Intended for healthcare professionals

Take off the rose-coloured glasses. A response to Drs Buchman and Blackmer

In June 2016, Canadian legislation came into effect with Bill C-14 that legalized Medical Assistance in Dying (MAiD), a euphemism for euthanasia and physician-assisted suicide. In Canada, most cases of MAiD are via euthanasia, where patients’ lives are ended through a lethal injection of drugs administered by a physician or a nurse practitioner. Many palliative care experts object to the term ‘assistance in dying’ because that is what palliative care physicians already do by helping people to die well, without hastening or causing death. Nevertheless, the term was formally adopted by the government, and continues to contribute to confusion regarding palliative care and MAiD.

The President-Elect of the Canadian Medical Association (CMA), Dr. Sandy Buchman, a palliative care physician and euthanasia provider, has exacerbated this confusion further. In his recent invited BMJ essay (2), Dr. Buchman describes providing euthanasia as the most patient- centered way to relieve suffering. Dr. Buchman’s views are not consistent with the official policy of the CMA regarding palliative care (3), or the position of the Canadian Society of Palliative Care Physicians (CSPCP) and the majority of palliative care physicians in Canada who do not view euthanasia as part of palliative care. In a recent survey, CSPCP members strongly agreed that euthanasia is not part of the provision of palliative care. The vast majority (92% of 213 respondents) do not provide euthanasia (4). The CSPCP position that palliative care strives to reduce suffering, not to end life (5), is consistent with international standards for palliative care, such as the World Health Organization definition (6). CMA Policy on Palliative Care also recognizes that palliative care and MAiD are distinct (3).

Dr. Buchman romanticizes euthanasia. He calls it “the most patient-centered service I could offer,” leading to “the most peaceful death I had ever witnessed.” Peer reviewed, published evidence demonstrates that most requests for euthanasia are motivated by a desire for control, or a fear of dying, not by uncontrolled symptoms such as pain or shortness of breath (7). The patient Dr. Buchman refers to in his essay illustrates the existential, not symptom-based, risk factors involved. These existential issues include fear of loss of control, questioning the meaning, purpose and value of life, fear of what comes after death, demoralization, and fear of being a burden to others (8). None of these issues are properly addressed by euthanasia, and hastening the death of a patient removes any further therapeutic opportunities. Simply bowing to “patient autonomy” and ending a life without working hard to alleviate the deeper total pain is hardly “patient centered” in the most robust sense of that term. As Chochinov and Mount beautifully express, “…to be clear, palliative care is not a panacea that can eliminate every instance and every facet of end-of life suffering. However, the physician-patient relationship is complex and profound. Preserving dignity for patients at the end of life is comprised of a steadfast commitment to non-abandonment and a tone of care marked by respect, kindness, and an unwavering affirmation of patient worth.” (9).

The other group of citizens ignored in Buchman’s account are those whose lives are made even more vulnerable by the very existence of euthanasia, including those with disabilities, mental illness, dementia, children, seniors, and those who lack resources including financial, social supports, or access to palliative care. The Vulnerable Persons Standard (VPS) has been developed to provide standards for safeguards needed in Canada to protect those who are most vulnerable to coercion, or who feel that they have no other option than to choose to have their lives ended (10). Sadly, these very practical, broadly supported and meticulously documented recommendations for true “patient-centered care” have been dismissed and ignored by supporters of euthanasia and all levels of government. The few regulations that have been implemented, such as the requirement for capacity – both at the time of request and at the time of delivery of euthanasia, and a ten day waiting period between formal request and death, have no standard system of oversight to ensure compliance, and enforcement is essentially non-existent. There are no standardized training requirements for capacity assessment or psychiatric consultation for MAiD. Individual physicians or nurse practitioners are solely responsible to determine eligibility and whether or not to waive the ten day interval. The assessments for receiving government supported workers’ compensation or home oxygen are often more lengthy and stringent than those done in preparation for MAiD!

Drs. Blackmer and Buchman assert that the CMA supports physicians who refuse to participate in euthanasia (1,2). They fail to note that some provincial medical regulators, including the largest one in Canada with over 40,000 physician members, demand strict physician participation through “effective referral” (11), and that physicians who refuse such participation could be forced to withdraw from practice or lose their licences altogether. Some of these physicians are fighting a lengthy and expensive court battle to resist this coercion (12). A number of medical groups have supported these physicians by requesting intervener status in the case. The CMA has not.

Two and a half years after its legalization in Canada, strong lobbies are intensifying their push for euthanasia as a response to mental illness, physical disability, cognitively incapacitated patients through advance directives, and children. In Toronto, the Hospital for Sick Children has already drafted policy on providing euthanasia to mature minors (children felt to be capable of making their own medical decisions, despite not yet reaching the age of majority), anticipating a change in legislation later this year that would make euthanasia permissible for these children (13).

These developments, and the ongoing jeopardy faced by objecting physicians in Canada, contradict the optimistic, rosy assessment offered by Drs. Blackmer and Buchman. Other jurisdictions need to take a hard look at the reality of the Canadian context before holding Canada up as an example to be emulated.

Dr. Leonie Herx, Division Chair & Associate Professor of Palliative Medicine, Connell Chair in Palliative Medicine, Queen's University, Kingston, Ontario, Canada

Dr. Srini Chary, Associate Professor, Division of Palliative Medicine, University of Calgary, Calgary, Alberta Canada

Dr. Ed Dubland, Palliative Medicine Consultant, Burnaby, British Columbia, Canada

Dr. Robin Fainsinger, Professor, Division of Palliative Care Medicine Medicine, Edmonton, Alberta, Canada

Dr. David Henderson Palliative Medicine Consultant, Truro, Nova Scotia, Canada

Dr. Bernard Lapointe, Associate Professor, Departments of Oncology & Family Medicine, Director of Palliative Care, McGill University, Montreal, Quebec, Canada

Dr. Valerie Schulz, Professor, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada

1. Blackmer J. Commentary: How the Canadian Medical Association found a third way to support all its members on assisted dying. BMJ. 2019 Jan 30;364:l415.
2. Buchman S. Why I decided to provide assisted dying: it is truly patient centred care. BMJ. 2019 Jan 30;364:l412.
3. Palliative Care (Policy). Canadian Medical Association. 2016. Accessed on February 6, 2019: https://www.cma.ca/sites/default/files/2018-11/cma-policy-palliative-car...
4. Medical Assistance in Dying Member Survey (October 2017). Canadian Society of Palliative Care Physicians (CSPCP) 2018 February. Accessed on February 6, 2019: https://www.cspcp.ca/wp-content/uploads/2018/02/CSPCP-MAID-survey-report...
5. Key Messages: Physician-Hastened Death. Canadian Society of Palliative Care Physicians (CSPCP) 2015, October. Accessed on February 6, 2019: http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf
6. WHO Definition of Palliative Care. Accessed on February 6, 2019: https://www.who.int/cancer/palliative/definition/en/
7. Palliative Care (Policy). Canadian Medical Association. 2016. Accessed on February 6, 2019: https://www.cma.ca/sites/default/files/2018-11/cma-policy-palliative-car...
8. Rodríguez-Prat A et al. Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open. 2017 Sep 29;7(9):e016659. Accessed on February 6, 2019: https://bmjopen.bmj.com/content/7/9/e016659.long
9. Chochinov, H. Dying, Dignity, and New Horizons in Palliative End‐of‐Life Care. CA: A Cancer Journal for Clinicians. 2006; 56: 84-103. doi:10.3322/canjclin.56.2.84
10. Chochinov H, Mount B. Physician Hastened Death: Awaiting a Verdict. CMAJ Blog. 2014 October, 14. Accessed on February 6, 2019: https://cmajblogs.com/physician-hastened-death-awaiting-a-verdict/
11. Vulnerable Persons Standard. Accessed on February 6, 2019: http://www.vps-npv.ca/
12. Medical Assistance in Dying (Policy). College of Physicians and Surgeon of Ontario. 2016 Accessed on February 6, 2019: https://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-i...
13. Leiva, R et al. Euthanasia in Canada: a cautionary tale. World Medical Journal. 2018 64(3):17 Accessed on February 6, 2019: https://www.wma.net/wp-content/uploads/2019/01/wmj_4_2018_WEB.pdf
14. DeMichelis C, Zlotnik Shaul R, Rapoport A. Medical Assistance in Dying at a paediatric hospital. J Med Ethics. 2019 Jan;45(1):60-67.

Competing interests: No competing interests

08 February 2019
Leonie Herx
Associate Professor of Palliative Medicine
Srini Chary, Ed Dubland, David Henderson, Bernard Lapointe, Robin Fainsinger, Valerie Schulz.
Queen's University
Division of Palliative Medicine