Assisted-death debate not yet put to rest 

By Lauren Vogel | CMAJ | Aug. 22, 2016

Assisted death is only available for consenting adults for whom natural death is foreseeable: one of many limits inciting legal battles over access to the service. (KatarzynaBialasjewicz/iStock)

Legalizing assisted death is only the beginning of the end-of-life conversation, delegates to the Canadian Medical Association (CMA) General Council heard in an ethics session on Aug. 22.

Canada introduced federal legislation allowing assisted death for some adults on June 17. Now it’s up to provincial–territorial governments, professional regulators and medical institutions to determine where and how the service is provided.

“The profession is divided on the issue of assisted dying, and this is as true today as when we started the conversation,” said Dr. Jeff Blackmer, CMA’s vice-president of medical professionalism.

Federal law allows assisted death for adults who are experiencing unbearable suffering from a condition in an “advanced state of irreversible decline,” so long as natural death is “reasonably foreseeable.”

“The CMA was very vocal in support of this piece of legislation,” says Blackmer. However, he predicts “there will be cases where it will be a challenge for physicians to determine if a patient meets the criteria,” particularly when it comes to assessing when natural death is likely to occur.

A British Columbia woman with spinal muscular atrophy has already launched a constitutional challenge to that limit, arguing that it deliberately excludes access to assisted death for Canadians whose suffering is not terminal.

“We will follow that court challenge very carefully,” said Blackmer. “Certainly the discussion is not finished and if the experience in other jurisdictions is any indication, in fact it is only beginning.”

The current law does not allow assisted death for mature minors or for otherwise healthy patients experiencing unbearable suffering from mental illness, and it does not permit patients to request assistance to die through advance directives. Blackmer argues that the federal government took an appropriately cautious approach by committing to further study these issues before ruling one way or another.

Certainly, the discussion is not finished and if the experience in other jurisdictions is any indication, in fact, it is only beginning.

“In other jurisdictions where assisted dying has been legalized, they didn’t start with these things either,” he notes. “They have some important lessons for us to learn in terms of what has worked and what hasn’t and the CMA will continue to represent doctors in those conversations as well.”

How provinces handle physicians who object to providing or referring patients for medical aid in dying is also still in flux, with some delegates at the general council expressing concern about “patchwork” regulations across the country.

According to Blackmer, “a number of provinces have enacted or are working on central coordinating and referral mechanisms to make sure there is a timely connection between patients and willing providers.” Alberta is one such province, and an “excellent example of a solution to make sure access is not compromised by physician rights to conscience,” he says.

A legal battle between objecting physicians and Ontario over regulations that force doctors to provide direct referrals for medical aid in dying “may provide some clarity at the legal and constitutional level,” Blackmer added. “I’m sure that conversation is not over yet.”

Although these issues remain controversial, the relaxed atmosphere of the ethics session was markedly different from the lengthy and emotional discussions about assisted death at last year’s general council meeting. There were few questions from the floor and the biggest applause went to a comment from Dr. Tim Holland from Nova Scotia about the value of the CMA’s ethics committee.

“The committee on ethics is the last standing core committee [after recent CMA restructuring] and I heard its future is not certain,” Holland said. “When I talk to other doctors [about the benefits of CMA membership], I don’t talk about hotel or car rental deals, I talk about ethics and that’s what convinces them of the importance of the CMA, and so I really want to implore the CMA to retain the committee on ethics as a priority.”

Dr. David Gass is stepping down from his role as chair of the ethics committee this year and said a reduction in the length of the group’s meetings as a result of restructuring has “made completion of our challenging agenda even more challenging.”

To connect with CMAJ, follow us on one of these social media platforms

Pin It on Pinterest

Share This