As I mention in an earlier blog post, the Supreme Court of Canada, in the case Carter vs. Canada, unanimously determined that an absolute prohibition on Physician Assisted Death violates the Charter of Rights and Freedoms. Currently this service is accessible only through exemption from a superior court judge, but it is anticipated that this legal requirement will also disappear by June 6, 2016. The College, not content to leave physicians of Ontario without guidance, has published its Interim Guidance on Physician-Assisted Death in the current issue of Dialogue, Volume 12, Issue 1, 2016.
The document lays out professional and legal obligations, criteria for PAD, and guidance on the practice related issues. It reminds us first that ‘professionalism’ in the medical context includes compassion, service, altruism and trustworthiness, the key values which are the foundations of medical teaching to this day.
These values are reflected in the behaviors we all expect from of physicians: respecting patient autonomy, ensuring all patients receive equitable access to care, communication effectively and sensitively in a manner supporting the patients’ autonomy, and demonstrating competence (clinical, legal and professional).
From the Interim Guidance, it is possible and probably necessary to create a checklist:
- The patient must be a competent adult;
- The patient clearly consents to termination of life (this presumes they are informed);
- The patient has a grievous and irremediable condition (illness, disease, or disability); and
- The patient experiences enduring suffering that is intolerable to them.
The checklist can continue as a form of process map:
- First request is to the attending physician, whereupon the attending physician either refers to someone for this service or assesses the patient to ensure that criteria 1. through 4. have been satisfied;
- The physician reminds the patient they have the ability to rescind the request at any time;
- The attending physician finds that the patient meets these criteria, and documents the assessment with the date of the first request. If the physician finds that the patient does not meet criteria 1. through 4., the patient is entitled to make a request of another physician, who would then follow this procedure.
- A period of reflection follows, the length undefined;
- The patient makes a second request, which requires formal documentation;
- The patient’s written request, or transcribed oral request must be dated and signed by the patient, countersigned by an independent witness, and signed by the physician;
- A second consulting physician must again follow criteria 1. through 4., 6. and 7.;
Options of Service
- The patient may be given the prescription for a fatal dose of medication to take at home, or receive voluntary euthanasia administered by the physician;
- In the former case, patient and caregivers must be educated with respect to safeguarding the medication and ensuring that the process can actually be managed by the patient. Additionally, the physician must educate the patient and caregivers on what to expect;
- Physicians should consult Ontario government for guidance with respect to completion of the death certificates.
Frequently Asked Questions
The College document is supported by a section in the Journal issue referred to as ‘College’s bridging document on physician-assisted death’ starting on page 9. This has obviously been a contentious issue, and the article includes an FAQ.
There is important discussion of age (physicians are pretty used to this being fuzzy, recognizing the wide variation) which incorporates capacity and maturity, especially when the patient is less than 18 years of age.
Grievous and irremediable is more commonly a legal term, but the important issue for physicians is that imminent death is not a requirement, nor is the patient required to follow advice or treatment recommendations of physicians for their condition to be determined irremediable.
Intolerable suffering is determined by the patient, reminding me of Dr. Balfour Mount’s famous statement, “Pain is what the patient says it is, when the patient says it is.”
Capacity is required to the end; the patient must be in a state of being capable of declining the service and rescinding the order until the treatment is given successfully completed.
No patient is to be excluded from this service by virtue of mental illness; rather the important issue is their capacity to comprehend, and to receive and understand in order to provide informed consent.
The College does not address the concern of objecting family members in their document, but our Canadian Medical Protective Association is fully aware of the issues, and is willing to provide help to physicians facing such difficulties.
This issue has perhaps raised some of the greatest concerns among a small section of physicians and general public. In the extreme, it has been argued that some physicians who object to providing this service also object to discussing it with patients or referring to others who would do so.
Notwithstanding those objections, the College does indicate what it considers to be the appropriate response of such a physician:
- The physician must respect the patient’s dignity.
- Physicians must not impede access to PAD even if it conflicts with their religious beliefs.
- Physicians must communicate their objection directly to the patient, and do so with sensitivity, pointing out that this decision is their personal decision, not a clinical decision for the patient.
- Physicians must not express personal moral judgments about the patient’s beliefs, lifestyle, identity or character.
- Physicians are required to provide information about all options for care that may be available; they must not withhold information about the existence of any service because it conflicts with the physicians’ conscience or religious beliefs.
- The physician is required to make an effective referral to a non-objecting, available and accessible physician or agency.
- Patients must not be exposed to adverse clinical outcomes due to delayed referral.
The message here is clear. Physicians may not rely on their conscience or their religious beliefs to avoid compliance with this guidance. The will of the people and importantly, the patient, take precedence over any conscientious or religious objection, frankly, very much as is required for abortion services.
My other blog has referred to the inflammatory and insensitive reference to PAD or euthanasia as ‘killing’, a word that seems to be used by the religious leaders as a means of imposing their authority over the issue. In addition, it is clear that the act of referring a patient to another physician does not ensure that PAD will actually take place. In fact, my impression is that the availability of PAD will actually go on to save lives, as one of my friends wrote to me the other day (thank you J. McG.) because the knowing of this option being readily available will help the patient endure trials of other treatments.
And for those physicians who cannot comply? In my opinion, your options are clear. Either you remove yourself from the conflict, or you lie and pray that nobody ever complains, because if you willfully fail your patient with regard to this guidance, you expose yourself to the allegation of professional misconduct.
Of course, there is a second problem for conscientious objectors who cannot compromise and do not withdraw themselves from the conflict (practice in areas of medicine where they can never be asked for this such as pathology, laboratory services, maybe radiology). If they think this through carefully, they can never refer to a physician who is a non-objector, lest that lead to offering the service of PAD against their conscience or religious beliefs. Is ignorance of the beliefs of the consulting physicians a reasonable defence? Not inside their conscience or religious beliefs, it isn’t.
I hope the conscientious objectors do compromise enough to refer these patients to others, realizing that the patient may not choose PAD. I know some of these doctors personally, who are fine physicians. We will have patients and families in our midst who object to this type of service because of religion and other beliefs, and it is important that the population of physicians reflects the population at large. The conscientious objectors provide services to these and many others, and while I may disagree with their premises and conclusions, I cannot dispute their discipline or integrity on the basis of their beliefs.
I hope that the understanding of PAD as a comforting option (that may actually help patients to take some ease in their end-of-life decisions) even if their patients never use PAD, will allow the conscientious objectors to accept what may be the greater good: that they compromise by making effective referrals and continue to provide the excellent care that all our patients deserve, thereby helping that many more.