Commentary: How the Canadian Medical Association found a third way to support all its members on assisted dyingBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l415 (Published 30 January 2019) Cite this as: BMJ 2019;364:l415
For many years, the Canadian Medical Association (CMA) has followed the public debate in Canada on assisted dying and voluntary euthanasia. (In assisted dying, doctors prescribe drugs that eligible patients themselves choose to take to hasten their death. In euthanasia, professionals administer the drugs.)
Both subjects are extremely controversial and divisive, particularly for an organisation like the CMA. It represents almost 90 000 physicians, who hold wide ranging views on assisted dying. The CMA’s initial policy was that assisted dying and euthanasia were illegal in Canada and that physicians should not participate.
In 2013, a case was working its way through the Canadian judicial system.1 Kay Carter had severe spinal stenosis and travelled to Switzerland to obtain assisted dying. Her family subsequently challenged the federal Canadian law banning assisted dying as unconstitutional.
Important to be involved
This case had the potential to change the law in Canada, and the CMA decided it was important to be involved. It hosted public meetings on end-of-life care, and consulted extensively with its membership, including about terminology, palliative care, advance care planning, and medical assistance in dying (MAID, which includes both assisted dying and voluntary euthanasia). Although views were divergent, the consensus was clear: Canada needed a framework to protect vulnerable patients.
The CMA recognised that its policy needed to evolve: if the law were to change, the organisation would support all its members, regardless of their views, in deciding whether to participate in MAID. This was a watershed moment, enabling the association to lead national discussions and to give evidence before Canada’s Supreme Court.
In 2015, the Supreme Court ruled on the Carter case, finding that federal law prohibiting assisted dying was unconstitutional.2 The court gave the government 12 months to draft new legislation, later extended to 16 months.
Supporting conscientious objection
The court referenced the CMA’s position to provide equal support for conscientious participation and conscientious objection, stating, “Nothing . . . would compel physicians to provide assistance in dying. The declaration simply renders the criminal prohibition invalid.”
The CMA spent 16 months meeting with legislators, regulators, government officials, and others to help represent the diversity of views in the medical profession. It developed recommendations to help guide the implementation of MAID.3 In addition, it participated in federal and provincial government consultations to represent the wide ranging perspectives of the medical profession.
The association also spent many hours advocating for members who did not want to be forced to participate in MAID in any way, including by referring a patient to another physician for this intervention. The Supreme Court in its ruling quoted from the CMA’s submission and clarified that no healthcare practitioner should be forced to participate against his or her wishes.
Legal assisted dying is not entirely settled in Canada. The country is still examining MAID for patients whose only diagnosis is mental illness and for mature minors, as well as the use of advance directives, for example.
When the legislation was passed in 2016, it was entirely consistent with the CMA’s policy. It contained provisions to protect potentially vulnerable patients (for example, a waiting period between the decision and implementation of MAID and the requirement to use fully independent witnesses for the documentation). It also contained clarification on who would qualify for MAID (the patient’s death would have to be “reasonably foreseeable.”)
As part of the CMA’s ongoing efforts to support physicians who choose to participate in or provide MAID, it has also introduced an accredited education programme to ensure understanding, compliance with the legislation, and excellence and competency in care.
Definitions under dispute
Proponents and opponents of assisted dying do not all agree on the terminology used to describe the process.
Assisted dying—Proponents of the Assisted Dying Bill 2015 in England and Wales argue that this term best describes prescribing life ending drugs for terminally ill, mentally competent adults to administer themselves after meeting strict legal safeguards. Assisted dying, as defined like this, is legal and regulated in the US states of Oregon, Vermont, Washington, Montana, Hawaii, California, and Colorado, and in Washington, DC. In 2017, similar legislation was passed in Victoria, Australia
Assisted suicide—This term is often intended to describe giving assistance to die to people with long term progressive conditions and other people who are not dying, in addition to patients with a terminal illness. The drugs are self administered. Some opponents of assisted dying do not accept that it is different from assisted suicide. Assisted suicide, as defined like this, is permitted in Switzerland
Voluntary euthanasia—This term describes a doctor directly administering life ending drugs to a patient who has given consent. Voluntary euthanasia is permitted in the Netherlands, Belgium, and Luxembourg. In 2016, Canada legalised both voluntary euthanasia and assisted dying for people whose death is “reasonably foreseeable,” in what it calls “medical assistance in dying” (MAID)
For all The BMJ’s content on assisted dying see bmj.com/content/assisted-dying
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.