quite clearly, both sides had their logic and justifications. Both sides were equally strong in the debate. But at the end of it, after debriefing, all agreed that although the arguments to support medicalizing FGM may be convincing, it was fundamentally wrong for health workers to participate in FGM for the very reason that it violated the basic rights of those who couldn’t speak for themselves—girls and women who were pressured into being mutilated in order to ensure their marriageability. Clearly the analogy cannot be completely extended to physician assisted suicide but there are ethical principles which are shared: a service can be demanded by the majority which still violates the rights of the vulnerable within the community.
THE WHAT:
The original Supreme Court Decision guarantees that physicians would not be required to provide assistance in dying. In the judgement of the Supreme Court of Canada Carter v. Canada (Attorney General) 2015 SCC 5, [2015] 1 S.C.R. 331, it states: “Nothing in this declaration would compel physicians to provide assistance in dying.” It is clear from the response of many Ontario physicians that they feel that they are being compelled—that to be required to provide a referral for PAD to another physician is indeed participating in this service. In fact, the referral must be quick and ‘not delayed’. Other conditions such as unrelenting pain for severe endometriosis does not seem to be treated as critical as PAD—even though the young patient may be suffering intolerably—there doesn’t seem to be a potential penalty for long waited referrals to gynaecological specialists for these patients. It seems to be double tiered and potentially a double standard in how the two types of referrals should be managed.
There are many physicians who see the current CPSO guideline as being contrary to the guarantee of conscientious freedom for all Canadians – including physicians and other health workers with whom they work.
I would like to wholeheartedly agree with the physician’s comment who addressed the CPSO on Jan 4, 2016 who stated that if PAD were to be legally offered in Canada:
“Canadian physicians who are opposed to physician assisted suicide, who do not regard the killing of a patient to be a medical act, should not be forced to refer to another physician as if it were are medical act. A separate system should be set up whereby the patient has access to all the information so they can make an informed decision to seek physician assisted death, and then can self refer to institutions set up to provide the service and deal with the complications which will surely occur.”
In conclusion, the current CPSO policy does not protect the vulnerable – the CPSO online forum is filled with genuine concerns and questions about a procedure that has no recourse. It also violates the court’s very clear statement that physicians would NOT be compelled to assist in dying. If a referral to another physician is not a service, then one has to ask the question why there are stipulations in the policy around the speediness of the referral required—indeed, it is a service that is also required and governed by professional standards.
My thanks again for seriously reflecting on these concerns of many CPSO members as well as many for whom they care.
I am very concerned that Physicians will be required to either provide assisted suicide or recommend a physician who will to a patient who has requested this procedure. I am also concerned that a physician who refuses to provide or recommend this procedure will be prevented from being employed in various hospitals across the country.
Our country is becoming far too liberal, the Supreme Court system smacks in the face of a democracy, 12 unelected individuals deciding laws for the population by their determinations.
This is going to be another procedure that is financed by the taxpayer against many of their wishes and religious values, it will become washed out and performed will little forethought once it becomes the norm. We as a country should not be allowing murder in our institutions, the Supreme Court needs to be challenged vigorously on this decision.
Euthanasia and assisted suicide have nothing to do with medicine or health at all, so doctors and medical professionals should never be required to provide them or make referrals against their moral convictions.
As recently stated quite succinctly, “The only profession that comes close to providing something like this would be that of the hangman.”
Who would want anything to do with any such so-called professional?
I would like to express my concerns and requests about the protection of conscience rights for Ontario physicians who refuse to participate in procedures such as abortion and euthanasia.
I have been informed that the College of Physicians and Surgeons of Ontario has developed policies that require physicians to refer for or participate in these and other procedures despite their moral convictions. I consider referral, even to a third party, to be a type of participation.
I request that whatever legislation or policies are in place in Ontario take into account the need to fully protect physicians’ conscience rights.
I understand that the Canadian Charter of Rights and Freedoms protects Canadian citizens against being forced to do things against their moral or religious convictions.
Dedicated physicians who try their best to preserve life should not have to concern themselves that their career may be endangered or that professional disciplinary action may be taken against them because they wish to follow their conscience NOT to end someone’s life!
If all of these physicians are forced to leave the Province because of these shortsighted policies, then patients like me will be unable to find the kind of doctor that we prefer.
Is the role of the College to uphold the interests of the public?
I would greatly appreciate if you would please consider my requests as these policy deliberations are conducted.
I am writing today to offer comments with regards the draft policy entitled “CPSO Interim Guidance on Physician-Assisted Death”.
Firstly, I share with the CPSO that patient care must of the paramount priority and all physicians must strive to uphold key medical values of compassion, service, altruism, and trustworthiness. However, I am gravely concerned that requiring physicians’ with conscientious objection to physician-assisted death to make an effective referral would in fact do damage to patient care in Ontario.
Forcing a duty to refer for procedures one is unwilling to perform oneself is not arriving at a middle ground, rather, it forces physician participation in that which they have judged to be morally inexorable. In particular, physicians who have moral objection to physician-assisted death see both euthanasia and physician-assisted suicide as participation in an act of homicide. If forced to make an “effective referral”, physicians, who previously practiced without fault to patient care, will be forced to leave a practice that can no longer achieve moral accord. Alternatively, our physicians may decide to comply with the CPSO’s requirement and participate in an element of practice that goes against deeply held beliefs; such interior conflict will undoubtedly lead to physician burnout. Either way, Ontarians will suffer the loss of their well-qualified physicians, and hence, compromise access to good quality, sustainable patient care in the province.
Consider that the Supreme Court of Canada in their ruling of February 2015 does not compel physicians with conscientious objection to provide physician-assisted dying. Do not draft a policy that negates the rights and freedoms of physicians without true benefit to patient care. By mandating a requirement for an “effective referral”, the College is undoubtedly creating conditions ripe for systemic discrimination against certain religious groups (such as Muslims, certain Christian groups).
We must draft a policy that maintains physicians’, as well as patients’, rights as defined by the Charter of Rights and Freedoms in order to avoid systemic discrimination based on conscience or religious beliefs. Any policy that is effected by the CPSO that will limit a physician’s Right to Freedom of Conscience and Religion by forcing a duty to refer or provide a service is in affronts with what Canadians’ value as set out in the tenets of Canadian law. Consider carefully this draft policy. I urge you not to compromise the Canadian value that all must be protected under the Charter of Rights Freedoms, including the providers of services. Please, protect our physicians’ freedom from systemic discrimination. Remove the duty of physicians to make an “effective referral.” Instead, allow requirements of truthful communication of the objection and a discussion of the available options done in a manner respectful of patient dignity to continue to best serve our patients.
I am writing to express my concern about the document’s requirement that physicians who object to physician assisted death provide “an effective referral to another [non-objecting] health-care provider”. Competent and compassionate physicians object to PAD because they understand it to cause harm to the patient, the medical profession, and society in general. In all other clinical situations, a physician provides a referral for a service that he/she believes is in the best interests of the patient but lacks the knowledge or technical skills required to perform it him/herself. Providing a referral, therefore, makes a physician a participant in the controversial procedure. This policy departs from 2400 years of established medical ethics, ignores the Charter guarantee of freedom of conscience, and, ironically, contradicts the College’s aim to promote professionalism as it has the potential to jeopardize patient-doctor trust, inflict moral injury on physicians, and cause division within the profession. A better option, one that respects both patients’ autonomy and physicians’ moral integrity, would be a regime that facilitates self-referral for PAD. Thank you for your consideration of my comments.
I want to add my voice to support physicians in the matter of euthanasia. First of all I am against euthanasia, if this is allowed in Canada it will open a very dangerous door. However if this law is passed there should be a very strong conscience clause to protect physicians who do not agree with euthanasia. The fact that the person requests euthanasia does not absolve the physician in the matter of their conscience. Countries in the west have had a tradition of “Conscientious Objectors” in the time of war. If this euthanasia is going to become law I hope that an accommodation can be made for physicians who object on the grounds of their conscience.
PETITION TO THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO (CPSO) AND THE ONTARIO GOVERNMENT
for physicians’ conscience rights and for patient protection against physician-assisted suicide
A proposed policy of the College of Physicians and Surgeons of Ontario (CPSO) demands that doctors refer for, and in some cases actually perform, procedures like birth control, abortion and even euthanasia. This policy will seriously infringe on physicians’ conscience rights and especially on Catholic and Christian doctors’ freedom of religious and moral conscience. His Eminence Thomas Cardinal Collins has expressed his concern against such policy. Policies of the CPSO must fulfill the dual roles of saving lives and advancing the highest standards of professional moral practice.
The signed petition states:
‘Whereas a proposed policy of the College of Physicians and Surgeons of Ontario (CPSO) demands that doctors refer for, and in some cases actually perform, procedures like birth control, abortion and even euthanasia. This policy will seriously infringe on physicians’ conscience rights and especially on Catholic and Christian doctors’ freedom of religious and moral conscience.
Whereas policies of the CPSO must fulfill the dual roles of saving lives and advancing the highest standards of professional moral practice.
THEREFORE BE IT RESOLVED: We, the undersigned, urge the College and the Government of Ontario not to go through with this unjust policy, but to provide all who are suffering with the best medical assistance that can offer.’
We ask that the Ontario government and the CPSO, as bodies that care for the well being of the public, to seriously consider the voice and the concern of the people and care for them accordingly.
[**MESSAGE FROM ADMINISTRATOR: WE RECEIVED 1307 SIGNATURES TO THIS PETITION. ALTHOUGH THIS FEEDBACK HAS NOT BEEN PUBLISHED IN DUPLICATE, THE COLLEGE ACKNOWLEDGES RECEIPT OF EACH OF THESE SUBMISSIONS.**]
Canadian Medical Association
Response in PDF format.
I believe in the right for the elderly who have lived a full life. Their minds have left them, they are put in hallways day after day in wheelchairs. They should have had a choice. I am Catholic, just buried my aunt. She was 93, she had dementia but really was not bad until the last few years. We watch her the last three days of her life. They were very much like my dads, anxious for us. Terrible to watch. She could have element the last four days
Ontario Hospital Association
Response in PDF format.
I congratulate the CPSO and the draft guidelines presented. Overall they are very good. 1. One important thing that is certainly not appropriate is the denial of acceptance of duly executed advanced directives. Patients can rescind, at any time, their request for an assisted death. I prefer that my request for same be followed. At some point the dementia robs me of one of the requirements (sound mind). Now what does the family do? Please reconsider and permit advanced directives but have them duly signed, dated and witnessed. I would suggest a lawyer be a witness.
2. An important truth needs to be emphasized. One does not leap from disease treatment to disease progression to request for an assisted death! There is not going to be a huge wave of humanity clamoring for death. We are at a time and place to maximize the skills and techniques to deliver exemplary palliative care. Here, again, the provinces need to step up and provide the resources to care for these patients. The spectrum of palliative care runs from none to god awful to very good right across this country. For many diseases appropriate palliative care will support the patient and family through to a symptom controlled and dignified death. For the patients that palliative symptom (emotional and physical) control is not achievable, there is now the option of a self-directed, physician assisted humane death.
3. Physicians send patients to a specialist for advice OR to take over care of a complicated disease. What the specialist decides is their responsibility.
The assisted death eligibility determination does not rest with the referring doctor but they have fulfilled their duty to the patient and to the College.
Finally, our perspectives, in some cases, need to be adjusted. As compassionate, human beings we need to recognize the autonomy of the individual and not impose our beliefs, whatever they may be, into theirs. We have not walked in their shoes.
While having a lawyer as a witness sounds like a good idea in theory, it may not be practical or affordable. However, I would suggest that the people who witness the signature on the advance directives subsequently sign affidavits in front of a lawyer stating that they saw the person sign in the presence of the other witness, believe the person was not under duress, etc.
Ontario Association of Social Workers
The Ontario Association of Social Workers (OASW) is pleased to have the opportunity to make comments on CPSO’s Draft Interim Guidance Document. We are very impressed with the clarity, breadth and depth of this draft document.
We respectfully wish to comment on the reference in the document to the issue of coercion or undue influence on the patient’s decision to undergo physician-assisted death by external parties. However, we wish to point out that other factors can also influence the patient’s request in this regard. These include financial strain, caregiver burden/burnout, lack of understanding or knowledge of the full range of services and supports available, and the family/caregiver’s difficulty in adjusting to altered goals of care.
We encourage that consideration be given to involving other health care professionals as required, to understand the broader context of the individual’s life including health and social disparities as well as interpersonal factors that can impact on his/her request and decision to die.
Catholic Civil Rights League
Response in PDF format.
Conscientious objection should include the right of a doctor to refuse to administer lethal injection, as well as the right to refuse to refer to another physician for lethal injection. In all actuality, physician assisted suicide is still suicide. It will take of no benefit to anyone. If there is anything I have learned, it is that there is a beauty and value in suffering. We as a country, province and in our communities, need to focus efforts on providing better medical care to provide more effective comfort for the dying. There is awakening a double standard to do no harm, except in certain cases, and this is frightening we need only look to toe Netherlands to see you unfortunate outcome of their same goal. Canada, don’t be naive about this. If we move forward with this, forcing doctors to violate their conscience, we will only end up where the Netherlands is, and the doctors that are being abused through this will leave.
I have practiced Oncology for forty years. Not one of my patients, probably over thirty thousand by now, has ever expressed the ‘beauty and value of suffering.’ I doubt they would like to hear me suggest it either.
Curiously, I suspect very few of my patients will undertake physician assisted death, but I suspect that ALL will appreciate that the option for it is there if they need it.
Christian Medical and Dental Society
Response in PDF format.
This is a frustrating discussion to have with people who believe their religion mandates them to prevent others from obtaining PAD, the so-called Conscientious Objectors (CO). Patients may justifiably ask them for this service, and just how are they going to respond?
“I don’t think that’s a good idea,” is about as mild as the CO can be, and is surely more than enough to be obstructive, to prevent some patients from seeking a legally accepted procedure in this country. Failing to provide at the very least a referral is obstruction to legal treatment. Telling the patient they are wrong for making the request, unless that judgment is based on clear medical reasons unrelated to religious teaching, is imposing their own beliefs on the patient.
It is, in essence, a conflict of interest for a CO to be involved in any way with a patient who may wish PAD, if they are not willing to suppress their own feelings of conscience and refer the patient to someone who can do this. And frankly, that is all this document is asking of the CO, to step out of the way and refer, not to lecture or obstruct by any subtle means. It is similar to the abortion question, and means that any CO unwilling to refer on, or willing to put up even small roadblocks in the form of moral disapproval (frowns, raised eyebrows), is in a ‘conflict of interest’ when they practice medicine in a context where their patients might be in a position to request this type of service.
If a physician is a Scientologist, and refuses to prescribe anti-depressants, or a Christian Scientist, and refuses to refer for surgery, they are in a conflict of interest. Placing obstructions before your patient for legal treatments, even subtle things like refusing to talk about it, or refusing to inform, or refusing to refer, is a conflict of interest. All this document requests is that physicians plan ahead, and point their patients to someone else to obtain this legal treatment, quietly, unobtrusively, without disapproval of the patient.
Is that too much?
I must respectfully disagree with the SCC’s ruling on Physician-Assisted-Death. The CPSO Interim Guidance Document states that “The SCC unanimously determined that an absolute prohibition on physician-assisted death does violate the Charter rights of these individuals, and is unconstitutional” It is unclear to me where the Charter envisions that an individual has the right to insist that another person participate in bringing about their own death.
The prohibition against the direct killing of another human being has a very long pedigree in the history of civilization (capital punishment being an exception and bearing no relevance to the topic currently under discussion). I don’t see how our Charter reverses that tradition, or how in the framing of the Charter, any such outcome was intended.
In fact Section C of the CPSO Interim Guidance Document states: “Where a physician declines to provide physician-assisted death for reasons of conscience or religion, the physician must not abandon the patient. An effective referral to another health-care provider must be provided.” This explicitly contradicts Section 2 of the Charter, which states that freedom of conscience and religion are fundamental human freedoms. Making a referral is a direct form of participation in the killing of the patient, which the physician has declined to do as it conflicts with conscience. If freedom of conscience and religion does not apply to individual’s actions, then to what does it apply? Acting against one’s conscience is in fact a violation of one’s conscience.
Forcing an individual to act against conscience through some form of penalty if they do not comply is therefore contrary to the Charter and, quite frankly, coercive.
As Canadians, we can do much better.
I am against this notion. I have heard far too frequently from our colleagues and others that in those countries where this notion exists it has been routinely abused. Palliative care is becoming more widely available and is regularly improving in quality. If people wish to shorten their lives because they are suffering, let them find others to assist them, not doctors.
As a resident of Ontario, I am gravely concerned about the “Interim Guidance on Physician Assisted Death” draft policy.
As it stands, the draft policy does not respect the conscience rights of physicians. It would oblige physicians to refer patients for physician assisted suicide — and even to perform the act in certain cases — regardless of their convictions and professional judgement.
This is a serious violation of the basic human rights of individuals in a free and open society. Furthermore, it discourages doctors with deeply held convictions from practicing, and encourages medical staff that comply with the ideas of the day, regardless of their objections as professionals. We cannot permit ourselves to drive doctors with conviction and integrity out of the medical profession. Their courage and integrity are of great benefit to patients and to society as a whole.
Response in PDF format.
Response in PDF format.
Response in PDF format.
Evangelical Fellowship of Canada
The Evangelical Fellowship of Canada (EFC) was an intervener before the Supreme Court in Carter v. Canada. The EFC has been involved in discussions on euthanasia and assisted suicide for decades. We are a national association of evangelical Christians, with affiliates including 42 denominations, 65 ministry organizations, 38 educational institutions and more than 700 individual congregations.
The CPSO Interim Guidance on Physician-Assisted Death specifies that physicians who decline to participate in physician-assisted death for reasons of conscience or religion must provide a referral. However, this requirement to refer violates the Charter right of freedom of conscience and religion of conscientiously-objecting physicians.
In the Carter decision, the Supreme Court did not establish a positive right to assisted suicide. The Court found that a patient who fits the circumstances has a “right” to be free of the state prohibition against assisted suicide and request assistance. The focus of the Court was on patient autonomy and the freedom to request, and not on the provision of assisted suicide. The implication of the ruling is that a willing physician who freely assists them in their suicide would also be free from the prohibition. The Court did envision a “carefully designed and monitored system of safeguards” (par. 117). However, the Court was explicit that its ruling is confined to the right (freedom) of someone to seek assistance, and not to those who might provide assistance. (par. 69).
In the Headnote to the Carter decision, the Court said, “Nothing in this declaration would compel physicians to provide assistance in dying.” A person in certain circumstances has the freedom to request assisted suicide. The Court did not rule that the patient has a right to access state assistance or compel anyone to assist them in their suicide. In this regard, there is no “right” to assistance, and no one, neither physicians nor institutions, should be required to participate. The State is also therefore not required to provide or fund access to assisted suicide.
Physicians must have the right to refuse to participate in physician-assisted suicide for reasons of conscience, either directly or indirectly, including the right not to have to provide a referral. Providing a referral facilitates the treatment that follows. It is in effect a professional recommendation for a course of treatment. In the case of physician-assisted suicide or euthanasia, it is a form of participation in an action that is destructive to the patient. It is recommending, and participating, in an action that is contrary to the physician’s conscience. Most physicians who attend churches affiliated with the EFC consider participation in assisted suicide or euthanasia an offence against God’s commandments. If this policy is passed they will face the grim choice between following deeply-held religious beliefs or being disciplined by their professional body. It will mean that Evangelical physicians may have to alter their practices or leave direct patient care. If this were to happen it would amount to a prima facie case of discrimination against a class of persons because of their religious beliefs and moral convictions.
The Court’s statement, “The Charter rights of patients and physicians will need to be reconciled in any legislative and regulatory response to this judgment” immediately follows the assertion, quoted above, that “Nothing in this declaration would compel physicians to provide assistance in dying.” These statements taken together indicate a need to reconcile the rights of patients and physicians without compelling objecting physicians to provide assistance, direct or indirect..
We urge the CPSO to remove the requirement to refer from its Interim Guidance, and to seek a policy that would respect the conscience rights of its members.
Freedom of conscience and religion is protected. You are just not supposed to force yours on your patient. And you always have the option, unlike the patient, of not being a doctor.
Line 99: I would suggest substituting the phrase “lethal substance” for “lethal medication” as the original phrase may cause confusion and anxiety in the patient, if this language is forwarded to him or her by the physician or other health care provider. I speak as one who currently is experiencing an intolerable and as yet incurable condition. The word “medication” implies a good future result perceptible to the patient which in this context cannot be the case. Please trust me – you have to be in my shoes to be able to appreciate this. Thank you.
Advocacy Centre for the Elderly
Response in PDF format.
Christian Legal Fellowship
Response in PDF format.
‘Constitutional freedom of conscience’ has not been denied for conscientious objectors because, in the most extreme behaviour where the CO will not even tell their patients PAD exists, they are not being required to practice medicine; that is their choice.
As someone deeply concerned with the burning subject of assisted death services, I can only ask, beg, and implore you not to go through with the impending legislation. Doctors are formed, in principle, not to harm human life, but to do all in their power to protect it. Would it not be possible, and eventually more humanistic, to provide more palliative care for those whose lives are clearly coming to an end, so that they may leave this earth in human dignity, not by rejecting the gift of life which they had enjoyed for the many years beforehand, but by being cared for professionally, loved, and finally given back to the One who gave it in the first place?
I myself have had to care for my marvellous and dynamic mother, who died recently at her home at the age of 95 years, and I was allowed to feed, medicate, clean, and advise the PSWs when they came according to their calling. During this 24/7 job which went on for 6 full months, I had to learn from scratch what to do, how to do it, and when to do it. It was a real education, and I fully enjoyed taking care of the one who had given me birth and taken care of me for so many years beforehand. It was this palliative care which has made me a better person, and which has impelled me to write this, hoping that assisted death services would be blocked, both federally and provincially, that the culture of life and the respect of those who have been in the forefront of life may be put in the forefront of the policies of this Government, and that palliative care for the ill and very aged would be better provided for.
BC Civil Liberties Association
Thank you for the opportunity to comment on the draft guidelines. It is clear that the College has been very thoughtful in its approach to the issue, and has taken leadership among the provincial colleges to facilitate patient access to physician-assisted dying as soon as possible.
The BCCLA takes the position that physician-assisted dying can and should be treated like other medical decisions, and be governed by the established norms of informed consent law, which has shown itself to be perfectly adequate as a framework for life-and-death medical decisions.
We wish to make a few brief comments on the draft.
• Line 47 should be edited to read: “Acting in the best interests (consistent with the wishes) of their patients…” to ensure that the wishes of the patient are paramount to the physician’s view of what the patient’s best interests might be.
• The requirements that a physician assess and be satisfied of a patient’s “due consideration” and “non-ambivalence” go beyond the legal requirement in the Supreme Court of Canada’s decision. This requirement is much more confusing than simply requiring clear intention, and risks introducing unnecessary barriers to a patient receiving the care to which they are entitled. It should not be for a physician to second guess the amount of patient thinking that is required for a patient to manifest a clear intention. The requirement to give an amount of consideration that is “due” is not a required element to establish informed consent according to the College of Physicians and Surgeons of Ontario’s own policy on Consent to Treatment. That policy states that “In order for consent to be valid, it must be related to the treatment, informed, given voluntarily, and not obtained through misrepresentation or fraud.” The requirement be for “clear” consent as that is the legal standard set out in the Supreme Court’s ruling.
• Line 145 should be edited to state: “the physician must be satisfied that, in the opinion of the patient, the patient’s condition…”. The existing language allows room for the physician’s opinion as to whether the patient’s suffering is tolerable to enter into decision-making. The decision as to whether a particular degree of suffering is tolerable or intolerable must, according to the Court, be a subjective assessment that is entirely up to the patient.
• On the subject of conscientious objection, all physicians are required to provide information about physician-assisted dying according to the established norms of informed consent law. Physicians are not required to provide physician-assisted death. The patient’s right to access physician-assisted dying must be reconciled with the right of their physician to conscientiously object to providing that treatment. In order to reconcile these two competing rights, it should be recognized that the conscientious objector has a duty to immediately notify the patient of their objection, and to immediately inform a third party (for example, a hospital, local health authority, or the provincial or territorial regulatory college) of their objection. The third party should be placed under a responsibility to contact the patient as soon as possible to provide a referral to a willing physician. A physician must obtain the consent of the patient to disclose the request to the third party, such as a hospital, the College, or health authority, and consent for that agency to contact the patient. A physician must not abandon the patient, or discuss in detail their personal beliefs or pressure patients to disclose or justify their own beliefs. This approach is similar to that adopted in Quebec, and is similar to the part of your proposed draft and the Provincial-Territorial Expert Advisory Group’s recommendations contemplating the involvement of a third party.
In relation to the process to be used to carry out requests for physician-assisted dying, the BCCLA takes the position that there need not be a difference between requests for PAD and requests for other end-of-life medical treatments.
In Stage 1, the text be edited in number (4) to read: “in the opinion of the patient be experiencing enduring suffering…” Consistent with the point made earlier, this will keep the subjectivity of the assessment of suffering clear.
We fundamentally disagree with the proposals for a waiting period, and for a second request to be made. The Supreme Court of Canada decision does not require a waiting period. Physicians should have the right to use their own judgment, as they do in all cases in which a patient exercises informed consent in respect of an end-of-life decision. The critical considerations are whether the patient meets the criteria to access the PAD and clearly consents.
The requirement for a witness is superfluous and risks creating a barrier for individuals to access treatment and the requirement for two witnesses makes the situation worse. There need not be a difference between requests for PAD and requests for other end-of-life medical treatments. We think it is contrary to a patient’s right to privacy to require witnesses, and for each of these to have to attest to the patient’s capacity and their having made the decision voluntarily. To be able to make such an attestation, a witness would need to be highly involved with the patient. This requirement alone may make some patients reluctant to access PAD as they may not wish to share their details with people other than the physician.
The proposed process then creates additional barriers to accessing the constitutional right to PAD at stage 2. The requirement for a second physician’s opinion is needlessly bureaucratic and a departure from the normal standards of consent around end-of-life decision-making. There is no evidence to support such a requirement. As noted by the Supreme Court of Canada at paragraphs 106-107, physicians can assess competence and voluntariness, and the same applies for a determination of whether the eligibility criteria are met. Normal medical standards include the option of physicians to seek consultation from other physicians as necessary to assist with patient care. This should not be imposed as a requirement because it would add an additional step that is not necessary, based on the evidence, in each case. When another physician’s opinion is sought, the other doctor should be independent, meaning that the physicians are not in a direct supervisory relationship with each other.
Concerning the assessment of capacity, we support the requirement to refer a patient for a specialized capacity assessment in situations where a physician is uncertain that a patient fully understands and appreciates the nature and consequences of the decision to seek PAD. This is consistent with practice for other treatments. The final bullet of stage 2 means that someone who has met the criteria and has a constitutional right to access PAD might not be able to get it. This would amount to a violation of the patient’s rights. Competence should not be required at the time of the provision of PAD, but at the time of the request.
We thank the College for this opportunity to provide comments on the draft Interim Guidance. We commend the College for its proactive work in creating this guidance, which we know are intended at ensuring that qualifying patients in Ontario can exercise their right to choose a dignified end to life.
As a resident of Ontario, I am gravely concerned about the “Interim Guidance on Physician Assisted Death” draft policy.
As it stands, the draft policy does not respect the conscience rights of physicians. This is a serious violation of the basic human rights of individuals and professionals in a free and open society. Furthermore, it discourages doctors with deeply held convictions from practicing, and encourages medical staff that will comply with the directives of the day, regardless of their objections as professionals. This would represent a major loss for residents of Ontario who, like all medical patients, are greatly in need of medical professionals with integrity.
Integrity is not restricted to conscientious objectors.
I would like to express my view regarding Physician Assisted Suicide. The College of Physicians and Surgeons of Ontario (CPSO) has proposed that physicians must take part in physician assisted suicide by either offering physician assisted suicide or directly referring or transferring his/her patient to another physician. This means no doctors with religious beliefs (and who respect lives) against physician-assisted suicide can practice anymore. This is against the Charter of Rights which guarantees freedom of conscience and religion.
Doctors should be given the legal right to decide what they want to do about this issue (instead of being forced to do something against their views/religion).
Thank you for your attention. Please let me know if you have any questions or require any further information.
I agree with the above.
The Charter of Rights and Freedoms does not absolve physicians from practicing the accepted standard of care because of their religious beliefs. It protects them from being forced to be a physician.
St. Alphonsus CWL Woller
It is a very hard decision for any party involved. We must consider the person first then the professional side second
I am very uncomfortable with this supreme court decision and subsequent lack of guidance and legislation. I am a small town physician with a large senior population caseload and have already been asked for the “death pill” five times. I provide end of life care and assist with easing people through the final stages of their diseases. I do this because their death is imminent and unavoidable and I can help make it less horrendous for patient and family. I am not prepared to inject some lethal mixture of drugs into a patient who is fully cognizant, engaged in conversation with me, looking me in the eye. That act would change me in ways that I do not want. I anticipate people will request many details for their planned deaths including the setting, the participants, the atmosphere (i.e. on a special cliff overlooking the lake, family and friends at their side, specific music playing…?). I can imagine that this new opportunity to dictate when and how you die will become commonplace (?). I resent the expectation that I MUST provide a colleague who will carryout this assisted death, and that I must do so w/in a narrow window of time (i.e before my patient loses his faculties and no longer has capacity). And if I do not do so, that I am potentially exposed to sanctions from the college.
Ontario Medical Association
Response in PDF format.
Dying with Dignity
Response in PDF format.
Hamilton Health Sciences Medical Advisory Committee and Office of Ethics
Response in PDF format.
I welcome the CPSO’s proposed rules for physician assisted dying and believe they represent a compassionate, patient-centred approach to regulating choice at end of life. I am especially pleased that under the CPSO’s proposed guidelines, patients will not be abandoned as a result of a doctor’s moral or religious objection to physician assisted dying.Overall, the guidelines are reasonable and reflect the CPSO’s leadership on the issue.
I do, however, still have 3 key concerns with the Draft CPSO Interim Guidance on PhysicianAssisted Death.
1. Witnesses:
In its interim guidance document, the CPSO states a patient must make two requests for assisted death.
The second request must be accompanied by signatures of two witnesses who can attest to the patient’s capacity and confirm that the patient is acting voluntarily and free from coercion.
They advise that one of the witnesses cannot be: the attending doctor, a relative, an estate beneficiary or the owner, operator or an employee of a health facility where the patient is being treated.
This could represent an unfair barrier to access for some of Ontario’s most desperately ill patients; some may have difficulty obtaining the required second signature, especially if they are confined to a hospital, hospice or long-term care facility.
I believe that people who are alone may have difficulties with this barrier.
This potential barrier to access should be reconsidered by the CPSO.
2. Competency at Time of Assisted Death:
According to the CPSO’s sample process map, the patient must make the two formal requests at least 15 days apart. Two doctors — the attending physician and a consulting physician — must establish the mental competency of the patient before the process can move ahead. However, the policy states that “if at any time the patient loses the mental capacity to rescind his/her decision, physician assisted death ceases to be an option.”
This condition is problematic in cases of patients who receive approval but fall into an unexpected coma or other unresponsive state before being able to follow through with a physician assisted death.
3. Conscientious Objection and the Protection of Physicians:
I am supportive of a physician’s right to conscientious objection based on their personal moral or religious grounds. To balance a physician’s right to conscientious objection and a patient’s right to care, the CPSO has mandated a policy of effective referral to ensure that patients aren’t abandoned by the medical system. However, the policy does not address how to protect physicians who provide assisted death from sanctions from institutions that oppose it.
While protections may be addressed by federal guidelines, this matter should be included in the CPSO’s dialogue moving forward.
I wish to express my gratitude to the College of Physicians and Surgeons of Ontario for their consideration and their leadership on the issue.
63% of Canadian MDs say they would refuse to provide medical aide in dying for various reasons. Given this fact, there has to be a clear provision in the CPSO policy to allow for conscientious objectors to not be forced to refer for this service.
I think it unconscionable that a medical doctor who has taken the Hippocratic oath to save and preserve life, should now be mandated against his conscience and oath to offer directly or indirectly the elimination of life; that the emphasis should shift from palliative care and pain relief through science – to execution at the request of an ill person, or of an old person. Just research in an unbiased manner the experience internationally of abuses in countries that allow euthanasia.
As a disabled person I have great concern for people who may be vulnerable and easily make a decision from pressure on themselves, whether it is outside pressure or pressure they put on themselves. There are many times I felt a burden to others and have suffered depression. The thought was, I would be doing others a service by ending my life. I am forever great full for those who counseled me. I have since lived and continue to live a full life, helping others. I feel the assisted suicide is a very dangerous slippery slope. Horrendous suffering is a tragic and unbearable thought, but the taking of a life is for ever. We must use strict and utmost caution.
I am a practicing specialist in Ontario for 21 years. I consider it very sad that Ontario and the CPSO has embraced this policy.
I would like to emphasize my right as a physician to reject this policy as I consider it to be immoral.
I will not be able to participate in Physician assisted suicide or be a participant in the referral of a patient. I will not be able to provide information
on the services provided and I would encourage the CPSO to set up some other type of service model, if the CPSO expects these services
to be offered to Ontario citizens. I became a physician to help people get well and die dignified. We have all the resources required in the field of
palliative care for this to be accomplished.
I make this special appeal to all medical doctors to take a stand against the push for euthanasia and assisted suicide which the people of Canada are undergoing. I believe that your position, as a whole, in this vital matter carries the most weight; concurrently, it implies being held accountable (to God) to the highest degree. Is the Lord Jesus—our Great Physician—Lord of each of your lives? Is the medical profession under the authority of the Lord Jesus, or has it given way to becoming a sinful structure (where sin produces sin, and becomes dominant; thus resulting in an unjust structure)?
In the midst of your busy schedules, could you please set aside some time for reflection on the outlook conveyed in the forwarded message and the attachment? My hope is that, with the help of God’s grace, it will be of assistance for viewing the current circumstances in a meaningful, personal way.
I commend all physicians who are living out their beliefs of faith in their practice of medicine in fulfilment of our Lord’s calling. May the Holy Spirit continue to give each of you courage and perseverance.
I pray that Parliament does not allow itself to be bullied by the nine (unelected) Supreme Court of Canada judges who have betrayed this intent in an even more obvious manner with their latest ruling on this matter (granting a four-month extension to the February 6, 2016 deadline).
You still have an opportunity to voice objections to the implementation of physician-assisted suicide in Canada by making a submission to, or presentation before, the Special Joint Committee on Physician-Assisted Dying (http://www.parl.gc.ca/Committees/en/PDAM).
Assisted dying is a euphemism for killing. Please be clear in your language. There is a precept of natural law which the government has an obligation to uphold and that is killing of innocent persons is a crime against humanity.
When a young person is suicidal we want to help that person not commit suicide. However, if the person is terminally ill, handicapped, we are now saying that person has a right to be killed. In other words those who support euthanasia do not consider that person’s life valuable, they are not worth living.
The Canadian gov’t must oppose euthanasia in order to protect it’s citizens. That is it’s job.
Your respondents have a right to read “Medical Science Under the Dictatorship” by Leo Alexander M.D. and published in the New England Journal of Medicine. 1949.
http://www.nenzen.net/medical-
dictatorship.html
Bottom line: You shall not kill. Work on palliative care.
Response in PDF format.
Lines 61-66: Criteria – there is an opportunity to have build in tools here for competency, what constitutes a irremediable medical condition and how to assess suffering.
Lines 85-86: Reference to HCCA and Consent to Treatment policy – This is a policy that is in general speak and not that easy or practical to follow. The opportunity to create workshops or webinars or documents that make these policies real for family doctors is present and could be a test with PAD.
Line 155: OHIP Billing – Nothing in OHIP about this so hope the OMA is coming through on this one.
Line 173: Conscientious objectors must inform patient their objection is for personal reasons – Disagree that I need to let a patient know my personal views. This will impose judgement on a patient that I have a relationship with. Family doctors are different! WE should never let our personal views be known- it is not about US. So I feel strongly that I make a referral stating it is not within my scope or comfort of practice.
Lines 188-189: Referrals must not expose patients to adverse clinical outcomes – Not feasible in todays health care system so feel this is setting someone up for failure. Would leave this line out or change to state “Every attempt will be made to lessen the probability of a delayed referral causing adverse clinical outcome”
Lines 205-206: Documentation requirements – The most critical content and making sure that there is a template for the necessary medical record would be very helpful. Especially having an EMR template so involving ONTMd to make sure they understand the clinical content is important.
Stage 1: Waiting period can be shorter when time is of the essence – Please remove this line. I cannot fathom a time when it would be needed. Someone with a PPS of 20% will die within 2 weeks. Someone with a PPS of above this needs to consider this very carefully and without the 15 days patients will show up to my office demanding it (like an ear syringe) or to the ER department. This is a tool of care and not an emergency procedure. WE have ketamine drips and phenobarb so palliative sedation remains an option.
Stage 2: Specialized Capacity Assessment – Where are these coming from…..we have a limited supply of capacity assessors in medicine. A new industry?
Stage 3: Drug Protocols – Reasonable articles but I really think we need to create a tool from them for our family doctors.