Organization
[November 30, 2022 3:19 PM]
Ontario Medical Association (OMA)
Response in PDF format.
Physician (including retired)
[November 29, 2022 2:17 AM]
Writer fully supports post 83 from the Canadian Society of Palliative Care Physicians.

The draft CPSO MAID policy references the Human Rights in the Provision of Health Services policy that is also in consultation. There is concern that the latter is being interpreted to mean that Physicians have an a new positive obligation of raising MAID as a treatment option to every patient that would be potentially eligible.

Furthermore, the MAID policy relies heavily on a document from The Canadian Association of MAID Assessors and Providers (CAMAP), "Bringing up Medical Assistance In Dying (MAID) as a clinical care option" that argues for such an obligation. The document contains a fundamental flaw in that it conflates medical diagnoses with the full legal eligibility criteria for a "grievous and irremediable medical condition":

"The appropriate timing of the initiation of a discussion about MAiD should be at the discretion of the clinician, taking into account all of the circumstances of each patient. For example, in almost all circumstances, it would be clinically inappropriate to initiate such a discussion immediately upon delivery of a diagnosis of a grievous and irremediable medical condition. However, once options for all treatment options including cessation of treatment are being presented to the patient, it would be appropriate to disclose the availability of MAiD."

If one applies the legal definition of a "grievous and irremediable condition", MAID should NOT be proactively included in the treatment options presented to a patient by a Clinician, as the patient would ONLY meet the definition and be potentially eligible for MAID if NONE of the presented treatment options for relief of their suffering are under conditions considered ACCEPTABLE to the patient.

By implying that a grievous and irremediable medical condition can be "delivered as a diagnosis", the presence of CAMAP's document at the centre of the MAID policy would mislead Clinicians into incorrectly considering a large proportion of patients potentially eligible for MAID. This would greatly expand the pool of patients whom Clinicians may feel obligated to discuss MAID, and perpetuate the very harm CAMAP claims to seek to reduce, i.e. bringing up MAID to patients who clearly would not qualify.
Physician (including retired)
[November 29, 2022 12:13 AM]
The point to make is that MAID removes the absolute, objective standard of the value of human life in our law and replaces it with a subjective standard. Under MAID, the value of human life is determined by something (more to the point, someone) other than the former absolute standard of value. MAID says it is only the individual who can decide if the individual's life continues to merit legal protection or not. But the MAID statute violates its own premise by relying on the diagnoses and prognoses of physicians to determine if an individual is qualified to make the subjective life or death decision for the individual. Now the criteria of MAID extends far beyond the original supposed standard of imminent death, to include mental health challenges and "irremediable suffering" in many or any forms. This is an incurably subjective standard. In these circumstances it is difficult if not impossible to delineate, in determining the declaration of life unworthy of life, between the subjective opinion of the physician and the subjective opinion of the individual. In this way the power to speak death is shucked onto physicians' shoulders whether they want or not.
Member of the public
[November 28, 2022 11:58 PM]
The submission by the Society of Palliative Care Physicians contained the most compelling arguments for me as a member of the public. My appreciation to the College and its members for the work done on this difficult subject.
Physician (including retired)
[November 28, 2022 11:50 PM]
We were told in 2015 that there would be no ‘slippery slope’. Now with mental health patients on the list to access Medically Administered Death, psychiatrists and primary care physicians are having to rework in their minds/hearts that the “rights” of patients have just awakened a life-ending treatment option namely, the death procedure. Why is the CPSO / Quebec so eager to make MAiD a treatment option - Death has become a treatment which apparently can’t be acknowledged on a death certificate… the cause of death is the procedure … ‘the surgery was a success because the patient died’ Is there oversight for the death treatment like there would be for the treatment of surgery or chemotherapy? Provinces have volunteers that have stepped up to do the deed but ‘like a surgeon’ where is the oversight? Who determines that there isn’t a conflict of interest or that someone has other motives in wanting to complete a treatment - especially if you aren’t suppose document it?
Member of the public
[November 28, 2022 11:16 PM]
I am writing to provide feedback on the above mentioned draft policy and advice documents.
 
The College of Physicians and Surgeons of Ontario [CPSO] draft policies appear to normalize MAID as a standard treatment that should be offered by health care professionals to all people who might qualify. The Draft Medical Assistance in Dying Policy, and the Draft Human Rights in the Provision of Health Services Policy fail to clearly identify the need to protect disabled people without discrimination against premature death and introduce some requirements that appear to create a tension with physicians‘ duties related to helping their patients avoid premature death, and this on a non-discriminatory basis. I urge the CPSO to revise the draft policies to address these concerns. The policies should at a minimum recognize and address the tension between providing access to MAID and the need to protect against premature death on a non-discriminatory basis.
 
Neither the Supreme Court, nor federal law, nor any other jurisdiction in the world, treats MAID as a standard medical procedure. The Supreme Court emphasized in Carter that MAID should only be permitted in exceptional circumstances, and that the practice should be surrounded by the strictest safeguards. We see that also reflected in our current law—albeit arguably insufficiently—to the extent that the law introduces additional requirements, over and beyond those that exist in medical care. Assisting someone to die remains a criminal code offense, punishable by imprisonment, and MAID is carved out as an exemption to this prohibition, in defined circumstances. The CPSO policies should emphasize that suicide prevention remains a key obligation of physicians, which applies regardless of whether a patient has a disability. The policies should remind physicians that direct involvement in termination of life and counselling to support suicide remain prohibited in the criminal code. This emphasis is important, to avoid that ending of life is normalized as standard treatment. It is particularly important now that MAID has been legalized outside the end-of-life context.
 
I further want to express specific concerns about the following:
 
1) The CPSO Draft Advice to the Profession suggests that there is a duty to bring up MAID as part of the informed consent process. Th Draft Document has the following provision that refers to and appears to endorse a Canadian Association of MAID Assessors and Providers [CAMAP] policy:
 
“Physicians will have to use their professional judgment to determine if, when, and how to discuss MAID with their patients. The Canadian Association of MAID Assessors and Providers (CAMAP) has a clinical guidance document on Bringing up MAID as a clinical care option, which includes the following:
  • The appropriate timing of discussions regarding MAID is determined by the clinical context and the specific circumstances of the patient.
  • When discussing MAID as a treatment option, be aware of the physician-patient power dynamic and ensure MAID is presented as one of the treatment options, and not as a coercive recommendation to pursue that option.
  • It is important to approach discussions regarding MAID from a place of respect and trust and allow for sufficient time to have such sensitive conversations.”
The CAMAP policy also explicitly states, however, that MAID should be introduced to everyone who ‘might qualify’. If one applies this policy, a capable disabled person with irreversible decline of capability who consults a health care provider to help address a medical condition that might create serious suffering, would have to be told by the provider that MAID is an option. That seems reckless and constitutes a violation of the standard of care. Decisions to bring it up will be influenced by health care providers’ potential ableist perceptions of the quality of life of disabled persons. It will harm the doctor-patient relation to introduce MAID in this context and can be inappropriately inducive. Considering the power imbalance of the health care provider-patient relation, and the context in which this issue will come up, it is in my opinion inappropriate to indirectly endorse the CAMAP policy. On the contrary, the CPSO should explicitly state that health care providers should NOT bring up MAID unless explicitly asked. This should be the presumption, particularly outside the end-of-life context, and clearly also in relation to patients who struggle with mental health issues or who may be suicidal.
 
Other jurisdictions which have recently introduced Assisted Suicide for persons with a terminal illness diagnosis (e.g. New Zealand and Victoria (Australia)) explicitly prohibit physicians from introducing MAID to patients without being asked about it. In Belgium & The Netherlands, the law does not explicitly prohibit physicians from bringing it up, but it is emphasized that the initiative has to come from the patient. Moreover, in those jurisdictions, physicians cannot offer it if other treatment options are available that have not yet been tried. Physicians need to agree in those jurisdictions that there are no other options left to address the unresolved suffering. Offering it as part of an initial informed consent process to a patient who ‘might qualify’ seems thereby inconceivable. I urge the CPSO to explore how to introduce an explicit prohibition for health care providers to bring up MAID without being invited by the patient to talk about it. This is particularly important outside of the end-of-life context.
 
2) The CPSO Draft Policy on Human Rights in the Provision of Health Services - The ‘effective referral’ provisions will, according to this draft policy, also be applicable outside the end-of-life context. This, combined with the issues raised above, is problematic. The CPSO invokes the Ontario Court of Appeal decision in Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393, but this decision dealt with MAID practice in a more restrictive end-of-life context under the previous law. Applying this obligation outside the end-of-life context brings up more significant concerns about the lack of clear standards and safeguards to determine irremediability and ‘irreversible decline of capability’.
  • Physicians who know that there are reliable treatment options for patients who may have years and decades of life left, may now be forced to accept a perhaps impulsive treatment refusal, and may feel under a professional obligation—enforceable by sanction--to refer their patient to physicians who are known to be open-ended about offering MAID, even if they themselves feel that it violates their professional duties to provide MAId in that situation. This would be the case even if they feel, in their professional opinion, that their colleagues may be too flexible about offering MAID in those circumstances. The fact that the criteria to obtain MAID are open-ended makes this a very real possibility. The CPSO guidelines may thereby result in a spiraling towards the most recklessly flexible MAID standards. This puts numerous patients are risk of premature death, particularly—but not only—in the mental health context.
  • The “effective referral” obligations under point 9 appear to create obligations that go beyond the obligations that a physician has in a normal clinical context when making a referral. Remarkably, when a physician has a conscience or religious objection, the policy appears to create a stronger duty to ensure ‘effective’ referral for conscientious objectors than the duty a physician without conscience or religious objection has.
  • With Bill C-7, there is a commitment to introduce MAID for mental illness as of March 2023. Neither the federal law, nor any existing or proposed guidelines propose further safeguards to protect persons with mental illness in the MAID context, notwithstanding significant concerns expressed by the patient and mental healthcare provider community. There is, for example, no indication as to what ‘irremediability’ means in the context of mental health, or in the context of the intersection between various disabilities and mental health. The CPSO should clarify that irremediability is a key requirement for MAID, and that this concept applies regardless of a patient’s refusal of therapy or the acceptability of a treatment option from the patient’s perspective. Of course, patients cannot be forced to undergo treatment, but the CPSO should specify that irremediability remains an independent requirement.
  • The ‘Duty to Provide Services Free from Discrimination’ (point 5) fails to mention a most important duty: the duty to protect patients against premature death, including death from suicide, without discrimination based on a protected ground. The Human Rights policy should explicitly refer to an obligation to provide equal protection against premature death of disabled persons, including by providing adequate suicide prevention.
 
 
The Draft Policy contains the following provision:
 
“11.When completing the medical certificate of death, physicians: a. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and b. must not make any reference to MAID or the medications administered on the certificate”
  • If there ever was a justification for this practice—in my view there never was—, the justification no longer holds. Requesting physicians to invent a cause of death on a death certificate, particularly when a person who died by MAID would otherwise have lived for years or decades, is hugely problematic. It constitutes the creation of a professional obligation to falsify official forms, which is from a professional regulatory perspective deeply problematic and sets a terrible precedent.
  • This provision was in my view already problematic when MAID was restricted to a reasonable foreseeable natural death, because of the above concern, i.e. normalizing the falsification of a document. With the already broad interpretation of RFND this was also already a problem, in that a person who might have had two or three years of life left was now deemed to have died of a condition which normally does not cause death (e.g. osteoarthritis). But it becomes even more problematic when a person is not in any way otherwise approaching their natural death. It seems absurd, but also problematic from a disability rights perspective, to frame it as if persons died from a disability that does not cause death.
  • I further wonder what this may mean for statistical and research purposes, if we now start registering causes of death that are regulatory constructions and removed from reality.
 
4) I recommend that the CPSO introduce its own detailed quality control standards and strict oversight over the practice of MAID, as part of its MAID policy. This should include, for example, control over who is providing MAID, on what basis, and how frequently. The CPSO already engages in some control over, for example, medicine prescription practices. When it comes to a procedure that inevitably results in death, sufficient control seems so much more essential.
 
I would be happy to provide further feedback and help reflect on how the CPSO could address the discriminatory lack of protection against premature death of disabled persons in the context of the practice of MAID; how it could prohibit bringing up MAID outside well-defined circumstances, introduce better safeguards and standards, and improve regulatory oversight.
Physician (including retired)
[November 28, 2022 11:02 PM]
Physicians must not be required to discuss MAID unsolicited. To do so can undermine confidence and trust in patients seeking life-affirming care. It may also be perceived as a suggestion or recommendation by vulnerable patients.
Physician (including retired)
[November 28, 2022 10:47 PM]
If MAID is the cause of death then it should be listed as such. To do otherwise is dishonest. Why are physicians being told to lie?
Organization
[November 28, 2022 10:00 PM]
Catholic Civil Rights League (CCRL)
The Catholic Civil Rights League (CCRL) is pleased to provide this submission to the College of Physicians and Surgeons of Ontario (CPSO) regarding the general consultation on Medical Assistance in Dying and the proposed revisions of the current euthanasia/assisted suicide policy.
 
We strongly advocate for the protection of the Charter right of freedom of conscience and religion for all Canadians, including physicians and health care professionals, in the daily routine of the provision of care and healing to patients. That freedom is at the core of many individual medical practices, and provides real diversity from a compelled narrative so contrary to Hippocratic principles.
 
The CCRL rejected and continues to reject the compulsion for a physician opposed to euthanasia and assisted suicide to make an effective referral to one who will carry out the objectionable act. It is wrong to compel someone to do wrong in their practices.
 
The League notes that in CMDS et al v. CPSO the court acknowledged the infringement of physicians’ freedom of religion in its decision and further accepted workarounds as a reasonable means of balancing the rights of patients with the rights of objecting physicians.
 
The CCRL submits that the proposed revisions in line 333 under the question, “Does the expectation to provide patients with an effective referral apply in faith-based hospitals and hospices?” and in 339, “Can I end the physician-patient relationship because my patient wishes to explore a care option that conflicts with my conscience or religious beliefs?” need to be addressed with an overriding concern that a patient’s demand should not trump the freedom of religion of the physician, or the institutional freedom of religion of a religious hospital.
 
The CCRL believes that the continuance of historically recognized allowances, or workarounds that facilitate religious objection, should be maintained as part of our social fabric, and in recognition of the authentic pluralism of a free and democratic society. A forced compulsion over such rights is the negation of a truly authentic pluralist society.
 
With this submission, we at the CCRL sincerely hope that any revisions to the current euthanasia and assisted suicide regime does not compel Catholic hospitals to violate their core belief in the sanctity of human life, from conception until natural death, which has been a consistent life ethic for the hundreds of years of their operation in Ontario. It is not the time to trample on that rich history of care and concern with a radical exaggeration of the notion of autonomy at every institution providing health care.
 
The acceptance of abortion, or euthanasia, soon to be provided for those with mental illness, should not be allowed to undermine the charism of Catholic hospitals. That was not the intended effect of such changes to the law. The people of Ontario, whether of faith or no faith, have not turned against Catholic hospitals with such a fierce intolerance.
 
Recognition of religious differences adds to the social fabric of our society. It is at the core of a true pluralist and diverse population agreeing to disagree at times, always respectful of differences. Differences of opinion on moral judgments should not be trivialized by rejecting such differences in favour of the bully in the room.
Physician (including retired)
[November 28, 2022 9:13 PM]
The predominant problem with the document is found in Capacity and Consent (page 2) of Medical Assistance in Dying Draft Policy. It states "physicians must ensure the patient is capable and provides valid consent to receive MAID. Valid consent is described in the document as "given voluntarily." However, in the present conditions in which disabled people live, and according to their own testimony, consent for many patients who request MAID is not given voluntarily but rather the result of coercive impoverishment that is a direct consequence of insufficient state funding for ODSP, pharmacare, and palliative care. There has been sufficient testimony from palliative care doctors, disabled activists, and disabled patients to infer that a disabled person requesting MAID on the basis of their disability may be doing so due to mitigable factors like poverty and homelessness.
I am equally gravely concerned about MAID being offered to people on the basis of only mental health conditions, given the lack of safeguards in place for this.
Prefer not to say
[November 28, 2022 8:37 PM]
Health care professionals SWEAR to do NO HARM. Yet, they are the ones who cause the most harm to a Terminally ill patient. If MAiD had been legal when my mom was sick, and she begged for us to pull the plug.... to help her have it be over, you bet we would have done it for her. She deserved to die with dignity.... on her terms.... health care professionals who vote against this should all be reminded about DO NO HARM!!!! NOT BE THE CAUSE OF SOMEONE'S PAUN AND SUFFERING.
Organization
[November 28, 2022 6:39 PM]
Evangelical Fellowship of Canada
Response in PDF format.
Physician (including retired)
[November 28, 2022 6:00 PM]
I am very concerned with the fact that as a conscientious objector to MAID, that I would be compelled to discuss this as a "treatment" option with my patient. Firstly, there is an inherent power imbalance between patient and doctor and to even suggest MAID as an option, can be construed by the patient as something that is recommended. As a conscientious objector I cannot discuss calmly and objectively ending someone's life. I should not be held to account for not doing so. The acronym "MAID" has been sugar coated to make it into an everyday procedure. It is not a treatment at all -- a treatment implies a possible positive response. This is a procedure which ends treatment. Lastly, I object to falsifying a death certificate. It is an insult to the integrity of our profession to ask us to lie on the death certificate, and also of concern is the lack of accountability for MAID. I believe in the sanctity of life and I would give up my licence before I could in good conscience take part in the act to actively end a life, even if that meant I needed to discuss and refer. We are stooping to a new low when asked to lie and be forced to take part in a "treatment" to end a life.
Physician (including retired)
[November 28, 2022 5:44 PM]
CAMAP advice document says that clinicians have an obligation to discuss maid with all potential patints. They have no authority to make this an obligation and the College is unwise to accept it as a policy. It would be similar to the Vegan Society dictating their version of the Canada food guide be discussed with every patient.
CAMAP have a vested interest which is not objective or evidence based. Please reject this advice in lines 25-26.
Thank You.

MAID for infants is abhorrent to practising physicians such as me. How can the College have deserted its principles so far?
Organization
[November 28, 2022 3:29 PM]
Christian Medical and Dental Association of Canada
Response in PDF format.
Member of the public
[November 28, 2022 3:11 PM]
If enacted, these "draft" policies would demand that doctors must refer patients to their deaths and they require that death be raised as a "treatment option" (anytime?) instead of a exceptional service and that doctors not state physician-assisted suicide or "MAiD" as the cause of death on death certificates. So... how will we know who died of their disease, and who decided to kill themselves with medical complicity? This is not a trustworthy health care system, there is no care anymore!

This is appalling and I will not stay in Ontario if the medical system goes down this route. I will VOTE (my family tax money) to another province, and I will NOT wait for a TRAGEDY to happen in my family or neighbors' lives before I act. This is my family and acquaintances we are talking about here, our grandparents, parents, children, friends!!
Organization
[November 28, 2022 3:09 PM]
Canadian Physicians for Life
Response in PDF format.
Organization
[November 28, 2022 3:08 PM]
Ontario Ministry of Health
Response in PDF format:
Physician (including retired)
[November 28, 2022 12:32 PM]
Advice to the Profession: Medical Assistance in Dying

I am concerned that the CPSO mandate to "Guide the Profession and Protect the Public" has been lost as evidenced by this document.

I will get a bit historical and remind us all that the Hippocratic oath which used to be part of the graduation process for physicians, was based on medical practitioners going against social and political norms and seeking a higher standard. The very fact that preventing self harm or harm to others was stated was that this oath was in sharp contrast to the norms of the time when euthanasia was common practice and done by medical practitioners. For centuries since medical practitioners sought the higher road and worked to provide care where euthanasia was neither practised nor needed because healing and addressing of medical needs (including the psycho social determinants of health) was the priority and so patients did not need to request it. Physicians championed both for medical care and social change.

This policy states the psycho social aspects of medical care ought to be addressed in lines 226-233, but just as quickly abandons them. The CPSO ought to be addressing the lack of these services that improve the psycho social determinants of health, rather than aquiescing to misguided legislation that allows governments to discharge their obligation to society at the lowest bar, that is, if we can not care for you, we can kill you mercifully"

MAID should not be happening or offered in the scenario where patients do not get enough funding to live, lack social support, lack access to mental health services or home care services as is happening now. The CPSO should be championing patients rights to good care and not a second option that is really no option in the absence of choice for proper care.

The CPSO is an independent entity that is supposed to guide the profession not bow to political pressure and malfeasance (government refusing to adequately fund health care services and choosing a cheaper option as evidenced by CMAJ article January 2017 on the health care cost savings of MAID). The CPSO needs to provide guidance on how to improve and protect our patients from this extension of MAID beyond the initial goal for reasonably forseeable death. In this document it is clear that there is vagueness of judicial comments regarding guidance on forseeable death. In fact, the judiciary clearly state they are not the experts in these matters. The CPSO and it's members are the experts. They should provide guidance and input to government for what is best for the patients and not the reverse.

The CPSO missed the mark and its mandate in this document. Physicians do not need advice on how to implement bad legislation. They need advice and leadership in doing what is best for patients who need government assistance for their medical issues. We need Hippocratic physicians who will do what is best for the patient and not conform to social or governmental pressures to do less than the best for patients needs and rights to access good care.
Physician (including retired)
[November 28, 2022 12:17 PM]
The "Medical Assistance in Dying" document is a confusing and conflicted set of guidelines. No where else in CPSO guidelines are we instructed to falsify a medical record, indeed we are instructed to not do so.

MAID is the Cause of death, not the cancer, not the depression, not congestive heart failure, not any other reason, MAID is the reason they died. Death certificates clearly state cause of death and contributing conditions. Thus cause of death is MAID secondary to cancer, depression, congestive heart failure or whatever that secondary condition was.

What is the big issue about stating the true cause of death. Insurance policies can not be negated. Families generally know or can find out in other ways.

Falsifying death certificates only allows MAID not to be tracked. What need is there to hide that when MAID is a legal and acceptable medical practice? It hampers research. It makes it impossible to actually assess the access of these services that are paid for by the public purse. I do not see how lying on medical records fits into the CPSO mandate to "Guide the Profession or Protect the Public".
Other health care professional (including retired)
[November 28, 2022 12:02 PM]
Note: Some content has been edited in accordance with our posting guidelines.
MAiD should not be part of our medical system in Canada. The stats I heard were 30,000 people have been killed by this already. These these laws come in on pussycat feet and then end up being voracious lions. If i were practicing I would not recommend this for anyone as I am a God fearing, prolife citizen of a country founded on Psalm 72:8. [redacted]. I do not like the way this country is changing having been a native here I see the changes and would leave if my husband would come. Canada scares me now. Our medical system scares me.
Physician (including retired)
[November 28, 2022 11:22 AM]
I have devoted my professional life to Canada's indigenous peoples. I find it difficult to explain Goals of Care to elderly patients, because they are afraid I am withholding care. There is still a deep distrust of white medicine. How then can I offer MAID?
Physician (including retired)
[November 28, 2022 11:14 AM]
CPSO, you must know that there are many hard-working doctors who will not cross the line of offering and referring for MAID, thereby participating in the taking of human lives. If you want to start disciplining all of them, you will have your hands full, and in the end, you will have fewer doctors.
Physician (including retired)
[November 28, 2022 10:42 AM]
Making effective mandatory places the health care provider with ethical concerns in a tenuous situation. This predisposes the health care provider to moral distress, which occurs when one is unable to take an ethically appropriate or right course of action, including avoiding moral wrongdoing or harm, because of medico legal barriers. This moral distress can lead to moral injury in time, and adversely affect the provider’s mental health. Moral distress and injury are well documented in scientific literature and the ramifications of imposing effective referral in this regard should not be ignored.
Physician (including retired)
[November 28, 2022 10:29 AM]
Effective referral of the patient for a procedure that the physician considers bad medicine makes the physician complicit in what she considers an poor medical practice. There are alternatives to effective referral that should be considered instead of making effective referral mandatory for the physician.
Physician (including retired)
[November 28, 2022 9:41 AM]
This policy is completely unacceptable.

First, it requires doctors to state inaccurate information on death certificates, which are supposed to be accurate and specific legal documents.
The cause of death on certificates should be medically-administered death, followed by the condition which led to the patient being qualified for it.

Second, doctors should not be forced to include medically-administered suicide as a 'treatment' option for any illness. Period. There is plenty of opportunity for patients to raise this topic of discussion themselves. It should never be introduced by the health care team as even the perception of being told "it would be fine for you to kill yourself" is harmful to patients.
Physician (including retired)
[November 28, 2022 9:40 AM]
The alarming number of MAID deaths in Canada is worrisome and may be indicative of sub-standard quality of care. It would be useful to know if patients who receive "state-of-the-art" palliative care are opting for MAID.
Physician (including retired)
[November 28, 2022 3:21 AM]
CPSO fails to protect the vulnerable, cooperates in the legitimization of killing, compels physicians to become complicit in the killing, and then compels falsification of records. Unbelievable!
Physician (including retired)
[November 28, 2022 12:02 AM]
I am concerned that this document will support the notion that physicians have an obligation to list MAiD as a possible treatment option, even though unsolicited by patients. To suggest death by physician-assisted suicide is really not appropriate the vast majority of the time. It is also troubling given the fact that many of our patients desire to live and yet at the same time are despairing due to the limitations and significant life changes imposed by their conditions. I think that coercing physicians to suggest/offer MAiD as treatment is dangerous for Canadians in general.
I don't quite understand why death by MAiD cannot be listed on an individuals birth certificate? I cannot think of a single good reason for refraining to specify as precisely as possible the nature of an persons death. This is really important information to be capturing, for a variety of reasons, at the very least statistical so that Canadians, as well as us physicians, can have a reasonable estimate at how many deaths are occurring by MAiD, and for what specific medical conditions the MAiD procedure was provided. This ensures a basic level of accountability, both amongst physicians/healthcare providers, and government.
Physician (including retired)
[November 27, 2022 11:46 PM]
I have the following issues with the Medical Assistance in Dying and the Human Rights in the Provision of Health Services policies:
1) Physicians killing their patients
2) Disregard for conscience rights and mandating effective referrals
3) Insistence that physicians lie on a medical document about the cause of death

1) Physicians killing their patients
MAID is an euphemism for killing patients.

Details are changed so please don't redact this. I know an adolescent boy in Canada who had sudden onset paralysis from the neck down. To the horror of the patient and his parents, one of the physicians on their medical team proposed assisted suicide as a "treatment option" because he wasn't improving. They understandably lost faith in the medical profession and felt like their team had given up on their child.

It's hubris on the part of our society, the physicians offering assisted suicide, and the College to think that they know whose life is no longer worth living. To insist on offering death under the façade of autonomy shows a complete disregard for the aforementioned boy and countless others with disabilities and mental illness who will be harmed by policies such as these. Patients who are suffering need hope and our help, not an offer of death.

2) Disregard for conscience rights and mandating effective referrals
Regardless of one's views on assisted suicide, why in the world would you want to raise up a generation of physician who are so lacking in moral reasoning and conviction that they are willing to refer a patient for something they believe to be wrong and harmful to the patient?

There is no evidence that mandating an effective referral is necessary for ensuring patient access to assisted suicide. I challenge the College to publish such evidence if they have it. Many provinces have found ways to ensure patient access (e.g. hotlines for outpatients, direct transfer of care for inpatients) without infringing on the conscience rights of physicians.

The attempt to pit a physician's conscience or beliefs and values against professional obligations and patient care is ludicrous. Many of my colleagues with differing worldviews have values and beliefs which motivate them to dedicate themselves selflessly to the care of their patients. Allowing it to guide our care for patients when convenient for the College then asking us to completely disregard it the next is preposterous.

3) Insistence that physicians lie on a medical document about the cause of death
This should be self evident... It's disgraceful, dishonourable and unprofessional. The very conduct that the College is supposed to prevent and discipline its members for. I understand the concern for patient privacy but it doesn't justify forcing physicians to lie.

The College disregards the ethical and moral norms that have guided our profession for millennia (e.g., to first do no harm and to respect the conscience of our colleagues) to the detriment of our profession and the wellbeing of our patients.
Physician (including retired)
[November 27, 2022 11:44 PM]
Thank you very much for the opportunity to comment on the documents “Medical Assistance in Dying” and “Advice Document to the Profession re: MAiD.”

There are three areas of this policy which greatly concern me.

The first is the requirement to inform patients of “all treatment options” with reference to the document “Bringing up Medical Assistance in Dying (MAiD) as a Clinical Care Option,” written by the Canadian Association of MAiD Assessors and Providers (CAMAP). This effectively implies that the CPSO will be requiring physicians to inform patients that they are likely eligible for euthanasia, even if the patient has not raised the issue of euthanasia themselves, or given any indication that he or she is interested in a hastened death. It is my understanding that in some jurisdictions around the world where euthanasia is legal, physicians are specifically prohibited from initiating conversations about euthanasia, and I am not aware of any other jurisdiction where physicians are actually required to do so. That would make this an unprecedented move on the part of the CPSO, and limits the possibility of having any foresight as to how this requirement will affect patients’ experiences of care, specifically to what degree patients might receive this information as a form of subtle (or not so subtle) coercion to end their lives prematurely.

We already know that feeling like a burden is a common reason for patients to request a hastened death. We also know that Canadians who are not dying, but rather suffering with chronic illness and/or disability, are requesting euthanasia because they lack the financial means and social supports to live a dignified life. Disability rights organizations have identified the expansion of euthanasia to people with disabilities who are not near death as a form of ableism. Canada’s expanded euthanasia law has been called out as a human rights violation by UN Special Rapporteur on the rights of persons with disabilities. Given these realities, requiring physicians to actually offer euthanasia to their patients risks making Canada more hostile to people with chronic illness, disabilities, and, come March 2023, mental illness.

Even the aforementioned CAMAP document acknowledges that “there is no risk-free way to bring up MAiD” (page 6, paragraph 4). The potential harm here is that patients will be motivated to have themselves killed because of a conversation initiated by their physician; thanks to Canada’s wide-open eligibility criteria for euthanasia this could include patients who may have gotten better and may have had decades of life ahead of them. This simply is not an acceptable risk for physicians to take.

The second part of this document that concerns me is the requirement that physicians who do not provide or assess for euthanasia for reasons of conscience or religion are directed to follow the “Human Rights in the Provision of Health Services” policy, the draft of which now specifies that objecting physicians must not only refer patients for the services to which they conscientiously object but take the further step of ensuring the patient has connected with the person or service to which the referral was made. This, along with the requirement to initiate discussions about euthanasia, increases the degree to which physicians are expected to be complicit in an act that may contradict their most fundamental convictions about what it means to be human and, indeed, about what it means to do no harm. This strips a subset of physicians, namely those who disagree with euthanasia on moral grounds, of their ability to be people of integrity in their practices. It is a further violation of their Charter rights to freedom of conscience and/or religion, over and above the violation already represented by the effective referral policy. I can personally attest to the emotional, social and professional consequences of having one’s integrity perpetually threatened; the emotional and social distress associated with practicing under the effective referral policy led me to leave Palliative Care in 2019. With these further requirements to be complicit in euthanasia, it is difficult to imagine ever finding a way back.

Lastly, the requirement to falsify death certificates by making to mention of euthanasia as the cause of death is concerning not only because it represents a directive to physicians to lie, but also because of the potential effect it could have on keeping accurate records of euthanasia deaths. As well, there is no provision made for physicians who might object to lying on a death certificate which, again, threatens the moral integrity of any physician who might have a problem with lying.

While I do not pretend to know the intentions of the College, upon reading these documents, together with the “Human Rights in the Provision of Health Services,” it is difficult not to see a subtext of acceptance of euthanasia as a part of ordinary care, as opposed to an exceptional measure taken in exceptional circumstances. That is a significant paradigm shift, and the potential effects of such a viewpoint becoming common-place in the healthcare system should be thoroughly and honestly explored. This is not something that should be insidiously introduced into the profession through policy changes.

I thank you again for the opportunity to comment on these documents and I implore you to please carefully consider my concerns.
Physician (including retired)
[November 27, 2022 11:27 PM]
I have concerns about the process. Enough forethought or consultation has not gone into this.
For Psychiatric disorders, who determines irremediability in the absence of resources. If one has not received all the evidences based treatment that will alleviate distress and remediation of symptoms.
Are we treating MAID as a medical intervention ? Why ? Especially as we can not put it on a death certificate. I think we should not treat it the same way we treat other medical treatments especially as it is a life ending interventions.

The policy as outlined does confuse me. Should MAID be raised as an option to patients at initial assessment for their presentation with a suicidality. How do we protect vulnerable patients where the wish to die is a symptom of the illness rather than a true informed choice ?

How does this impact recovery oriented treatments which is present and available

Would offering MAiD seem at odds with the patient who has been detained against their will under the mental health act for their own attempts to take their own life. Would the difference between eligibility for a depressed suicidal patient be that one is state sanctioned and the other is self directed.
What protection is there for eligibity assessments and the criteria / experience of the assessors in what is going to be a complex area. How fo we safeguard vulnerable adults with neurodevelopmental problems, cognitive problems , lack of insight which may affect/ confound capacity. Is there really enough man power, specialists physicians in the already stretched field of Psychiatry to manage these. Some areas in Ontario have patients waiting 2 years for a general psychiatry consult.
Some psychiatric disorders are associated with unstable sense of self with changes in mind around living being part of that.
How are we going to make sure there are enough specialists to deal with this complex area of care/ capacity and active mental illness for a non- reversible procedure.
I think this has not been thought through with adequate consultation for a very vulnerable group.
Physician (including retired)
[November 27, 2022 11:15 PM]
MAID is and will always be controversial because it requires the active taking of a human life by another human being. . The idea that the College is trying to pass this on as a “medical treatment” and as thus to fall under the laws governing the access to medical treatment, is a gross misuse of the power of the College and is an act of injustice towards any members of the College who do not want to participate in the killing of their patients, (whether directly or indirectly by way of referral). The idea that the College would force its members to be involved in actions that their members feel are morally unacceptable and force them to betray their conscience is unacceptable and entirely unnecessary. Persons in the province can have access to MAID without having to force all physicians to abandon their principles. The Province can provide access to MAID and MAID information that is independent of their physicians. Full access to MAID and respect for the conscientious objection of health care professionals is not mutually exclusive; In Manitoba both principles have been effectively honored.

The following areas require change:

1–Document 1– lines 93-126 document 2 lines 325-332
Objecting physicians should not be forced to comply by way of an effective referral; self referral should be an option;

2–Doc. 2 lines 333-338
CPSO directs all physicians working in a Faith based hospital to comply even if the procedures are not provided in the institution;
Abstaining or faith based institutions or physicians should not be forced to take an active role or to provide an effective referral role in MAID;
Access to information for self referral should be made available to the individual who wants to access MAID.
The College should not use its regulatory power to subvert freedom of religion of religious denominations and institutions;

3–Doc 1 lines 89-91; This refers to MAID as a possible “treatment “ option; Suggesting that all treatment options should be made available to the patient; However MAID should not be considered a treatment but rather an exceptional service;

4–Doc. 1 39-40; refusal to provide MAID may be weaponized against conscientious objectors because it may be interpreted as “ Physicians must not impose their religious beliefs” on patients.

I believe that the College can provide guidelines to allow access to MAID services to those in the province who desire this, while at the same time respect the conscientious objections of some of its members. Both are possible and are of equally importance.
Physician (including retired)
[November 27, 2022 10:48 PM]
Excellent!! Thank you for this very clear and thoughtful presentation. CPSO please listen!
Physician (including retired)
[November 27, 2022 10:29 PM]
I share the concern with not listing MAID on official death certiciates alongside underlying disease(s) that has been raised by many in this discussion. This seems misleading and unhelpful at best.

I am also concerned that the expectations referenced in this document around the need to raise MAID as an option and to provide an effective referral with its confirmation are particularly unrealistic in the current healthcare and economic environment of Ontario where wait times for evidence-based therapies are often measured in years. Many of my most vulnerable patients are unable to access evidence-based assessment and treatments that could alleviate their suffering and I think that sections of this policy will worsen burnout and workforce limitations that exacerbate rather than alleviate long standing inequities. In particular, there are patients in my practice who have expressed a desire to receive MAID because the wait for interventions that might enable them to live with the quality and dignity they desire are simply unavailable within a timeframe acceptable to them in the public healthcare system. As one of these marginalized patients with mental and physical ailments desiring MAID recently stated "I can't afford to live any more." I find this morally distressing and am trying to support these suffering patients in a manner that may help them to find purpose and hope to continue living because I believe that this is possible even though they may not at this time.

Thank you for taking these thoughts and stories into consideration as you review your policy and consider revisions that will promote the health and wellbeing of everyone in Ontario.
Physician (including retired)
[November 27, 2022 10:26 PM]
The doctor-patient relationship is based on trust; therefore physicians must always be truthful in their communication with patients and the records of their interactions. It is unthinkable that a physician would not accurately document on the death certificate that a patient was assisted in dying. Society and government need to know the extent of MAiD for reasons of accountability/transparency and assessing the needs of the healthcare system.
Physician (including retired)
[November 27, 2022 10:24 PM]
A conversation about MAID should never be initiated by a physician. We were taught to ask people, "Have you ever felt that life is not worth living?" and then provide appropriate care if the person had suicidal ideation. To suggest that MAID be mentioned by the physician as one of the possible "treatment options" is to imply, "Yes, I agree that your life is not worth living and here's a way to end it." We know about suicide contagion and the power differential between physician and patient. It's not appropriate to insist that physicians must list MAID in discussions with patients. There is no reason that MAID should require a physician's "effective referral". Several provinces have set up centralized registries that patients can self refer to. This allows access for those who wish to avail themselves of it and prevents the moral distress and early retirement of physicians who are conscientious objectors. Those of us who took the Hippocratic Oath in Medical School are grateful for the direction that it has provided to our profession for over 2,000 years. Why should we discard it now? Our health care system is in crisis. We need all the concerned, thoughtful physicians that we can have and shouldn't be putting up inappropriate hurdles. Falsifying death certificates by not listing MAID as the cause of death is wrong. We have always been taught the importance of being truthful in record keeping. It is important to be able to have accurate statistics about the frequency of death by MAID. This will not be possible and abuses of the procedure will be covered up if death certificates are not completed accurately.
Physician (including retired)
[November 27, 2022 9:18 PM]
I disagree with this policy in that it requires physicians to bring up MAiD with patients who may qualify. In my work, at least 50% of my patients would qualify for MAiD but they are accessing emergency services because they want help to live, not help to die. I had someone ask me about MAiD in the last month because they were fearful of becoming homeless and they thought MAiD would be the solution to that situation. These kind of cases are being reported in the news where those who are not receiving the care they need or those who are facing homelessness are considering MAiD because they are fearful of the life they will have without the resources they require. There should be a way that patients could access MAiD without requiring that the physician to make an effective referral. It is widely known that MAiD is a controversial procedure but the CPSO is writing this policy as if it is completely accepted by every one in our society. A large portion of our society are being ignored by those who are pro-MAiD (pro-euthanasia). I also disagree with the mandate to refrain from writing MAiD as a cause of death on the death certificate. This is a legal document and it is difficult to understand why this would not be written on the document, particularly if this is something that the CPSO considers to be merely a form of treatment. I do wonder how long I will be able to practice medicine in Ontario or when I may lose my license because I chose to practice according to my integrity rather than suffer moral injury by participating in something which goes against my moral compass.
Physician (including retired)
[November 27, 2022 9:18 PM]
To the Ontario Government and CPSO policy department:

My husband and I are two concerned family physicians practicing in rural Ontario. We share many concerns of the Bill C-7 and the detriment it holds to the lives of Canadians. From what I understand, Bill C-7 will expand access to medical assistance in dying (MAiD) to those with chronic illness, disability, and mental illness.

Our concerns lie in the unclear and unfair wording of the bill which states that physicians have a right to conscience and participation in MAiD should be voluntary; the physician MUST, however, provide an effective referral and ensure that this referral is effective. This necessarily negates the individuals’ right to conscientious objection, as they must follow up on an action they have not agreed to (a stipulation that a non-conscientious objector must not follow through with).

The Bill also proposes that physicians must offer the option of MAiD as a medical treatment for illness. If the physician does not believe this is a medically appropriate option, they must not say that they object for personal reasons, but should feel empowered to express their professional medical opinion, which offers better alternatives. Furthermore, suggesting this to a vulnerable patient who may be in crisis and sees death as a professional recommendation at the moment, but has the ability to recover with appropriate and comprehensive medication and psychological support systems which the medical system should be able to offer, but unfortunately, is not readily available to many Canadians (this is my first-hand experience with mental health referrals).

We request your policies be reconciled to respect conscience and patient safety in all patient settings. We ask the government to fulfill its duty to protect vulnerable persons and its health care workers. We can honestly say that as two physicians, we feel trapped and threatened in our current medical system with regards to MAiD requests. We feel that we are not able to express professional medical judgment for fear of reprimand.

I certainly hope that the CPSO takes into consideration the serious implications of Bill C-7 and continues to advocate for physicians like me.
Physician (including retired)
[November 27, 2022 8:58 PM]
Response in PDF format.
Physician (including retired)
[November 27, 2022 8:30 PM]
We've had a long 2 years. CPSO policies that once again try to incriminate physicians of faith or certain religious backgrounds for not participating in MAiD just feel like the final nail in the coffin.

I do mostly palliative care and geriatric care. I'm concerned about my extremely vulnerable patients if this policy and the human rights policy go forward as written.

I have written into so many CPSO consultations before and nothing has changed. My hope (and prayer) is that you will see these responses and alter your policies which wrongfully discriminate against the disabled and the vulnerable.

Why are physicians being told to falsify death certificates? For data collection purposes, for proper medical record keeping, etc. this should NOT occur.

Physicians should not be bringing up MAiD as a treatment option. This is not a treatment option. Patients can bring it up if they wish but it is not the same as offering lasix for CHF or dilaudid for pain. What have we come to?
Organization
[November 27, 2022 7:17 PM]
Canadian Association For Suicide Prevention
Response in PDF format.
Physician (including retired)
[November 27, 2022 6:56 PM]
Forcing effective referral on conscientious objectors is counterproductive. Why do patients seeking euthanasia require referral from a physician? Why can they not simply self-refer to a centralized service in each region? This would uphold both patient autonomy as well as the conscience rights of health care providers.
Physician (including retired)
[November 27, 2022 6:12 PM]
This CPSO document should state explicitly that physicians should not be bringing up MAID unsolicited. We have already seen MAID being brought up unsolicited to our veterans with mental health struggles and the devasting impact. If a physician, without being asked, states that MAID is an option -- it will be interpreted by many patients as a physician recommendation. (When physicians describe treatment options, it means they feel these treatments are reasonable and should be considered in that particular case; i.e. a physician is not going to bring up a treatment that is unreasonable or ineffective). Therefore, the unsolicited discussion of MAID will communicate to patients a value judgment: patients may feel directed towards MAID, because their care provider, whom they trust, is saying it is something they should be considering.
Physician (including retired)
[November 27, 2022 5:50 PM]
The CPSO has no credible evidence that trampling on the conscience rights of physicians is necessary to provide adequate "care" for those who want to kill or mutilate themselves. How does the CPSO know that life after death will be better for those who want to kill themselves? If the afterlife is worse, is a faster death really "caring" for the patient? Should providing all the options for a patient looking for a quick death not include explaining the possible spiritual ramifications? Instead, the CPSO wishes to squash anything that hints at spirituality, even though the CPSO knows little or nothing about the spiritual realm.
Physician (including retired)
[November 27, 2022 5:03 PM]
Line 99: b. must not make any reference to MAID or the medications administered on the certificate. - this is legally enforcing physicians to lie and give false representation.

In Advice document:
Line 26: Bringing up MAID as a clinical care option, which includes the following: - The Canadian Association of MAID Assessors and
Providers (CAMAP) clinical guidance document by offering MAiD as a clinical care option is leading physicians to directly engage in possible criminally illegal activity of coercing or giving external pressure to patients to request for medical assistance in dying. This clinical guidance document is biased in favour of MAiD and should NOT be the basis of defining what is the requirement of a physician in offering clinical care options.
Physician (including retired)
[November 27, 2022 4:18 PM]
Medically administered death is not a treatment option, it is abandonment.

Falsification of records is never the right thing to do. If MAiD is such a good thing, why should it not be referenced? Such obfuscation is appalling.

Until I know that a patient is interested in death, to counsel suicide is illegal. More importantly, it is coercive, given the power imbalance between a physician and a patient who is desperate enough to consider suicide. It is to counsel hopelessness, when providing hope is such a core part of our role as physicians. Why has CAMAP found such a receptive audience within the CPSO? To act as if everyone agrees on this point is hubris.

To pretend that effective referral (with requirements far beyond referral for any other reason!) negates the complicity, culpability, and subsequent moral injury to the physician who opposes MAiD is to be wilfully blind. Doctors are struggling mightily to meet the need of Canadians these days. This document adds further to the burden. That small, fractious group of conscientious refuseniks will only grow as the indications for MAiD expand. This is bad for medicine, and bad medicine.
Physician (including retired)
[November 27, 2022 4:15 PM]
The Canadian Charter of Rights and Freedoms applies to the acts and conduct of government, which includes the CPSO. Section 2(a) of the Charter guarantees freedom of conscience. In trying to ensure the public has access to MAID, the CPSO demands physicians who are conscientious objectors to become complicit by requiring them to provide an effective referral.
The CPSO must balance competing the rights/freedoms of patients and physicians properly; there are methods of ensuring patient access to MAID without infringing on the rights of physicians. The burden of providing access to this service lies with the government, not individual physicians. The availability of a centralized self-referring service for MAID would satisfy both the competing rights without infringing on either party's rights. I request that the CPSO consider its obligations under the Canadian Charter of Rights and Freedoms carefully.

Additionally, falsifying death certificates so that they do not reflect MAID as the cause of death is unethical. It is also diametrically opposed to what Health Canada suggests in its guidelines (https://www.canada.ca/en/health-canada/services/publications/health-system-services/guidelines-death-certificates.html) which states the immediate cause of death should be listed "as the toxicity of the drugs administered for the purposes of a medically-assisted death". I would like to bring up two additional considerations regarding falsifying death certificates. 1) It also hinders data collection and the statistics of both the underlying medical cause and MAID. For example, how many people died from lung cancer in Ontario last year? It may be inflated because some of those patients received MAID. Also, how many people died from MAID last year? 2) If there is nothing wrong with MAID, why is the CPSO trying to hide it? Something for the CPSO to consider.

Finally, the advice to follow CAMAP guidance is very worrisome. CAMAP suggests that clinicians have a professional obligation to bring up MAID (unsolicited) to all potentially eligible patients. Does this mean physicians should bring up MAID as a "treatment" option for all patients? Imagine your family member is admitted to hospital with chest pain and the physician brings up MAID as a treatment option. Indeed it would end their "suffering" right away. But what a farcical idea it would be to propose death as the treatment. Many patients may take offence to being told they need to die (it is also interesting to consider why many would take offence, if this is indeed a "treatment"). MAID should only be discussed if brought up by the patient.
Physician (including retired)
[November 27, 2022 4:15 PM]
To Policy Department, CPSO

I am writing regarding a proposed clause in the CPSO’s draft MAiD policy.

In Document 3 (MAiD), lines 25-26, it appears that the CPSO is expecting physicians to falsify Death Certification when the cause of death is MAiD provision. I understand that some people, for their own reasons, may not wish family members to know that they had been made dead via legal MAiD. If that is the justification being used for this unusual policy proscription, it seems to me to be an over-reach of policy. It is likely contestable that revealing this in a legal document against a person’s wish is an affront to their privacy. A typical Canadian accommodation would allow for uncommon exceptions to the cause of death declaration for a patient who has an important reason for not having death from MAiD be revealed. Criteria and processes for these exceptions can be developed. For all others, the correct cause of death should be registered on the Death Certificate.

The CPSO is expecting its members to deliberately lie regarding the cause of death. That is a demand to be unprofessional. It will cause moral distress for some clinicians. It also flies in the face of the CMA Code of Ethics and Professionalism. One wonders how the CPSO will manage legal challenges within Hearings and Complaint Appeals that deal with this issue, especially when the CPSO’s policy is counter to the expectations outlined in the CMA Code of Ethics and Professionalism.

This proposed policy clause will cause disrepute and non-confidence in summative mortality statistics. The important mechanism of mortality data for health care delivery decisions, funding decisions, advocacy, and research will be increasingly unhelpful, especially if MAiD continues to escalate in its use as a percentage of all deaths.
The negative impact is magnified in the setting in which people with non-terminal conditions are now eligible for MAiD and might avail themselves of that option.

The proposal might impact insurance decisions for the patient’s estate and insurability issues for relatives of the patient. One can imagine a person seeking insurance who in the inquiry about family history reveals death from an inheritable condition that was not really the cause of their death.

I hope the CPSO can re-think and either eliminate or at least majorly refine this disturbing policy clause proposal.
Physician (including retired)
[November 27, 2022 4:09 PM]
Please give due respect and consideration to our PC colleagues who, from the beginning of the very idea of PC, have excluded the hastening of death from their mandate. Medically administered killing has no place in the House of Medicine. If we must tolerate it, let it be in the furthest corner of the basement, with as little impact on the true practice of medicine as possible.
Physician (including retired)
[November 27, 2022 4:05 PM]
Please give careful consideration and weight to every point in this document. I fully agree with it.
Member of the public
[November 27, 2022 4:03 PM]
Note: Some content has been edited in accordance with our posting guidelines.
Hello,
 
After reading the three documents and the discussion comments, much about the entries on the death certificate and spending time considering my response, it follows now.
 
As a member of the public and with continuing interest in this important topic since it was first evolving at a federal then provincial level and having been invited to contribute since the early CPSO drafts including even before the name Medical Assistance In Dying (MAID) was confirmed I have had much time to consider what I would chose for myself and I know I would support another (family, friend) considering MAID.
 
At age seventy five, a widow for a long time, living independently, with family and friends nearby, some further away, I am grateful MAID might be an option at a later stage in my life.
 
My perspective of intolerable for example might vary greatly from what someone else might chose.
 
You may be familiar with the book “This Is Assisted Dying”, author Stephanie Green, MD. She is a physician in the province of British Columbia.
 
DEATH CERTIFICATE: Bottom of page 99 of her book, which I bought when it was launched earlier this year states that “each province was different but none of them had billing codes set up for MAID”. Is this by chance a minor factor in some of the choices being made about what to enter for cause of death? For this, might the Canadian Medical Association (CMA) along with other appropriate professional organizations be able to reach consensus on best uniform terminology for the death certificate?
 
The reality of the status of health care and the overextended medical professionals - doctors, nurses, others - along with support staff along with the long term care home and other assisted living choices means more mature adults might be considering future medical care choices that include potentially MAID. The professional staff, the funding, other critical requirements for quality health care are and likely will be very much rationed, going forward. Far too political too.
 
Before closing, a real time example to share. My friend, age sixty one, with cancer care for more than five years with an excellent hematologist/oncologist found her cancer became fairly aggressive by September and tests at [redacted hospital] prior to new chemotherapy revealed her cancer was palliative meaning up to three months. She shared this with me [redacted] after sharing with her family the day before. She knew her choice was MAID at home and a late [redacted] date was chosen. She also knew I supported her choices. She and her closest family member met with the lawyer, funeral home, usual local palliative care requirements were complete. Her death in fact was at least 11-12 days prior to the date for her MAID. Of note, her death at home with family present was after dark on a recent weeknight. The funeral home service visited around midnight to remove her body. This discrete timing allowed for privacy for her family until they were ready to share her news.
 
This is the reality for some families and their close friends. To have the option for MAID provided some comfort for her and her family.
 
Please consider my communication as the current drafts are under review.
 
Respectfully
 
[redacted]
Physician (including retired)
[November 27, 2022 3:58 PM]
"Regardless of one's opinion of MAiD, the right to self-determination and to act on one's conscience is recognized as a fundamental freedom in all peoples." All peoples -- including all health professionals. Absolutely.
Physician (including retired)
[November 27, 2022 3:56 PM]
I am writing to lend my support to this document.
Physician (including retired)
[November 27, 2022 3:52 PM]
It is hubris for the CPSO to frame medically assisted death as just one more treatment option (the view of CAMAP), rather than acknowledging that there continues to be serious disagreement within the profession and the public regarding its place in Medicine and in society. There is increasing unease being expressed in legacy and social about the rapid expansion of death as the solution for life's ills in Canada. The CPSO's encouragement of MAiD as a treatment option, and discouragement of honest disagreement with that view, puts our most vulnerable at risk. If one can't see that "effective referral" still requires complicity and culpability with pathways that many consider gravely (pun intended) wrong is to be wilfully blind.
Member of the public
[November 27, 2022 3:33 PM]
In Hitler's Germany, the doctors and nurses provided the means of genocide. Nurses gently held infants while giving lethal injections - compassion at its worst. Some day when society wakes up, it will hold you to account, and you will not be able to hide by falsifying death certificates. We are watching you.
Physician (including retired)
[November 27, 2022 3:27 PM]
Physicians should not have to inform patients of MAiD as an "option" because it is not a regular medical "treatment" as in medical or surgical care: iy is an exceptional service. Simply bringing it up can imply to a patient that there is nothing more to live for.

MAID providers should notify the Medical Examiner that MAiD is the immediate cause of death.
To say otherwise is a falsification.

These 2022 draft policies are much worse than the previous drafts sent for consultation in 2021 and it is critical that as many people as possible let CPSO know of their concerns. This is not only an Ontario issue - it will set precedent for other provincial medical regulatory authority policies.
Physician (including retired)
[November 27, 2022 3:24 PM]
Exactly!
Member of the public
[November 27, 2022 3:13 PM]
I oppose listing the cause of death only as the underlying illness. It may be useful to record these illnesses for statistical purposes. However, truth must also be stated: that the actual cause of death is MAiD.
Physician (including retired)
[November 27, 2022 2:56 PM]
This is an activist document, straight from CAMAP. The Criminal Code of Canada specifically prohibits counselling anyone else to commit suicide. There should be a clear, bright line that nobody but the patient ever raises MAID. MAID is suicide (or more accurately homicide, with a legal carve-out)--It is absolutely unconscionable that ANYONE but the patient ever bring this up.

Contrary to what others have said, MAID is not just "one treatment option among many"--it is fraught with moral weight. The entire practice of medicine is deeply moral, not just technical. If I have the cure for cancer and withhold it from you, is that not an immoral act? To treat medicine as technology is to discount the value of long-term, relationship-based care and the immense personal sacrifices I have made for my patients in my 16 years of rural full-scope family practice.

Many of my elderly patients are already fearful of being actively euthanized. This actually leads them to request inappropriate care (more aggressive than appropriate to the clinical situation/prognosis), and I need to constantly reassure them that I will not euthanize them. The purpose of these regulatory colleges is to promote public trust in the profession. Lying on death certificates and offering MAID for every possibly terminal case is not going to improve the degree of trust the public has in the profession.
Physician (including retired)
[November 27, 2022 2:22 PM]
Dear CPSO,

I am in my final year of medical residency. I am currently certified in Family Medicine and am now expanding my training to include Emergency Medicine. These are two of the most in demand medical specialties in the country. Although I currently reside in Ontario, I have ties to multiple provinces and within the next few months, I will be deciding where I want to take my skills and settle down to practice medicine. I am explaining this because I think you should know that if you enact the proposed policy changes, it won't be Ontario.

The answer to me, seems fairly obvious.

Other provinces within Canada have developed systems of effective patient access that do not violate healthcare worker's human right of conscientious objection. In this province however, you are continuing to place greater and greater demands on those of us with valid ethical concerns about euthanasia. In fact, if the policy changes are passed, physicians who conscientiously object to euthanasia will have additional requirements placed upon them that are not in place for those who do not engage in MAiD for other non-conscience related reasons (ie lack of training), as we will be required not only to make referrals but to ensure the patient has made contact with the party they are being referred to.

In other words, we will be required to do extra work and undertake extra steps, not because we don't practice MAiD, but due to our religious or ethical beliefs. That sounds a lot like religious discrimination to me and when I can work anywhere in the country, why would I want to work in a province where I am being actively discriminated against?

Since I know that I am not the only one that feels this way, I ask the CPSO and the provincial government to consider which is more important: Making a minor political statement by changing the requirements of doctors to ensure access to a service for which there is no evidence that an access problem exits? Or retaining physicians to provide urgently needed in your province instead of alienating them and making it harder for them to do their jobs.
Physician (including retired)
[November 27, 2022 2:21 PM]
The CPSO's guidelines on MAID violate a physician's right to religious freedom and indeed violate the Hippocratic oath itself. Of course, you also violate the Hippocratic oath in regards to abortion.

If you want to violate the standards of ethical medical practice, well, that is sad. To attempt to coerce others into doing likewise is satanic. You could easily provide a website for those who want these services without forcing moral, ethical physician's to break the Hippocratic oath by referring patients for these horrible practices.

May God rebuke the current CPSO administrators.
Physician (including retired)
[November 27, 2022 1:31 PM]
To the College of Physicians and Surgeons of Ontario Policy Department;
 
I write to you with concerns regarding the CPSO’s draft policies on “MAiD” and “Human Rights in the Provision of Health Services”.
 
The two domains I wish to address are conscience adherence and clinical wisdom in the assessment of patient vulnerability.
 
With these draft policies, the CPSO appears to diminish these two important tenets of the practice of Medicine.
 
First, the development and exercise of conscience is central to meeting a physician’s fiduciary obligations to all patients as a physician appropriately guides and treats their patients. Emasculating conscience risks great harm to the array of challenging situations in which a physician and patient determine the best course of action together. We are all aware of numerous troubling historical examples in which authorities and laws were simply wrong, sometimes abhorrently so. Ought not conscience remain as a core character feature of physicians? In the case of MAiD, systems exist in other provinces such that patients who seek this legal procedure can readily be connected to an efficient, expert and broadly available service without requiring the participation of every physician. Those successful mechanisms assure availability for patients while protecting conscience adherence on the part of physicians, appropriately balancing the imperatives demanded in the Supreme Court’s decision in Carter.
 
Second, patients may well be significantly harmed by a proscription that requires physicians to inform all patients who may be eligible, about the option of assisted death. At a time of diagnosis of a potentially life-limiting illness or while being in a pathway of treatment/management of a chronic condition, do we adequately understand the impact on a person of being informed that an option is to be made dead? Is the patient particularly vulnerable in those interactions and should physicians not be encouraged to consider ideal timing of such conversations? The CPSO ought not debase the notion of clinical wisdom, carefully exercised while assessing the context, values, beliefs and history of each particular patient.
 
Please be mindful of these concerns as you deliberate on these two draft policies.
Physician (including retired)
[November 26, 2022 3:17 PM]
I strongly oppose the falsification of death certificates to remove MAID as cause of death. This precludes any evidence based review and scrutiny of this process going forward.
Physician (including retired)
[November 25, 2022 11:04 PM]
Note: Some content has been edited in accordance with our posting guidelines.
To Whom it May Concern:
 
I am an academic palliative care physician practicing at [redacted] Hospital. I urge you to reconsider several aspects of your revised policies as they pertain to MAID and their impact on the palliative care and human rights of the patients I serve.
 
Human Rights and the Obligation to introduce MAID as a Choice: By shifting professional obligations concerning MAID to the revised Human Rights policy, CPSO proposes to introduce an obligation to “bring up” MAID as an option in the many clinical situations in which MAID is now legal. Initiating a discussion of MAID with a patient will cause harm in a significant proportion of the patients for whom I care. This can be so easily misconstrued as a physician recommendation and thus represent a form of coercion. Patients struggling with severe illness or disability already exist in an emotionally and ethically charged situation. The professional needs to approach such patients with great caution particularly knowing the well-documented power imbalance in the patient-physician relationship. Vulnerable populations (e.g., people who are disabled, frail & elderly, racialized, mentally ill) often have valid reasons to mistrust the health care system and initiation of a MAID discussion without a prompt from the patient will destroy the potential to rebuild that trust. The empathetic physician should be asking open-ended questions but never initiating the discussion of MAID which often will be interpreted as proposing a course of action. Additionally, a new obligation for the physician to “take positive action to ensure the patient is connected” could be interpreted as an obligation to bring up the topic a second time to an ambivalent patient who has decided against pursuing the referral and that patient could interpret the physician action as further pressure in a power-over dynamic. Care planning should continue to be a matter of professional judgement and not rigid policy directive.
 
MAID and its Impact on Human Rights: I would encourage the College to reconsider the wider implications of MAID by taking a more neutral or even at times a more skeptical stance on the impact of MAID on the human rights of Ontarians. Your proposed policy revisions presumes that MAID is an obvious and unqualified advance in those rights by enhancing the autonomy of patients. Tightening of ‘effective referral’ criteria implies that some physicians who choose to limit their participation in the MAID process are blocking access and imposing their personal beliefs on their patients even though no evidence is presented to substantiate this fear. By positioning these rules within the Human Rights policy, the College implies that any skepticism about MAID will be viewed as a marker for opposition to human rights in general. In some provinces with higher rates of MAID there are no comparable restrictive policies on referral. If CPSO pushed the government of Ontario to fund a robust MAID coordination service that accepted referrals from both professionals and patients (as in Alberta), access issues, real or perceived, could be resolved easily and without threatening physicians with more rigid referral criteria.
 
The first years following legalization saw MAID embraced, in large part, by the white, educated, wealthy, privileged boomers who hold autonomy as their highest value. But the situation is fast changing. Ontario is a society with major structural inequalities that impact the health care of vulnerable sub-populations– people who are racialized, indigenous, disabled, homeless, experiencing chronic mental illness or addictions. With rapid MAID eligibility expansion, we can expect to see increasing numbers of patients from vulnerable sectors choosing MAID because they perceive that they have no other good choice. The lack of appropriate resources in health care, housing, social services, palliative care, and mental health care reinforces their belief that here is no other option. This poses a far greater threat to Human Rights than the imagined blocking of access by relatively few non-participating physicians. I would urge the College to refocus their policies on MAID and Human Rights to emphasize the strengthening of safeguards in the health care system including more robust palliative care so that no one in Ontario chooses MAID because of lack of resources or because of underlying structural inequalities.
 
Thank you for asking us to participate in your deliberations.
Organization
[November 25, 2022 6:17 PM]
Disability Filibuster
Response in PDF format.
Physician (including retired)
[November 25, 2022 2:38 PM]
Hello,

I would like to provide input to the draft CPSO policies regarding MAiD and Human Rights in the Provision of Health Services.

My understanding of these policies as written is that they provide for the following:

1. A duty to inform patients of all treatment options for which they are potentially eligible, including MAiD. CPSO references the Canadian Association of Maid Assessors and Providers (CAMAP) Bringing up MAiD document which states raising MAiD to all potentially eligible patients should be standardized practice.

2. Physician objections to MAiD have been reframed as personal/individual beliefs instead of evidenced-based professional objections shared by many expert groups.

3. A new positive obligation is to be placed on conscientious objectors. They must ensure an effective referral was successful by confirming with the patient that they were connected with a MAiD provider/assessor or coordinating service. Those who make referrals but do not object to MAiD are not required to make such a confirmation.

I request that your policies be reconciled to respect physician conscience on these matters as well as patient safety in all patient settings. Physician objections to MAiD are not simply personal beliefs but have evidence-informed backing. A physician who objects to MAiD should not have a duty to inform patients of treatment options which , in their clinical determination, is not in the patient’s best interest. And certainly no positive obligation can be placed on these physicians.
Physician (including retired)
[November 25, 2022 2:08 PM]
The original Bill C-14 MAID legislation states that in matters of conscience participation in MAID should be voluntary. The CPSO policy, on the other hand, requires that conscience objectors provide a referral for medically administered death and also to ensure that the referral was effective, thus mandating participation.
The policy also states that the physician must raise MAID as a "treatment option" to every patient who would be potentially eligible. Many patients would see this as a recommendation.
For family physicians, judging the capacity of their vulnerable, disabled, or depressed patients is very often difficult. Quality professional capacity assessments are expensive for patients, placing a heavy burden on the family doctor.
Physician (including retired)
[November 25, 2022 12:44 PM]
thank you for your post.
support your concerns entirely.
In fact the CAMAP information does provide for more care than the CPSO. They advise time to develop the Physician-Patient relationship, gentleness and not bringing it up if the patient does not meet eligibility criteria.
I am concerned that the references are all pro MAID. This is a worry for our PAIRO learners. No mention of the CSPCP website.
Physician (including retired)
[November 25, 2022 12:41 PM]
thank you for your post.
support your concerns entirely.
MAiD in our areas is treated as an emergency whereas patients need care face an increasing wait list.
Organization
[November 25, 2022 12:08 PM]
Canadian Society of Palliative Care Physicians
Response in PDF format.
Physician (including retired)
[November 25, 2022 12:07 PM]
As a provider of Palliative Care for over 3 decades, I wish to support the comments of the Physicians Together with Vulnerable Canadians and the PDF Indigenous Peoples Should Not Be Compelled to Provide or Facilitate Medical Assistance in Dying. I am also concerned about the prohibition of listing MAiD on the MCOD.

I specifically identify the addition of two "musts" in the CPSO draft: that of mandating the discussion of MAiD as a treatment option necessary in the provision of informed consent and the new obligation placed on the conscience objector to ensure the effective referral was successful.
I have a concern that the CPSO draft refers physicians and residents to the CAMAP site for further advice about conversations with patients about MAiD. This advice is very lengthy and repetitive but does include cautions about establishing a Physician-Patient relationship first; about context etc which are not included in the CPSO draft. I am deeply concerned that the CPSO does not include any reference to the Canadian Society of Palliative Care Physicians https://www.cspcp.ca/ including their position statements on the current legislation. This lack of balance is especially worrying especially given the clear interest expressed in the PAIRO submission.

I appreciate the CMPA statement which expresses concern that the CPSO reference to CAMAP or other sites may imply approval of their content.

I believe that the CPSO draft suggests that the 90 day reflection period for patients without foreseeable death may be shortened if there is perceived risk of loss of competency. This seems divergent from the legislation as I understand it.
Physician (including retired)
[November 24, 2022 2:58 PM]
I am tired. It's been a hard two years for everyone, and I am giving my little precious time to answer yet again another consultation by the CPSO on MAID.

I am opposed to the new guidelines. I do not think we should be lying on the death certificates. I also do not believe we should have to as practitioners phone the patient to assure their referral for death upon request has been done (do we have to do this for any other referral we do? Should I phone psychiatry who's wait list is over 2 years right now?). A duty to inform patient about Maid can also be taken as pressure or coercion during these difficult discussions. The moral distress that the system is putting on me is almost unbearable: the long hours, that I can't get my patients the care they need, the incredibly long waitlist of surgical procedures, the long wait times for mental health supports. I am against the Maid system because I think we can do better providing care to our patients post pandemic. There are quite public reports now of patient's who can't get care because our system is failing (https://www.theglobeandmail.com/canada/british-columbia/article-cancer-patients-treatment-wait-times/).

We must do better than killing patient's and forcing doctors to participate in this system.
Physician (including retired)
[November 24, 2022 11:32 AM]
The guidance document on when to initiate a discussion about MAID references the CAMAP "Bringing up MAiD" document which is extremely worrisome. The CAMAP document states that "...physicians and nurse practitioners...involved in care planning and consent processes have a professional obligation to initiate a discussion about MAiD if a patient might be eligible for MAiD. The discussion should include all treatment options, including palliative care and the option of MAiD." There is a power differential between physicians and their patients, and bringing up MAID to a patient will unintentionally lead to pressure to choose MAID for some patients, especially vulnerable patients. It will lead to increased barriers for patients who already have a significant distrust in the healthcare system. CPSO needs to explicitly ensure that physicians do not initiate MAID discussions with their patients. This does not mean physicians should not respond to questions about MAID when patients bring it up first. CPSO should remove the CAMAP reference as it will be interpreted by some physicians as a'duty to inform about all treatment options including MAID', even when patients have not initiated the discussion, and lead to significant harm in the long term to many patients.
Member of the public
[November 23, 2022 5:55 PM]
I am completetly dismayed at the thought of providing false information or records for any reason let alone euthanasia.
Member of the public
[November 23, 2022 11:08 AM]
You Doctors really need to question the integrity of the leadership of any organization that would condone, let alone recommend, the falsification of legal documents by "banning" the MAID designation as CoD.
Why are you following these people ???
Organization
[November 23, 2022 1:53 AM]
Protection of Conscience Project
Response in PDF format.
Physician (including retired)
[November 22, 2022 9:16 PM]
I am concerned that your directions for filling in the death certificate will cause inaccurate causes of death to be recorded. Line 11 a) states “Must list the illness, disease, or disability leading to the request for MAID as the cause of death”. But in 8 c ) “analysis undertaken to determine whether the patient’s natural death was or was not reasonably foreseeable“ it is clear that sometimes the death is not reasonably foreseeable, and that the disease, illness or disability may not ever cause their death. This will lead to some illnesses or disabilities looking in future as more lethal than they are.
For example depression: I had a patient with depression request MAID prior to mental health diagnoses being considered for MAID. A year later with good psychiatric care he was doing well and enjoying life. If he presented today and went through with MAID, and the draft instructions for completing the death certificate are followed, it will skew the results with depression appearing to be a more lethal disease than it is. We know that depression increases the risk of cardiovascular disease, and likely others, in addition to the rare unfortunate suicide. But if depression leads to MAID, and the cause of death is recorded as depression, it will misinform future research on the natural course of diseases.
Also, unless there is some other open registry being kept of MAID numbers, we will loose the ability to know the magnitude of MAID in our country.
Also, you are asking physicians to be less than truthful- when the obvious immediate cause of death is MAID, you are asking them to record some underlying disease, disability, or illness which may or may not ever cause their death.
Physician (including retired)
[November 22, 2022 5:51 PM]
What other fraudulent alteration of medical documents will be allowed instead of prosecuted and disciplined as in the past decades?
Why is individual conscience right secondary to selected "individual rights" clamoured for by strident minorities?
Why did the College stop protecting patients from harm by physicians and start promoting ultimate harm by physicians?
Physician (including retired)
[November 22, 2022 3:39 PM]
I have concerns that psychiatric patients who request MAID may do so because they have not received either the best treatment or their social circumstances are such that it is lack of housing and finances that have influenced their choice of MAID. I also think that psychiatric patients should be assessed by 2 psychiatrists who are better able to determine if all treatment options have been exhausted and that the patient is indeed sufferring to the point that continued existence is unbearable.

I am also concerned with the concept of "Self-administered" drugs that can be taken by the patient without the presence of a medical professional. This assumes that there will be no problems and that the drugs will work as expected and as a physyiian of many years experience that is not always the case. In taking the most serious of decisions to end their life - a patient should be given all medical help including the presence of medical personnel who will ensure that the act of euthanasia will be done without a hitch.
Physician (including retired)
[November 22, 2022 2:10 PM]
the death certificate must state the truth: that the administration of the MAID drugs is what caused the death.It can state what lead to that, the underlying medical condition, but never falsify those important documents.
Other health care professional (including retired)
[November 22, 2022 1:53 PM]
Safeguards are being eroded. For example, requests for MAiD were to be in writing before two independent witnesses, final consent and a waiting period were required. Now people can be offered MAiD, no need to have them request it; only one witness is necessary and independence from the person to be MAiDed is questionable; no waiting period in some cases; no written request; waiver of final consent before having the lethal medication injected. All this while MAiD eligibility expands. Feeling depressed or having hearing loss or being lonely does not kill people, administering a lethal dose of medication (MAiD) does. If MAiD is so virtuous why not put it on the death certificate? Why mandate that it NOT be put on the death certificate? If I were a conspiracy theorist I would think this policy is a cover up. Please be clear about why, "When completing the medical certificate of death, physicians: must list the illness, disease, or disability leading to the request for MAID as the cause of death; and must not make any reference to MAID or the medications administered on the certificate." If the medication killed the person, that is the cause of death that is to be written in the place on the death certificate that asks for Cause of Death. Do not lie.
Member of the public
[November 22, 2022 9:28 AM]
Am extremely concerned that the immediate cause of death would not be listed as MAID on the death certificate. Surely accurate statistics should be kept to aid in future health policies to help those who are perhaps choosing it for the wrong reasons e.g. poverty, loneliness, pressure from others etc. Also this is information which I feel families have a right to know.
Member of the public
[November 21, 2022 10:17 PM]
It is not anyone’s decision when a person should die. Everything possible should be done to make patients, people with mental illness, pain, lack of resources, and other disadvantages comfortable and ensure they have the help or counselling or care they need. No one should be desperate enough to want to die and should not be told it is an option when help to cope with life would help them.
Falsifying death certificates is unethical. State why and how the death occurred.
Member of the public
[November 21, 2022 5:57 PM]
You should not be attempting to hide the statistics for this evil program!!! Any attempt to do so should be viewed as an attempt to hide the evil that you are attempting to foist on an unsuspecting populace!!
Member of the public
[November 21, 2022 5:26 PM]
I am truly disappointed that there should ever be consideration to providing false information or records for any reason let alone euthanasia.
Organization
[November 21, 2022 4:14 PM]
Council of Canadians with Disabilities
Response in PDF format.
Organization
[November 21, 2022 12:01 PM]
Toujours Vivant-Not Dead Yet
Response in PDF format.
Physician (including retired)
[November 21, 2022 11:25 AM]
Hello,

1) The point that the maid provider "must not make any reference to MAID or the medications administered on the certificate" strikes me as curious. If there is a good reason for this, it should be clearly explained, as some might be led to think that the purpose of the guidance could be to obfuscate the number of people choosing MAID.

2) There is evidence from Johns Hopkins that the use of psilocybin therapy can produce substantial and sustained improvements in anxiety and depression in those with terminal diagnoses and end of life distress. https://pubmed.ncbi.nlm.nih.gov/27909165/

It would stand to reason that before people choose to end their life, they should have the option to attempt a treatment that may change their mind. I believe that we should be requesting the Federal Government to allow easier access to psilocybin in these patients. Sadly, it is currently a much easier process to gain approval for MAID than it is for this therapy.
Member of the public
[November 20, 2022 9:49 PM]
Regarding policy number 11 (B) it states a physician must NOT make any reference to MAID or the medications administered on the certificate. I believe it should be clearly recorded on the death certificate that MAID was utilized/used and the medication readily available for data purposes.
Member of the public
[November 20, 2022 7:55 PM]
I would like to know why physicians must not list death by MAID along with the illness that warranted it on the death certificate. This will make it impossible for anyone to truly know how many people are choosing to die by assisted suicide. And, more alarming, having no data on numbers could make it far easier to cover up abuse. It will also make future accountability for the use of MAID very difficult if not impossible. We need accountability!
Prefer not to say
[November 20, 2022 5:34 PM]
I think it should be mandatory that MAiD appear on the death certificate in addition to the underlying condition. Otherwise it will be impossible to track the true prevalence and changes in frequency of this procedure over time, particular as it relates to conditions fot which imminent death is not foreseeable.
Other health care professional (including retired)
[November 19, 2022 8:54 PM]
MAID is clearly not a treatment by definition. It is a death acceleration protocol. To not document that MAID is the actual cause of death is dishonest and misleading for all statistical analysis purposes. MAID goes against all codes of ethics for protection and trustworthy care of life until natural death. MAID is politically motivated as a cost saving measure with the burden directly placed on Physicians and Nurse Practitioners. It is offensive and against the Christian Faith.
Organization
[November 19, 2022 2:27 PM]
Indigenous Disability Canada
Response in PDF format.
Member of the public
[November 19, 2022 2:19 PM]
The draft policy states that doctors “must not make any reference to MAID” or the death cocktail “administered” on the death certificate. This effectively falsifies the death certificate. As a result, it will be impossible for anyone to truly know how many people are being killed by assisted suicide (perhaps this is the intent). Additionally, having no data on numbers will make it far easier to cover up abuse.
Physician (including retired)
[November 19, 2022 1:03 PM]
I have concerns about the proposal to allow MAID to be offered to patients with mental illness. We should not give up on these patients. They often have difficulty accessing diagnosis and treatment. And their mental illness may be due to underlying medical illnesses such as chronic infections (tick borne illnesses being an increasingly common example). When they find no relief these patients give up hope but MAID is clearly not the answer.
Physician (including retired)
[November 19, 2022 10:53 AM]
Physicians should not be expected to offer MAID as treatment option is all circumstances that it is allowable since these are now myriad and can include frailty and soon mental illness. It is not a treatment option, it is ending life. Bringing it up would have a deleterious effect on patients by suggesting we have given up on helping them, especially in the case of mental illness. It is a bit ridiculous to suggest that there is an appropriate time to offer MAID as an alternative to continuing to seek treatment, comfort, and care, especially when we do not adequately fund treatment and supports for so many disorders. How about a really sad, frustrated patient who is battling an eating disorder that seems overwhelming? Or a parent with complicated grief after the death of a child? This seems to suggest that I must jump in and suggest MAID in order to avoid facing discipline by the College. I do not think a physician should ever be compelled to bring up physician assisted suicide, and, if asked, should be able to provide a simple telephone number to a central service registry to connect them with a MAID service provider.I am pretty sure the patient will let us know if the number doesn't work if they want MAID. MAID must be listed on the death certificate as it is unethical and a falsification of records to omit it.
Member of the public
[November 19, 2022 3:54 AM]
The draft policy states that doctors “must not make any reference to MAID” or the drugs “administered” on the death certificate. This would make it impossible for anyone to truly know how many people are passing away by assisted suicide.

Reference to MAID and the drugs administered must be on the death certificates.
Member of the public
[November 19, 2022 2:20 AM]
I recently reviewed the draft Medical Assistance in Dying policy, prepared by the College of Physicians and Surgeons of Ontario.
I was thoroughly confused at the closing sentence:

11.When completing the medical certificate of death, physicians:
a. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and
b. must not make any reference to MAID or the medications administered on the certificate.

Given all the effort expended to implement and now expand assisted death, why would it become a requirement for physicians to hide the truth when MAID is administered?
If a person dies through a MAID process, it is imperative that this be noted on the person’s death certificate.
Any other reporting would be deceptive. A person dying through MAID does not, in fact, die of illness/ disease following its natural course.
For the death to be from illness or disease, MAID would not, in fact, have applied.
An unwell person could attempt suicide without assistance, and the cause of death would then be suicide.
If the College isn’t comfortable implementing MAID, then please refuse to participate in MAID.
Or, if the College agrees to participate, please follow proper documentation process of your work.
Failing to document MAID after one has administered it seems unprofessional.

I’m willing to listen to your explanation for why administration of MAID must be obscured, if it is a process worth fighting for.
Member of the public
[November 18, 2022 9:14 PM]
This letter is for you to include with feedback you are collecting from various sources on the plans for review of MAID policies.
I recall that the original legislation was set to cover relief of patients with severe circumstances as an exception to the goal for patient care with either prevention of mortality or a focus on symptom care at the end of life. As I understand it the idea was to remove what was previously considered to be criminal activity when the use of euthanasia was in keeping with the patient's beliefs and was undertaken with clear informed consent, and which was not done in the setting of suicidality with potentially treatable causes. Many of us feared that this new legislation would pass on these grounds and then progress to increasing application with looser criteria, and that it would put physicians in the role of having to turn from having conscious based decisions, and be expected to do wrongs because someone now tells them that right and wrong is only what your present regulator tells you it is.
This fear is now being shown to be valid.
The greatest concerns for some of us with new legislation is that we will be expected to advise patients routinely of the option of euthanasia at stages of illness which do not fit the criteria of the original goals of exceptional relief in dire situations. As well we are taken to be in favor with anything when we present it to patients. Again if we were to have this discussion with a patient years ago or with a patient who has questionable consent and capacity status this would be taken as criminal activity.
The other issue which of course is known to the CPSO is that issue of patient consent and we would have to be very careful about mentioning something to patients who may be vulnerable to suggestion by our advice but not truly capable of understanding the full issue, and perhaps biased in that understanding when a physician brings up the topic in emotional and anxiety based settings. This determination may often be very difficult and easy to question in hindsight.
A practical issue may be that many physicians close to retirement who have spent their careers following their ethics ( and in this case nothing is more important than ethics if you live in a free country and if you believe in ethics at all) will find it easier to retire several years earlier than planned , rather than to stay on with new uncomfortable or impossible rules for them, and this will further add to the physician shortages. In this case there will be no one to break the new rules since the patients will have a new system but no one to help them through , nor care for them the way family doctors usually do. Already doctors who do not find it moral to participate in MAID, still take time to support and counsel their patients who do believe in this activity so this should not be taken as a problem. The problem will be asking the doctors to show support for the activity rather than the patient.
We only need to look at other areas of the globe to see that many political rules in other societies are very distasteful to us, yet we do expect physicians in those places to remain ethical and not just change their roles based on what the local politics decides is correct. We should not take too lightly asking our physicians to lose this philosophy.
Physician (including retired)
[November 18, 2022 8:24 PM]
I have become aware that the CPSO is advancing a policy with the following clause
11.When completing the medical certificate of death, physicians:
a. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and b) must not make any reference to MAID or the medications administered on the
certificate.

I completely disagree with 11(b). If MAID is the cause of death it must be listed as such. Otherwise this is falsification of medical records: a serious offence. The draft policy also states that "These requirements were jointly developed by the Ministry of Health, the Ministry of Government and
Consumer Services, and the OCC." I trust these bodies do not want to participate in this offence.

Please amend this draft policy immediately.

Thank you
Member of the public
[November 18, 2022 8:04 PM]
I would suggest the review committee take a few moments to learn about, discuss, and reflect on a history lesson about Aktion 4, Deutschland's government euthanasia program. What is proposed is identical in recording & reporting procedure though, perhaps, not in intent nor scope. Sober reflection reveals it did not turn out well for all of the patients, (and a fair number of Doktors in 1946) . Public outcry finally stopped the killing of German citizens but unfortunately opened a door that's never been closed since...Please accept this as wise advice, not subtle criticism. You too will have to sign your name, regardless of the decision.
Physician (including retired)
[November 18, 2022 4:41 PM]
My main concern is for March 2023, and how guidelines for mental illness and MAiD will be interpreted, as I feel this is so complex, and the potential for harm is great. As someone said, it's hard to hold Hope in one pocket and MAiD in the other, especially if treatment seems to be ineffective
Prefer not to say
[November 18, 2022 2:45 PM]
The Ontario College of Surgeons and Physicians draft policy states that doctors “must not make any reference to MAID” or the death cocktail “administered” on the death certificate.
This would significantly hinder any attempt to identify or investigate abuses or murder. This must not be approved if there is any degree of desire for justice. Let us take steps that portect the vulnerable, rather than this proposed policy that would clearly put them a great risk.
Physician (including retired)
[November 18, 2022 1:24 PM]
Dear Colleague/s

The fundamental issue at stake in requiring objecting physicians to participate in MAiD against their will can be stated:

1. MAiD or medical euthanasia is not a morally neutral medical treatment, or one where benefits outweigh costs in all cases, therefore it is morally wrong to require physicians to recommend treatment that they consider to be harmful to their patients, even if they (appear to) request it.

2. Since this is regarded by some physicians as morally unjustifiable (on grounds of harm done to patients, to society, to conscience and to the medical ethic that forbids the deliberate taking of life as enshrined in the Hippocratic oath) those physicians should not be required to participate in any aspect of the process of MAiD which is a detailed process that includes referral, as much as the administration of lethal drugs.

In short, if someone asks me to push them off a bridge, and I refuse that should be the end of the matter. Your proposals would require me to get someone else to do the job, and then check to make sure I made it happen, and then punish me if I refuse to cooperate!

Active participation in MAiD is a clear violation of conscience for those physicians who object on moral grounds, at any stage of the process. The issue of harm to patients from non-participation is a moot point, since it clearly depends on each individual case. In some cases, a physician who objects may influence their patients to take a sober second thought and save their lives, and in many other cases patients would simply find another physician to refer them.

Thanks for your patience in reviewing my comments
Member of the public
[November 18, 2022 12:51 PM]
I believe that FULL disclosure is very important, particularly for the controversial MAID legislation. The public taxpayers have a right to know who is receiving MAID, who is administering this, the reason for receiving it, and whether other reasonable alternatives were explored.

Human life is sacred, and administering death drugs violates the Hyppocratic Oath.
Member of the public
[November 18, 2022 12:42 PM]
In issuing death certificates, all physicians administering MAID ought to be compelled by law to state MAID as the cause of death.
Other health care professional (including retired)
[November 18, 2022 11:58 AM]
I whole heartedly agree with you!

Are you not outraged as a physician that they are falsifying death certificates ?
As a nurse, I am disgusted.

There is far too much room for abuse, and there is a complete lack of transparency when
death certificates do not contain the true reason of a persons death, euthanasia/MAID.
Other health care professional (including retired)
[November 18, 2022 11:37 AM]
I find it unconscionable that when filling out death certificate physicians puts the patients medical condition or situation as the cause of patients death!
We must not be hiding the reason for anyone’s death, and this includes euthanasia and MAID!!!! We must be able to clearly see the number of people who are dying from euthanasia and MAID, not doing so enables abuses to occur and to be hidden. This is not acceptable!!!!
How can this be tolerated? There must be transparency from front to finish in any health care procedure, especially when we are talking about taking a persons life or assisting in taking a persons life.

I was shocked when I read that the physician who participated in euthanasia/MAID must be the one who fills out the death certificate, and this physician must not write that person died of euthanasia/MAID, but rather died from whatever drove them to get MAID (be it an illness or intolerable situation).
Yes for example, a man in Ontario who recently applied for MAID because he lived with chronic pain. But it was not the chronic pain that prompted him to apply for MAID, but rather that he was afraid of being homeless, he was losing his apartment, he clearly stated that his fear of being homeless was worse than his chronic pain. He also clearly stated that he didn’t want to die! But that he was afraid of losing his place and being homeless. Now how does this
happen???? How does a man who doesn’t want to die, get cleared for euthanasia/MAID based on fear of being homeless???? This is a travesty!!
Thank goodness a Good Samaritan (not the government ) stepped up to help him with his housing situation and he no longer wishes to die.

This unfortunately is not an isolated situation!!

Provisions must be made to clearly state when a person dies by euthanasia/MAID. The protection of patients depend on this. If this man died from euthanasia/MAID we would never have been able to hold people accountable for his death as there would be no record on his death certificate stating that he died by euthanasia and by lack of support. Abuses are occurring and we must hold those involved accountable for their actions, or lack of actions.

We also must have accurate and clear numbers of euthanasia/MAID deaths. I would carefully scrutinize anyone who has any objection to this. There is no acceptable reason for anyone to object to transparency when it comes to euthanasia and MAID.
Member of the public
[November 18, 2022 11:17 AM]
all particles MUST be stated on the Death certificate as to the potion given, the quantity, why administered.

Hiding the truth from the public is wrong and unethical.
Member of the public
[November 18, 2022 11:13 AM]
I don’t understand and seriously object to the statement that a death certificate “ must not make any reference to MAID” having being “administered “ . I see this as making it impossible to know how many people are being killed by assisted suicide , which can become a coverup for abuse. If this ISN’T true , why such deliberate instruction to exclude the fact ? Conspiracy theory again ?!
Member of the public
[November 18, 2022 11:07 AM]
The draft policy states that doctors “must not make any reference to MAID” or the death cocktail “administered” on the death certificate. - SICKENING! We are watching you...
Physician (including retired)
[November 18, 2022 10:59 AM]
Dear Colleague/s

My understanding is that the CPSO is proposing to set standards that effectively force physicians who are conscientious objectors to MAiD to make an effective referral, and to positively confirm that such as referral has been made; indeed that MAiD should be offered as a form of therapy in normal medical settings

It must be clear to the College that such a proposal represents a deep violation of conscience for the physicians involved. Furthermore it deliberately targets conscientious objectors by rubbing their noses in it, since physicians who refer without moral objection are not required to confirm an effective referral.

What is the point of acknowledging conscience if the rules you propose violate conscience? The idea that there will be needy patients who are prevented from taking part in MAiD by their physician is the only possible justification for these rules, but that is a theoretical scenario that seems very unlikely. Does the College have a shred of evidence that this is happening?

To those of us who believe that physicians should never deliberately take life, as a fundamental more of medical ethics, these proposals appear to amount to an all out war against the moral rights of individual physicians, as enshrined in this country's Charter of Rights and Freedoms

Furthermore, to frame the debate as though it were just about a few cranky off-beat physicians, a tiresome minority, is to forget the negative consequences of euthanasia on medicine and society at large. As Canada continues to operate this madness, more and more stories are emerging of the downsides of euthanasia. We know this from other countries such as the Netherlands, where infanticide is regularly practiced (for instance for children diagnosed with hydrocephalus after birth). Indeed there is a proposal before Parliament at present to extend MAiD to infants

Many thanks for taking my comments into consideration. My proposal would be to respect and protect the conscience rights of all physicians; those we do not wish to participate in MAiD should not be required to make or confirm a referral for their patients (as they can discover a referral route for themselves with ease, and sadly many physicians see no moral objection to MAiD) and should not be required to suggest MAiD as a medical option in their consultations with patients
Physician (including retired)
[November 18, 2022 10:41 AM]
Note: Some content has been edited in accordance with our posting guidelines.
Hello
 
My name is [redacted] and I am a family physician working in [redacted] Alberta with full scope of practice including a fair amount of palliative medicine.
 
I recently became aware of the proposed changes to the Ontario MAiD legislation and I wanted to express my concern especially regarding the opportunities for practitioners to conscientiously object. I see the obligation for conscientious objectors having to confirm that the patient was contacted by MAiD services, as distinctly different from other areas where we make referrals where one might object, namely in the circumstance of abortion. It is my understanding that a patient can self refer for this service, and so a physician's involvement is really minimal. I respect patient's right to choose, but I resent what appears to me to be discrimination for those conscientious objectors, when the same standard does not demanded of others who are more in favor of this service. I understand our society's want for more freedoms, and I truly question the necessity for Physicians' involvement in liaising this service. When access is not restricted to physician referral, I find conditions placed on a physician in this circumstance to be unnecessary and patronizing.
 
Thank you for your time.
Member of the public
[November 18, 2022 10:40 AM]
Views on policy-
any death based on this law must state Maid death and include the exact drugs used, and date of request and permission date.

Anything to make Maid easier is against my thinking. If anything, it should be made more difficult as per safeguards for mental problems such as depression or even loneliness, so that any other remedies are applied first.

AS you can tell, i am against the law in the first place but certainly do not want its use to be able to be hidden by lack of reference to its use.
Member of the public
[November 18, 2022 10:38 AM]
Killing someone is not health care. If the government and this CPSO body thinks it is then why the cover up of data. If a patient died of trauma or cancer, relay it as such. If the patient was killed by “ Maid” then keep that data too. Falsified records just add to the coercion, cover ups, and lack of respect for physicians by lack of public trust.
Other health care professional (including retired)
[November 18, 2022 10:22 AM]
On the death certificate, MAiD should be included along with the disease/ illness leading up to the decision to choose MAiD. Otherwise the data is not accurate and prevents tracking the number of assisted deaths. Or is this done intentionally so as not to be able to count the number of MAiD deaths? Not including MAiD on the death certificate promotes lack of accountability and transparency on the part of physician/nurse practitioner.
Physician (including retired)
[November 18, 2022 9:50 AM]
I agree this government has gone too far
Physician (including retired)
[November 17, 2022 11:11 PM]
The expectations set out in the draft policy is not reasonable for those physicians refusing to participate in MAID for reasons of conscience or on religious grounds. The MAID policy itself in fact discriminates against physician rights as humans.
A physician should not have to go against their own conscience and religious beliefs to accomodate the action of euthanasia ( the killing of patients). A physician should not have to participate in MAID nor have the responsibility of referral for MAID.
Physician (including retired)
[November 17, 2022 11:08 PM]
Death certificates have multiple lines for cause of death. The first line should state "Medically Administered Death", the second line which states "as a consequence of" could state the medical cause that lead to the request for MAD/MAID. If there is nothing wrong with MAID/MAD why would physicians be asked to cover it up and leave it off the death certificate? It's fraudulent to not list MAID/MAD as the first cause of death.
Physician (including retired)
[November 17, 2022 10:24 PM]
Correct medical records are essential to maintain trust in the medical community. Failure to meet standards are appropriately sanctionable by the Provincial Colleges. This should never be open to debate. It is a basic principle and already encoded in College Policy.
Physician (including retired)
[November 17, 2022 9:31 PM]
I oppose the falsification of medical records. Falsifying the cause of death serves no one's best interests. MAiD in general is not good medicine and is often the failure of mental health supports, adequate access to excellent palliative care, and/or a failure of society in general to genuinely show care to the most vulnerable.
Physician (including retired)
[November 17, 2022 8:40 PM]
Line 69 (of first document): Not clear what is meant by a "contingency plan"? As is we have back-up meds kit at bedside. Do we need something else? Is the plan supposed to be in writing?

Advice on MAiD document:
103: Refer to 'Bill C-7' rather than to 'recent legislative changes'; 'legislative changes' is ambiguous, since there will be more in March 2023 & likely further down the road
191: clarify that the need for 'expertise' refers only to patients whose natural death is NOT reasonably foreseeable
220: there is no 'requirement' that the information from the practitioner with expertise be in writing - this is only a suggestion in the federal legislation
Physician (including retired)
[November 17, 2022 8:31 PM]
It is a disgrace to our patients to facilitate MAID and still mark the illness as the cause of death. By providing MAID, we are the cause of death. It is a complete lie to write anything other in order to bring peace to our consciousness after providing something that should be considered immoral.
Physician (including retired)
[November 17, 2022 6:18 PM]
Where the patient’s capacity or voluntariness is in question, physicians must conduct and/or refer the patient for a specialized capacity assessment10

How would one define a specialized capacity assessment? And how accessible is this in most communities?
Member of the public
[November 17, 2022 3:11 PM]
Dear Maid Group,
 
I am looking through and reading your material.
 
With regards to this document: https://www.cpso.on.ca/en/Physicians/Policies-Guidance/Policies/Professional-Obligations-and-Human-Rights, it is NEVER in the best interests of the patient for the doctor to kill them.
 
If your recall the original hippocratic oath (https://doctors.practo.com/the-hippocratic-oath-the-original-and-revised-version/#The_Classic_Hippocratic_Oath) you will notice the following decrees.
 
With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurtor damage. Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will give no sort of medicineto any pregnant woman, with a view to destroy the chid.
Further, I will comport myself and use my knowledge in a godly manner.
 
Perhaps, your organization needs to give its head a good shake and stop
murdering your patients old, young and pre-born altogether.
 
Notice the role they gave to diet. Perhaps, that also would be something to heed.
 
This was a slippery slope from the start and Canada was warned.
 
 
If I were you, I would stop while I was still ahead.
 
 
thank you,
Organization
[November 17, 2022 2:25 PM]
Ontario Association for ACT & FACT
Response in PDF format.
Physician (including retired)
[November 17, 2022 1:07 PM]
Concerns about process: There is no acknowledgement in this CPSO policy consultation process that the Federal Government intends to include Mental Disorders as a sole eligibility criteria by March 2023. Current consultation has been done with the legal pretext that MAID for Mental Disorders as a Sole Underlying Medical Condition (MD-SUMC) would not be considered eligible (see criteria c and footnote 2 within the Legal Requirements Document1). Given that this consultation process has failed to consider a significant factor in the changing Federal Legal context of MAID, this consultation process and timeline should be extended and modified to reflect the current changing reality of federal laws as projected into March 2023.

With regard to MAID for MD-SUMC, the HR policy directive to physicians to inform of “all available” clinical options under the guise of informed consent implies that MAID for MD-SUMC would be raised by physicians, unsolicited, to patients. Doing so would endanger vulnerable patients by implicitly endorsing the option of suicide and undermine the effectiveness of appropriate recovery-oriented models of psychiatric care.

Patients who do not first inquire about MAID as a treatment option and are offered MAID as an available treatment option by their physician may interpret this action as a recommendation for MAID by their physician. The CPSO should not enact policies that expect physicians to participate in actions that could induce suicide, an outcome which may be an unintended consequence of this policy.
Within the context of MAID for MD-SUMC, the MAID policy refers to the HR policy8. Section 9 of the HR policy which directs physicians to make an “effective referral”9 if physicians learn that the patient was not able to connect to a willing third party, is problematic from a purely practical standpoint. Given the small numbers of psychiatrists who would be willing or have the expertise to assess and/or provide MAID for MD-SUMC10, it would be impractical to expect individual physicians to be able to find willing providers to assess and carry out MAID for MD-SUMC, thereby placing physicians in a position of breaching a college policy that for all intents and purposes would be unduly time-consuming, burdensome, and for some in certain areas, impossible to carry out.
Physician (including retired)
[November 17, 2022 11:44 AM]
Regarding the draft proposal relating to the completion of a death certificate, the CPSO states "must not make any reference to MAID or the medications administered on the certificate." This proposal is a disingenuous and white-washing notion which suppresses the truth. For a publicly governing body that has committed to truth and accuracy in medicine, this draft proposal is alarming and unethical! It denies agency which is of critical importance.
Member of the public
[November 17, 2022 11:20 AM]
Falsifying death certifcates is akin to giving false evidence in court. It's called lying. Does the CPSO want to be known as cheaters and liers. Please reconsider your outrageous move. It does not belong in medicine.
Physician (including retired)
[November 17, 2022 9:57 AM]
During most of my career our profession explicitly advocated that we strive only to help our patients and "to do no harm". Admittedly, on occasion the most conscientious physician found himself/herself in situations that appeared to be "grey". My concern is that the medical practitioner is now being mandated under some legal situations to be a participant in the function of "executioner". I believe that our society and the conscience of many of us would be better served if we were advocating and acting for more palliative care training and hospice care facilities, and progressively more mental health services and availability.
In all forms of legalized medically assisted death, from abortion to suicide, we must have open and honest documentation - never evasive. When we endorse subtle dishonesty in what we do and record, it facilitates demise of our integrity and society.
Respectfully yours.
Member of the public
[November 17, 2022 9:49 AM]
The CPSO proposes in their draft MAiD policy document that "[w]hen completing the medical certificate of death, physicians:
a. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and
b. must not make any reference to MAID or the medications administered on the
certificate."

This is the sinister falsification of death certificates. Listing an underlying condition as the CAUSE of death, when the individual died from lethal injections administered by the doctor or nurse practitioner is a lie. Even more ghastly: why the explicit forbiddance of making any reference to MAiD? This is bad medicine and bad record-keeping. I strongly oppose the CPSO's draft policy on MAiD.
Member of the public
[November 17, 2022 9:39 AM]
I am very concerned about the direction of the College to falsify death certificates. People don't die from hearing loss, but they can receive MAiD for hearing loss (Alan Nichols). Ending someone's life is serious. If we are going to understand the reasons behind requests for MAiD and be transparent about its' provision, it is important that death certificates are clear as to cause of death. With MAiD, the cause of death are the drugs being administered not hearing loss.
Member of the public
[November 17, 2022 8:21 AM]
My father died after being moved from Track 2 to Track 1 MAiD on Vancouver Island. Several things stand out relative to Ontario proposals and safeguarding:

1. Track moves and the reasons for them must be well documented. Mid-way through the 90-day assessment, my family were first contacted and told he was upgraded to reasonably foreseeable natural death after refusing food for three days and had slightly elevated WBC following a move five days nto a new assisted living apartment and a fall there after not eating. He was permitted alcoholic beverages by his clinicians and consumed those and caloric liquids like juice and coffee in the hours before his death. It was never explained to us how these conditions were irremediable or that death was imminent. Documentation we have received does not explain this either.

2. Full capacity assessments must be done immediately before final consent. This was not done in my father's case and his behaviour at the time suggested that he may have been intoxicated or had contraindications with painkillers.

3. Record MAiD and administered substances on all relevant death documentation. To do otherwise is dishonest and may have an adverse affect on surviving family, as it does mine.

4. Seek collateral information early from family members or others. Assessors in my father's case did not do this and so did not learn of his history of suicidal behaviour, mental illness, and substance use until just before he died, despite family attempts to communicate this to his assessors early in the process. He was acutely suicidal in the months before he learned of MAiD and C-7 passed and made no secret that his MAiD was suicide. He indicated that he did not ban assessors from doing so.

5. Where contrary or new collateral information is learned after assessments are passed, require an immediate suspension of approval and a full reassessment of the patient. Passing both assessments appeared to lock-in my father's death so new collateral information about suicidality was actively dismissed by his provider.
Physician (including retired)
[November 17, 2022 8:00 AM]
We need to protect life above all else
Physician (including retired)
[November 17, 2022 7:31 AM]
I oppose not listing MAID/ euthanasia as a cause of death. If euthanasia is requested and administered, that is the cause of death. All other health issues and diseases are merely contributing factors, not the cause.
Physician (including retired)
[November 17, 2022 6:02 AM]
As a practicing family physician with extensive palliative care experience I emphatically oppose any policy from the CPSO that would allow for the falsification of the cause of death for MAID patients.
Physician (including retired)
[November 17, 2022 4:20 AM]
The cause of death specified on a death certificate in a civilized and honest society will always be precise and truthful. If a citizen dies after a lethal injection by a euthanasia provider, the certificate must say so. Any illness or other relevant circumstances which the citizen was experiencing at the moment of a medically administered death should also be recorded. To officially direct any euthanasia providing person to omit the actual immediate cause of death, lethal injection, demonstrates a grave failure of institutional ethics and an injury to the common good.
Physician (including retired)
[November 17, 2022 12:37 AM]
Every person has an instinctual restraint to killing another human, especially a member of his or her family. This instinct is called the Species Specific Instinctual Restraint of Aggression and Abandonment. If anyone contributes to the death of a family member by consenting to the euthanasia of a friend or family member, their SSIRAA is weekend so that they are more likely to be aggressive or abandon the weak and wounded. This is particularly true of soldiers. They sense this and for that reason are careful to control their anger. Mothers know this instinctual response so that if they have ever lost control of their anger, they are more likely to hurt a child again and thus are quick to seek treatment. Thus those who consent to euthanasia are more likely to harm or abandon children. That is one of the reason that humans have not practiced any form of euthanasia.
Other health care professional (including retired)
[November 16, 2022 11:24 PM]
Medical Records must never be falsified as they may need to be used in situations such as Court cases and other events which may effect so many innocent people. Good Doctors are being forced out of Medicine as they are not prepared to go against their Oath: To Do No Harm. Euthanasia is direct killing and should never be a part of Medicine.
Other health care professional (including retired)
[November 16, 2022 9:35 PM]
A proper record of death under the auspices of MAiD is essential for society and the medical profession to uphold the very fabric of truthful integrity. Putting an end to these records or failing to report lethal injection as cause of death would be tantamount to a final exit for accountability. It is as if to say, as for this choice to die and the provision for it, society shall never be able to assess its own advances or mistakes, come what may. Nothing could be more ideological and less candid in the treatment of facts.
Physician (including retired)
[November 16, 2022 8:06 PM]
We should be recording the cause of death as physician-assisted suicide. This clearly describes what happened.

To record the cause as the underlying illness leading to the request for death is to conflate two completely different categories of deaths, hindering research, statistical analysis, and an understanding of our society. Did 1000 people die from lung cancer this year, or did 500 of them die from the cancer while 500 killed themselves who would have lived 1-2 more years? With such a policy, we will never know.

This will become even more of an issue if and when mental illness qualifies a patient for physician-assisted death. If we are falsely stating on the death certificate that all these 40-year-olds died from depression or schizophrenia, or just plain "completed life", we will be covering up the real causes. The purpose of recordkeeping on death certificates is to shed light on what happened, not obscure it.

This draft policy is asking us to falsify death certificates on a mass scale. I oppose it.
Physician (including retired)
[November 16, 2022 7:51 PM]
With the rapid expansion and some of the most lenient euthanasia laws in the world, it is important for us physicians to have our eyes wide open looking for abuse. I oppose the falsification of medical certificates and advocate for the proper record-keeping of all euthanasia deaths. Documentation should be transparent and true to the events that transpire.
Physician (including retired)
[November 16, 2022 7:21 PM]
Since MAiD has been deemed legal and is a cause of death, it must be so listed on the death certificate. To list the underlying illnesses or conditions as the cause of death when MAiD has been performed would be deceptive and would lead to unreliable statistical analyses of causes of death.
Stated another way: MAiD is not a treatment that can be shown to improve anyone’s health, but rather is an actual cause of death, so it must be included on the death certificate.
Member of the public
[November 16, 2022 6:56 PM]
I greatly oppose the idea of listing the cause of a MAID death as anything other than a MAID feath. Listing it as anything else is a complete lie as it was that procedure which caused death, not whatever factors led to that individual receiving a pre-meditated medically-induced death.
Physician (including retired)
[November 16, 2022 6:51 PM]
I trained in Canada and the people of Canada deserve better than the runaway euthanasia that is diminishing the value of life in the country.
Other health care professional (including retired)
[November 16, 2022 6:39 PM]
I am opposed to falsification of medical records. Where is the integrity and honesty in care and human life? As Is health care provider, I am appalled that a government agency or college would suggest I neglect telling the truth! There is mo integrity or credibility in this suggestion.
Euthanasia should not be a treatment option or solution when improved mental health supports, palliative care and respectful care should be the goal.
Other health care professional (including retired)
[November 16, 2022 6:32 PM]
I oppose the falsification of medical certificates and that you support the proper record-keeping of all MAID deaths.
Member of the public
[November 16, 2022 5:15 PM]
Note: The attached response was signed by 30 rabbis in the Greater Toronto Area (GTA).
Response in PDF format.
Organization
[November 07, 2022 6:36 PM]
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Physician (including retired)
[November 02, 2022 1:27 AM]
Note: The attached response was signed by Indigenous representatives including physicians, other health-care workers, and members of the public.
Response in PDF format.
Organization
[November 01, 2022 10:31 PM]
Physicians Together with Vulnerable Canadians
Note: During the consultation period, we received eight responses from individual respondents containing the following content.
Response in PDF format.
Organization
[November 01, 2022 1:37 PM]
Professional Association of Residents of Ontario (PARO)
This guidance is definitely helpful and necessary for physicians. The expectations set out seem clear and reasonable.
 
Regarding involving family in the decision for MAID, “It can be very challenging to navigate these situations and when they arise, it is important to keep in mind that it is ultimately a capable patient’s right to decide which clinically appropriate treatment options they pursue and who they want to share this decision with.” We believe that it could benefit from guidance in the circumstance where family collateral is necessary in assessing a patient's capacity to consent to MAID and whether a physician can advise the patient that it may not be possible to assess their capacity without family collateral.
 
“Mentorship refers to the guidance provided by a physician who is perceived to have greater relevant knowledge, wisdom, or experience (“mentor”) to another physician or nurse practitioner who is perceived to have less (“mentee”), and mentorship occurs regardless of the frequency of the guidance provided and the formality of the relationship”
 
The criteria around mentor and mentee are somewhat unclear. For example, if there is a recognized expert in the field, would only another recognized expert in the field by a valid second assessor?
 
We found the question and answer format delivers the information very well. We felt the expectations set out in the draft are clear and reasonable. We did not identify any issues not addressed that should be.
 
One note: “The Canadian Association of MAID Assessors and Providers (CAMAP) has a clinical guidance document on Bringing up MAID as a clinical care option, which includes the following...” The URL to the clinical guidance document directs to (https://camapcanada.ca/wp-content/uploads/2020/02/Bringing-up-MAiD.pdf). The page says “Oops The Page you're looking for isn't here.”
 
We once again appreciate being included in the CPSO's consultative process.
Member of the public
[October 11, 2022 8:15 PM]
The Legislative Assembly of Ontario continues to define the Scope of Practice of Medicine as:
Medicine Act Scope of practice 3 The practice of medicine is the assessment of the physical or mental condition of an individual and the diagnosis, treatment and prevention of any disease, disorder or dysfunction. 1991, c. 30, s. 3.
In that MAID is not a treatment, the prohibited controlled act (Regulated Health Professions Act 27 (2) 5 - administering a substance by injection or inhalation)) remains prohibited. CPSO is diverting from its object of applying the RHPA and The Medicine Act.
(An assumption that in Canada federal law over rides provincial law is false, refer to the principle of paramountcy. Both sets of laws apply. A Court may provide allow federal to prevail if there is a conflict.
Physician (including retired)
[September 28, 2022 3:41 PM]
MAID is political. The provincial MOH's should organize and provide MAID service to eligible requesting citizens.