Euthanasia research & response

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Brief to the Joint Committee on Assisted Suicide

January 30, 2016

LifeCanada is a national association of local and provincial educational groups across Canada that exist to promote the value of human life, to serve our members, and to advocate for the most vulnerable members of society. We represent approximately 80 groups and over 10,000 individuals in Canada. Among our many educational projects and campaigns, we are known for our extensive national polling that we undertake to assess the public’s attitude to the issues that concern us today, most especially euthanasia and assisted suicide.

While some political leaders are eager to apply the Supreme Court ruling and legislate as quickly as possible, we and those we represent are extremely concerned about the Supreme Court decision, which has found Sections 241 and 14 of the Criminal Code to be in violation of the Charter. .

The dignity of human life is not a subjective reality, but an inherent aspect of our human nature that must be upheld in law, as one of its primary objectives. Ours has become a secular society, and the duty of affirming and protecting human life falls on both law and medicine to maintain the inherent and inestimable value of that life.

What the Supreme Court has done in the Carter Decision is to render that dignity subject to individual autonomy and self-determination at the expense of considerations of the common good. It is asking the law to allow killing, something that has always been prohibited, even with consent, and it is asking medicine to be the means of inflicting that death. Ultimately it asks society to endorse the notion that there is such a thing as a life unworthy to be lived.

We believe that this decision, if accepted by Parliament, will have serious ramifications for all Canadians, today and in the decades to come. We agree with the ethicist and legal scholar Margaret Somerville (Canadian Press, Feb. 6/15):

"This is not an incremental change but a seismic shift in one of our most important foundational values – respect for human life at both the individual and societal levels. I believe that future generations will look back on this ruling, in light of its future consequences, as one of the important, harmful and regrettable ethical, legal and public policy decisions of the 21st century." 

One of the first areas to suffer will be good palliative care. In a recent opinion piece by Dr. Harvey Max Chochinov,* he notes the following (The Province, February 23, 2015):

"Despite the impressive strides that palliative care has taken — in areas such as pain and symptom management, and sensitivities to the psychosocial, existential and spiritual challenges facing dying patients and their families — at their time of licensure, physicians have been taught less about pain management than those graduating from veterinary medicine. Once in practice, most physicians have knowledge deficiencies that can significantly impair their ability to manage cancer pain." 

What is truly concerning about this decision is that doctors who have “knowledge deficiencies” in proper pain management and end of life care will, nevertheless, be licensed to kill.

Dr. Chochinov states that,

"It should be noted that the authority to provide a hastened death will be conferred on physicians, many of whom lack core competencies to care for patients nearing death. To be clear, dying badly in Canada will rarely be the fallout of not having access to a lethal overdose or injection, and will almost invariably be the result of inadequate or substandard end-of-life care." 

Consequently, society will be prioritizing the ending of life over caring for life in its final stages. We submit that this is misguided.

Like many we believe palliative care is the right of all Canadians, and should be accessible to all before procured death is even considered.

Of the many serious implications of the Supreme Court decision, there is none that concerns us more than the “suicide creep” argument, given that so many lives will now be at stake. Legislation that will allow for physician inflicted death will invariably send a strong message to the public that this action is a human right, prompting many to feel that they can demand and receive it according to their wishes, irrespective of what the law outlines.

Dr. Theo Boer, professor of health care ethics and a member of the Euthanasia Review Committee for the Dutch Government noted that laws allowing assisted suicide created a strong sense of entitlement among the population.

"Whereas the law sees assisted suicide and euthanasia as an exception, public opinion is shifting towards considering them rights, with corresponding duties on doctors to act. A new law is in the making that obliges doctors who refuse to provide assisted dying to refer their patients to a ‘willing’ colleague. Pressure on doctors to conform to patients’ (or in some cases relatives’) wishes can be intense." 

How will the law prohibit people who are not terminally ill but who want to die, from requesting and receiving death at the hand of a physician? How will the courts, having established suicide as a constitutional right on the basis of individual autonomy, argue against those who see assisted suicide as a universal right that must be administered on demand?

A look at legislation around the world shows that abuse is possible in every jurisdiction where the practice is legal, that the law itself can never guarantee that innocent lives will not be taken without consent, and that the list of conditions and situations in which people can request and receive medically induced death only widens.

Studies in the Canadian Medical Association Journal (June, 2010) indicated that the law in Belgium was widely abused. Almost one-third of euthanasia deaths were illegally performed without patient consent. And half of nurses administering euthanasia did so without the patient’s knowledge or consent. Nearly half of the nurses in the study - 120 of 248 - admitted they acted without patient consent.

"The nurses in our study operated beyond the legal margins of their profession,” said the report's authors.

A study in the New England Journal of Medicine (March 2015) found that euthanasia deaths in Belgium have more than doubled from 2007 to 2013.

Studies coming out of Oregon show that since 2005, the number of deaths by assisted suicide has doubled. Prescriptions to kill patients grew by 76 percent, whereas the population grew by only seven percent. (OR Death With Dignity Act 2013)

Washington State legislators have determined that their assisted suicide law is too restrictive. As suspected, they want to make assisted suicide available to those who judge their suffering unbearable but are not terminally ill, as well as those who are not competent but have previously asked for assisted suicide in an advanced directive.

Interestingly, between 2009 and 2012, the number of deaths by assisted suicide grew by 130 percent while Washington’s population grew only 18 percent. (WA Death With Dignity Act 2013)

And in the Netherlands, the number of deaths by euthanasia doubled between 2008 and 2013. Under the Groningen Protocol for physicians, the right to medically induced death has expanded to include babies. This protocol regulates the process of killing infants with life threatening illness and/or the prospect of great suffering. (2013 Netherlands Euthanasia Report)

In Quebec, where Bill 52 legalizing voluntary euthanasia for those over 18 was adopted last year, the secretary of the College of Physicians already sees the legislation as “only one step:” As Quebecers become accustomed to doctors administering lethal injections to dying patients, the questions will not be about who is receiving euthanasia but who is being denied it. We will have to think about that, not only for [incapable] adults but obviously for youngsters who face terminal diseases. (Yves Robert, cited in National Post Feb. 14/14)

Previous governments on both sides of the political divide have acknowledged that once assisted suicide or euthanasia is legalized, there will be no guarantee that innocent lives will not be taken. It was on these grounds that several previous governments did not open up this debate in Parliament and rightfully so.

Unfortunately the time constraints, (even with the current four month extension), required by the Carter ruling do not allow the people’s representatives sufficient time to deliberate these weighty matters. We therefore call upon the government to do all that it can, to listen to the majority of Canadians who have shown, in our years of national polling, that they are concerned or very concerned about some of the consequences of legalized physician death. We invite you to view our polls at www.lifecanada.org/services/national-polls.

Along with this letter we have included a list of itemized points that we feel need to be considered by any joint panel on assisted suicide. We trust that you will consider each point and act to limit the consequences of assisted suicide to the utmost of the law.

We invite you to view our polls at www.lifecanada.org/services/national-polls.

Sincerely,

Natalie Sonnen
Executive Director LifeCanada

*Dr. Chochinov is a Distinguished Professor of Psychiatry at the University of Manitoba and Director of the Manitoba Palliative Care Research Unit, CancerCare Manitoba. His seminal publications addressing psychosocial dimensions of palliation have helped define core-competencies and standards of end-of-life care. He holds the only Canada Research Chair in Palliative Care and is a member of the Governing Council of the Canadian Institutes of Health Research. He also chairs the CIHR’s Standing Committee on Ethics.

List of points to be considered by the Federal Joint Panel on Assisted Suicide

  1. Presently, Parliament is considering legislation on what is called “physician-assisted dying,” or “medical aid in dying” based on a Supreme Court ruling last year. Our polling has indicated that as many as 69% do not know what is meant by these terms.
  2. Palliative care provides pain relief and comfort care that can relieve the suffering of dying patients. It also offers emotional, social and spiritual support. Research shows that palliative care can often alleviate the desire for assisted suicide or euthanasia. Yet research also shows less than 30% of Canadians have good access to palliative care at the end of life. LifeCanada believes that it is an injustice to legalize assisted suicide and euthanasia without ensuring that all Canadians have good access to palliative care.
  3. Some legal proposals for assisted suicide and euthanasia restrict these measures to only people suffering from terminal illness. Other proposals extend the measures to people with chronic illness or a disability. We believe that in either case, those suffering from terminal illness and those with disability need the protection of the law, and will not benefit from having subtle societal pressures to end their lives, especially if they have no one to advocate for them.
  4. Some proposals for legalized assisted suicide and euthanasia pertain only to adults. But other proposals have no lower age limit, so that a teenager might legally be able to request these measures. The External Panel on Options for a Legislative Response to Carter v. Canada reported support for the proposal that if assisted suicide and euthanasia are legal, a teenager should be able to obtain them if a doctor believes the teenager understands what is involved. We believe that this will have a chilling effect on suicide prevention programs, and will send a message to youth that death is a way out of suffering, compromising the will necessary to explore alternative treatments.
  5. The External Panel on Options for a Legislative Response to Carter v. Canada deliberated that if assisted suicide and euthanasia are legal, questions about what should be listed on a death certificate as the cause of the person’s death would need to be raised. If assisted suicide or euthanasia, or even physician-assisted dying, are mentioned, it could complicate insurance claims. Some therefore say only the underlying medical condition should be listed. Others prefer an honest term like physician-assisted suicide. LifeCanada is concerned as to how these issues will be resolved.
  6. Most current proposals to legalize assisted suicide and euthanasia involve a physician complying with a patient’s request. However, the Canadian Nurses Association wants nurses to also be allowed to carry out such measures. The 2010 CMAJ study already discussed in our letter found that many nurses were performing the act illegally. LifeCanada believes that this will seriously compromise the very essence of nursing, and is not what is intended by the majority of people who enter the profession.
  7. Some doctors have ethical objections to assisted suicide and euthanasia. If assisted suicide and euthanasia are legal, such doctors may face a dilemma if patients ask them to provide these measures. LifeCanada is greatly concerned by the trend to force doctors to either perform the requested suicide or make an “effective referral” - something that objecting physicians cannot do.
  8. In Belgium, where euthanasia is legal, there have been many cases of people with depression have opted for and received assisted suicide. A well-known case was the mother of Tom Mortier, a 64 year old woman, who suffered from chronic depression but was otherwise healthy. She was euthanized after being dejected when her boyfriend left her. Whereas palliative care can apply only to those who are terminally ill, reasons to allow assisted dying grow and morph into many more cases, eventually leading to no reasons at all (assisted suicide on demand).
  9. Suicide is a serious problem in society. It is especially serious among youth and First Nations people. If assisted suicide is legal, LifeCanada is concerned it will tend to make suicide more socially acceptable and that it could result in an increase in suicide rates.
  10. Health care costs consume a growing part of government budgets. The care of the elderly is an especially expensive component of those costs, and society is aging. If assisted suicide and euthanasia are legal, LifeCanada is concerned that these measures could be used to contain rising costs.
  11. Elder abuse is recognized as a serious and growing problem by the federal government. The abuse is often carried out by family members or those who are supposed to be caregivers. If assisted suicide and euthanasia are legal, we are concerned that many elderly people will be pressured to end their lives.
  12. In Belgium euthanasia has been legal since 2002, when a patient who has a serious illness makes an explicit request for it. The 2010 CMAJ study showed that almost one-third of euthanasia deaths were occurring without patient consent; many were patients with Alzheimer’s disease who could not give consent. We are concerned that a Canadian law legalizing euthanasia will lead to the lives of many patients being ended without consent because they are considered to have a low quality of life.
  13. If assisted suicide and euthanasia are legal, it seems to establish a certain right to die through these measures. Even if restrictions are initially put on this right, some people believe that over time legalization will lead to a demand for physician-assisted dying to be regarded as a basic human right that everyone is entitled to; restrictions will therefore be challenged and removed. In Quebec, where medical aid in dying in the form of euthanasia is now legal when a dying patient requests, the Secretary of the Quebec College of Physicians has said the new law will raise questions about why some people are excluded, such as Alzheimer’s patients. The legalization of physician-assisted dying will tend to lead to a demand for it to be recognized as a basic human right to which everyone is entitled, with few restrictions.
  14. According to the Supreme Court of Canada, a criterion for physician-assisted dying is that the patient has “a grievous and irremediable medical condition.” The External Federal Panel Report proposed that for legalization a physician or a team of health care professionals should assess a patient’s condition as to whether it is “grievous and irremediable.” However, the organization Dying with Dignity maintains that any such assessment by anyone other than the patient infringes the patient’s autonomy. LifeCanada and those we represent are concerned that if physician-assisted dying is legal, it will be left to the patient to assess “grievous and irremediable medical condition”.
  15. Among a minority who favour legalized physician-assisted dying outright, some have the view that “It’s my body, my choice.” They believe that the right to die is a fundamental human right, and no one’s approval, even that of a doctor, should be required. According to this view, the doctor’s role is to respect the person’s right and help them to realize it in a medically sound manner, irrespective of the person’s medical condition or degree of suffering. We do not believe that there is an unrestricted right to physician-assisted suicide and euthanasia. Such belief is a radical departure from medical ethics and human rights theory, and is a death wish to any society that claims it.

For the Committee’s Consideration:

LifeCanada has done extensive polling on assisted suicide and euthanasia and, consistent with other polls, we have found that people support these practices in general. However, unlike most polling LifeCanada takes the time to further question respondents about concerns they may have. We feel that the a strong individualistic mentality influences many to support assisted suicide and euthanasia, but that the support is shallow and concerns about the consequences are serious and held by a majority of the population (over 60% and as high as 86%).

Here is a summary of our polling, and attitudes in general that through our experience we feel the public is concerned / very concerned about:

1. Many / most people do not clearly understand what “assisted dying” (Supreme Court) / “medical aid in dying” (Quebec law) means. (69%: Quebec Poll, 2013)

2. Many people who believe doctors should be allowed to prescribe a lethal drug for patients do not necessarily agree that doctors should be allowed to directly take the patient’s life by administering the drug.

3. Palliative care is only currently accessible to about 30% of Canadians. Experts in that field report that provision of good palliative care can change a patient’s request for assisted suicide / euthanasia. Many / most people agree that before assisted suicide / euthanasia are made available, Canadians should be provided with universal access to palliative care. (66%: National Poll, 2011)

4. Most people do not favour assisted suicide / euthanasia on demand

5. Most people do not favor tax-funded assisted suicide /euthanasia on demand

6. If people are free to have their lives terminated, most people agree that the idea will likely grow to include those seen to be suffering yet unable to decide for themselves – like disabled children or people with Alzheimers. The result will be euthanasia without consent. (82%: National Poll, 2011; 82% Quebec Poll, 2013)

7. Elder abuse is already a serious social problem, and is recognized as such by the federal government. If assisted suicide / euthanasia are readily available, most people are concerned / very concerned that many elderly persons will be pressured to end their lives. (76%: National Poll 2011; 84% Quebec Poll 2013)

8. Canadians were asked how concerned are they that the legalization of euthanasia would lead to a significant number of sick, elderly or disabled people being euthanized without their consent. A large majority of three-quarters say they are very (41%) or somewhat (33%) concerned that this would happen. (74%: National Poll 2011; 75%: Quebec Poll, 2013)

9. Health costs are rising and consume a growing part of government budgets, with the care of the elderly especially expensive. If assisted suicide /euthanasia are readily available, most people agree that pressure will grow to end the lives of some elderly persons as a cost-saving measure. (76%: Quebec Poll 2013)

10. Suicide is already a serious social problem, especially among the young. If assisted suicide /euthanasia are readily available, people will be more likely to end their lives prematurely. (82%: Quebec Poll, 2013)

11. People are concerned that with the legalization of assisted suicide / euthanasia, those suffering mental illness will seek to be killed through “medical aid in dying” instead of finding the help they need. (86%: Quebec Poll 2013)

12. Under present laws, minors can sometimes obtain an abortion without parental knowledge. If assisted suicide / euthanasia are readily available, most people are concerned /very concerned that teenagers might end their lives without parental knowledge.

13. Most people agree that if assisted suicide or euthanasia is contrary to a doctor’s conscience, the doctor should not be forced to perform it.

14. Most people agree that if assisted suicide or euthanasia is contrary to a doctor’s conscience, the doctor should not be forced to help a person obtain it from another physician.

15. Most people believe that in a democracy, on a controversial issue like this, the Canadian Parliament and not the Supreme Court of Canada should have the final word.