Medical Assistance in Dying: Exploring Ethical Considerations

Disclosures Insert disclosures from the faculty presenters

Workshop Outline Welcome and introduction Clinical vignettes, case scenarios related to MAID Review of current (relevant) legislation Quebec versus Federal legislation Key elements of the Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) S.C. 2016, c. 3 Interactive facilitated discussion Identify the ethical considerations with regard to Medical Aid in Dying Local directives and processes Personal Reflections on Medical Assistance in Dying Closing remarks and Evaluation http://laws-lois.justice.gc.ca/PDF/2016_3.pdf

Learning Objectives At the end of this workshop you will be able to: Explain the reasoning behind the legal and regulatory changes related to Medical Assistance in Dying (MAID). Identify the ethical considerations regarding the provision of MAID. Identify and assess personal values and beliefs related to MAID.

Welcome and introduction What would you describe is your most pressing ethical question concerning Medical Assistance in Dying? Have you had any prior experiences with Medical Assistance in Dying? What are your expectations for participating in the workshop today?

Alignment with CanMEDS This workshop is relevant to the following CanMEDS enabling competencies Professional Role 1.3 Recognize and respond to ethical issues encountered in practice 2.1 Demonstrate accountability to patients, society, and the professional by responding to societal expectations of physicians 3.1 Fulfill and adhere to the professional and ethical codes, standards of practice, and laws governing practice Medical Expert Role 2.3 Establish the goals of care in collaboration with patients and their families which may include…..palliation

Clinical vignettes/case scenarios Options based on local resources. Local clinical vignettes that illustrate the complexity of Medical Aid in Dying Case scenario from the Bioethics Curriculum (http://www.royalcollege.ca/rcsite/bioethics/cases/section- 5/providing-medical-assistance-dying-e or http://www.royalcollege.ca/rcsite/bioethics/cases/section- 5/conscientious-objection-medical-assistance-e) Videos examples of Dr. Don Low’s plea for assisted death at https://www.youtube.com/watch?v=q3jgSkxV1rw and/or other videos; podcasts

Clinical vignettes/case scenarios What do these vignettes case scenarios illustrate re: Complexity of issues related to Medical Assistance in Dying? What are the key questions that should be explored?

Medical Aid in Dying: the context If the workshop is held in Quebec Focus primarily on the legal requirements of the Quebec legislation Illustrate the differences between the Quebec legislation and the federal government of Canada’s legislation. If the workshop is held outside Quebec focus on: The previous inclusion of Medial Assistance in Dying within the criminal code The Carter case challenge The Supreme Court’s decision Illustrate the differences between the federal government of Canada legislation with the Quebec legislation

An act respecting end of life care S-32.0001 Passed in Québec’s National Assembly June 5, 2014; Assented to June 10, 2014 (predates Carter) Came into force Dec 10, 2015, six months prior to C-14 The objective of the Act was to ensure that all insured persons had access to the full range of end of life healthcare options. Therefore, palliative sedation and advance directives are also included in the Act.

Eligibility criteria Article 26. Only a patient who meets all of the following criteria may obtain medical aid in dying: (1)  be an insured person within the meaning of the Health Insurance Act (chapter A-29); (2)  be of full age and capable of giving consent to care; (3)  be at the end of life; (4)  suffer from a serious and incurable illness; (5)  be in an advanced state of irreversible decline in capability; and (6)  experience constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable.

Timeline 2006-8 – CMQ working group on clinical ethics November 2009 – CMQ position made public December 2009 – Commission on Dying with Dignity formed by Québec government March 2012 – Commission publishes its report (euthanasia renamed ‘medical aid in dying’, assisted suicide excluded) June 2013 – Bill 52 presented, further consultation sought June 5, 2014 - Bill passes in National Assembly on a free vote December 10, 2015 – The Act comes into force 12

Origins of the Act and the rationale behind it The Collège des Médecins du Québec (CMQ) was aware that there were cases of MDs hastening death but it was being done secretly with each physician acting on their own and without guidance or constraints. In 2005-6, the CMQ to asked its Working Group on Clinical Ethics to study end of life care as one of several clinical scenarios in which there were questions about how to determine the level of care required The working group aware of the intractability of the euthanasia debate when treated as a question abstracted from its clinical context. It proposed to start the discussion from the clinical context where questions of euthanasia most frequently arise: suffering at the end of life 13

Suffering at the end of life Article 58 of the CMQ Code of Ethics: «A physician must, when the death of a patient appears to him to be inevitable, act so that the death occurs with dignity. He must also ensure that the patient obtains the appropriate support and relief.» The working group noted that the CMQ’s own Code of Ethics indicated that MDs had a duty to provide support and relief at the end of life The group was considering patients near death. In these cases, no judgement is being made on whether this life is worth living. The patient is suffering and there is no hope this will change in the short period left. If it is an MDs duty to relieve suffering at the end of life, then MAID is a medical act (un soin).

Québec is the only jurisdiction in the world that explicitly defines MAID as a medical act (In Belgium, euthanasia is also considered a medical act, but it is not explicitly defined in law as such) There are several important implications of MAID being a medical act. Medical acts: are relational. Like any other medical act, MAID results from a decision-making process that happens in the context of a therapeutic relationship. can be regulated using the tools that regulate all of medical practice (e.g. consent and capacity, MD responsibility for the act). Additional protection: no SDM for MAID. suicide is not a relational act. Furthermore, MDs cannot assume appropriate responsibility for an act if they are not present, therefore assisted suicide is excluded. are the responsibility of the healthcare system and of the medical profession, not of individual MDs.

The Quebec Legislation Individuals who live in Quebec and meet the criteria for “medical aid in dying” under the Quebec legislation can access euthanasia through that legislation. They must “(1) be an insured person within the meaning of the Health Insurance Act; (2) be of full age and capable of giving consent to care; (3) be at the end of life; (4) suffer from a serious and incurable illness; (5) be in an advanced state of irreversible decline in capability; and (6) experience constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable” (s.26). Physicians who provide assistance must follow the rules of that legislation.

The Federal Legislation February 6, 2015: The Supreme Court of Canada unanimously overturns a legal ban on doctor-assisted suicide, ruling the law should be amended to allow doctors to help in specific situations. Sept. 30, 1993: The Supreme Court of Canada, in a 5-4 decision, dismisses the appeal of Sue Rodriguez, who has ALS (a.k.a. Lou Gehrig's disease) and wants a physician to help her die.  

The Carter Case (1/2) The British Columbia Civil Liberties Association (BCCLA) filed the case in April 2011 on behalf of Gloria Taylor, who suffered from ALS, Dr. William Schoichet, a family doctor, and Ms. Carter and Mr. Johnson, a married couple of Roberts Creek, B.C., who accompanied Lee’s 89-year-old mother, Kathleen (“Kay”) Carter, to Switzerland to peacefully end her life.

The Carter Case (2/2) The BCCLA lawsuit challenged both s. 14 and section 241(b) of Criminal Code (law that prohibits aiding a person to commit suicide), claiming they violated sections 7 (the right to "life, liberty, and security of the person) and 15(1) of the Canadian Charter of Rights and Freedoms (equality).[1]

At Issue Section 241 (b) of the Criminal Code says that everyone who aids or abets a person in committing suicide commits an indictable offence, and s. 14 says that no person may consent to death being inflicted on them. Together, these provisions prohibited the provision of assistance in dying in Canada.

Held The appeal should be allowed. Section 241 (b) and s. 14 of the Criminal Code unjustifiably infringe s. 7 of the Charter and are of no force or effect to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. The declaration of invalidity is suspended for 12 months.

Section 7 Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice. Principles of fundamental justice: Laws that impinge on life, liberty or security of the person must not be arbitrary, overbroad, or have consequences that are grossly disproportionate to their object.

The prohibition on physician-assisted dying infringes the right to life, liberty and security of the person in a manner that is not in accordance with the principles of fundamental justice. Since a total ban on assisted suicide clearly helps achieve this object, individuals’ rights are not deprived arbitrarily. However, the prohibition catches people outside the class of protected persons. It follows that the limitation on their rights is in at least some cases not connected to the objective and that the prohibition is thus overbroad.

In our view, nothing in the declaration of invalidity which we propose to issue would compel physicians to provide assistance in dying. The declaration simply renders the criminal prohibition invalid. What follows is in the hands of the physicians’ colleges, Parliament, and the provincial legislatures. … a physician’s decision to participate in assisted dying is a matter of conscience and, in some cases, of religious belief (pp. 95-96). In making this observation, we do not wish to pre-empt the legislative and regulatory response to this judgment. Rather, we underline that the Charter rights of patients and physicians will need to be reconciled.

From Justice Department http://www.justice.gc.ca/eng/cj-jp/ad-am/faq.html How is the legislation similar to or different from Quebec’s law? Canada Quebec Provision for both assisted suicide and voluntary euthanasia Permits only for voluntary euthanasia Eligibility criteria: intolerable suffering must be caused by the person’s medical condition Constant and unbearable suffering Natural death is "reasonably foreseeable” Patient must be "at the end of life”

Interactive Discussion Key Questions: What patient rights or obligations does the (applicable) legislation support? What key ethical issues do the clinical vignettes or cases illustrate?

Local directives and processes Provincial directives (if applicable) Health care institutions or region directives (if applicable) Describe the process by which patients: Can make a request for Medical Assistance in Dying. Will be assessed after having made a request for Medical Assistance in Dying. Describe who is charged with making the decision

Case 5.3.2 Providing Medical Assistance in Dying (MAiD) Case of Evelyn: What are the key ethical considerations that support the provision of MAiD? What are the key ethical considerations that challenge the provision of MAiD? How might MAiD change the physician-patient relationship, relate to the ‘ultimate goals of medicine’, and influence the dynamics of healthcare teams?

Key Ethical Considerations Suffering and death Subjective, context-dependant, relational Harms of physical/ psychological suffering of patient Provider comfort in discussing suffering and death Death as harm Autonomy Relational Patients’ right to self-determination/ to control timing and circumstances of death Concerns related to patient capacity/ vulnerable persons Physicians’ right to self-determination/ professional judgement/ obligations Dignity Personal dignity Human dignity

Key Ethical Considerations Physician-patient relationship Paternalistic model/ informative model/ interpretive model/ deliberative model Different power relationships Influenced by institutional structures Goals of Medicine Hippocratic Oath, saving and prolonging lives/ supporting patients wishes, values, and beliefs Team dynamics Role clarity Moral distress

Personal Reflections on MAiD What are you prepared to do? What are you willing or not willing to do?

Exploring personal perspectives on Medical Aid in Dying At the end of this workshop Were there any new perspectives or insights you gained? Are you able to have a discussion about the ethics of MAID with patients, colleagues or attending physicians? What concerns remain or are unresolved?

Conclusion This section could summarize the key issues related to the learning objectives for the workshop

Evaluation Two options Please take the next 5 minutes to complete the evaluation form developed for this workshop Send out a link to the evaluation form that would be completed post workshop anonymously (preferred)

Thank You