Abstracts: Volume 36, Number 3

February 2016

The Carriage of Death: What kind does Canada have?
By Louise R. Sweatman and M. Jasmine Sweatman
Using a carriage of death metaphor, based on Emily Dickenson’ poem Because I Could Not Stop for Death, the authors highlight the development of the last 40 years of the Canadian legal landscape and end of life decision making.  Beginning with the Canadian Criminal Code, moving through the Rodriguez decision and ending with the recent 2015 Carter decision they explore how the evolution of time has influenced Canada’s highest court. The authors conclude with an exploration of advance care directives and what we may expect as Canada continues its travels down this road.

Enabling choice: Aid in Living as a Predicate to Aid in Dying
By Tom Koch
In February 2016 the Canadian Supreme Court argued in a unanimous decision that criminal statutes prohibiting physician assisted or directed termination violated the Charter of Rights and Freedoms. In the unanimous judgment they argued that the promise of “life, liberty, and sanctity of person” in Section 7 enshrined patient choice as a principal Canadian virtue. But for choice to be real that requires a set of predicate conditions assuring fragile Canadians have free and ready access to a range of medical services including, in a partial list: expert counseling, home care aides, palliative treatment, rehabilitative services, and social support for themselves and familiar caregivers. Where those are absent choice is illusory and the promise of real choice illusory.

Carter v. Canada (Attorney General): will the Supreme Court of Canada’s decision on physician-assisted death apply to persons suffering from severe mental illness?
By Barbara Walker-Renshaw and Margot Finley
In this article, the authors address the question of whether the Supreme Court of Canada’s decision in Carter v. Canada (2015 SCC 5) leaves open the possibility that persons with severe, treatment-refractory mental illness may lawfully seek a physician-assisted death. If so, how will health care providers distinguish between suicidal ideation and intent that is a symptom of the pathology of a treatable mental illness, on the one hand; and suicidal ideation and intent that is, perhaps, a capable and thoughtful response to a “grievous and irremediable” condition, on the other hand? Mental illness is the most common risk factor for suicide. If physician-assisted death becomes an accepted practice in mental health care, how will that be reconciled with the well-established impetus in mental health care to prevent suicide? The authors consider the competing ethical values of beneficence and promoting patient autonomy, in the context of the recovery movement in mental health care.

Checklist for Legislators: Towards a Canadian Approach to End of Life Choices
By Gerald Chipeur
In this article, the author reviews Supreme Court of Canada and European Court of Human Rights case law to identify the factors the Parliament of Canada should take into account when it creates legislation regulating physician-assisted suicide. He also highlights the Criminal Code provisions that currently govern the provision of assistance in a suicide. The author concludes that the Charter of Rights and Freedoms requires a unique Canadian approach to the subject of physician-assisted suicide, an approach that provides adequate safeguards to protect the vulnerable, adequate oversight to ensure transparency and adequate accommodation for the ethical and moral concerns of physicians to respect their human rights.

Commentary: The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada
By Amir Attaran

Scrupulous monitoring of physician-assisted dying: The case for mandatory reporting to coroners and medical examiners of all physician-assisted deaths in Canada
By Juliet Guichon, Pauline Alakija, Christopher James Doig, Ian Mitchell and Pascal Thibeault
Although the practice of physician-assisted dying (hereinafter “PAD”) will soon be lawful in Canada, opponents of PAD claim that it might result in involuntary deaths. The Supreme Court of Canada in Carter v. Canada (Attorney General) rejected such arguments holding that involuntary deaths are preventable provided that jurisdictions devise stringent limits to the practice of PAD and that these stringent limits are “scrupulously monitored and enforced”.  This paper examines the question of how best to engage in scrupulous monitoring of physician-assisted dying. At present, the province of Quebec has legislated, and three expert groups have proposed the creation of new administrative offices to monitor the practice of PAD (these groups are the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying, the External Panel on Options for a Legislative Response to Carter v. Canada, and the Canadian Medical Association).  This paper argues that scrupulous monitoring can be better achieved by requiring explicit mandatory notification of all physician-assisted deaths to coroners and medical examiners, rather than by creating new administrative offices. It is more effective, efficient and prudent to use already existing coroner and medical examiner death reporting and investigative frameworks to report physician-assisted deaths than to create new, untried, parallel and potentially more expensive administrative offices. In Canada, almost all provincial and territorial statutes that govern the official actions of coroners and medical examiners currently require the reporting of non-natural deaths which include those that will be attributable to PAD. To achieve the scrupulous monitoring of PAD required by the Supreme Court, provincial and territorial governments, in collaboration with the federal government, should:

  1. review their coroner and fatality statutes to clarify that physician-assisted deaths (as non-natural deaths) are mandatorily notifiable;
  2. encourage forensic pathologists to collaborate on a national basis to agree upon uniform methods of death reporting and monitoring of PAD; and
  3. mandate that coroner and medical examiners offices should be adequately funded and staffed for the new task (which is likely to increase only marginally the caseload in accurate death reporting and monitoring).

Such actions will ensure the continued achievement of the legislative goals for coroner and medical examiner offices: to report deaths accurately and to investigate and monitor death for the purposes of protection, prosecution, prevention, health promotion and health planning. By ensuring that PAD is reportable to the statutorily-created offices that are expert in accurate death reporting, the public may be better assured that the new practice of PAD is used only to relieve suffering as permitted by law.

Suivi scrupuleux de l’aide médicale à mourir: Le cas de la déclaration obligatoire aux coroners et aux médecins légistes de tous les décès assistés par un médecin au Canada
Juliet Guichon, Pauline Alakija, Christopher James Doig, Ian Mitchell and Pascal Thibeault
Bien que la pratique de l’aide médicale à mourir (ci-après «AMM ») sera bientôt légale au Canada, ses opposants continuent d’affirmer que l’AMM pourrait entraîner des décès involontaires. Dans Carter c. Canada (Procureur général), la Cour suprême du Canada a rejeté ces arguments en soutenant que les décès involontaires sont évitables à condition que les gouvernements élaborent des limites strictes à la pratique de l’AMM et que ces limites soient « scrupuleusement surveillées et appliquées ».

Ce texte explore la question de la surveillance scrupuleuse de l’aide médicale à mourir. À l’heure actuelle, la province de Québec a légiféré et trois groupes d’experts ont proposé la création de nouveaux bureaux administratifs afin de surveiller la pratique de l’AMM (ces groupes sont le groupe consultatif provincial-territorial d’experts sur l’aide médicale à mourir, le comité externe sur les options de réponse législative à Carter c. Canada et l’Association médicale canadienne).

Cet article soutient que la surveillance scrupuleuse serait mieux assurée en exigeant de façon explicite la notification obligatoire aux coroners et aux médecins légistes de tous les décès assistés par un médecin, plutôt que de confier celle-ci à de nouveaux bureaux administratifs. À notre avis, il est plus efficace, efficient et prudent d’utiliser les institutions et les professionnels qui sont déjà en place que de créer de nouveaux bureaux parallèles, inexpérimentés et potentiellement plus coûteux que les organismes préexistants. Au Canada, presque toutes les lois provinciales et territoriales qui régissent les coroners et les médecins légistes exigent déjà la déclaration obligatoire des décès non naturels, ce qui inclut ceux qui seront attribués à l’AMM.

Pour réaliser le suivi scrupuleux de l’AMM requis par la Cour suprême, les gouvernements provinciaux et territoriaux en collaboration avec le gouvernement fédéral doivent :

  1. revoir leurs lois régissant les coroners et reliées à la mortalité afin de clarifier que les décès assistés par un médecin (en tant que décès non naturels) doivent obligatoirement être déclarés ;
  2. encourager les médecins légistes à collaborer sur une base nationale afin de s’entendre sur une méthode uniforme pour rapporter les décès et pour surveiller l’AMM ; et
  3. mandater que les bureaux du coroner et du médecin légiste doivent être adéquatement financés et dotés du personnel nécessaire afin d’accomplir cette nouvelle tâche (qui est susceptible de n’augmenter que de façon marginale le nombre de cas nécessitant d’être rapportés et suivis)

De telles actions permettraient de continuer d’assurer la réalisation continue des objectifs législatifs pour les bureaux du coroner et du médecin légiste, c’est-à-dire: de rapporter avec exactitude, d’enquêter et de surveiller les décès à des fins de prévention, de protection ainsi qu’à des fins de promotion et de planification de la santé. En veillant à ce que l’AMM soit signalée aux bureaux déjà créés et qui sont experts dans le traitement des rapports concernant les décès non naturels, le public pourra être assuré que la nouvelle pratique de l’AMM est utilisée seulement afin de soulager la souffrance, et ce en conformité avec la loi.

Navigating “Assisted Dying”
By Harvey Schipper
Carter is a bellwether decision, an adjudication on a narrow point of law whose implications are vast across society, and whose impact may not be realized for years. Coupled with Quebec’s Act Respecting End-of-life Care it has sharply changed the legal landscape with respect to actively ending a person’s life. ‘Medically assisted dying’ will be permitted under circumstances, and through processes, which have yet to be operationally defined. This decision carries with it moral assumptions, which mean that it will be difficult to reach a unifying consensus. For some, the decision and Act reflect a modern acknowledgement of individual autonomy. For others, allowing such acts is morally unspeakable.

Having opened the Pandora’s Box, the question becomes one of navigating a tolerable societal path. I believe it is possible to achieve a workable solution based on the core principle that ‘medically assisted dying’ should be a very rarely employed last option, subject to transparent ongoing review, specifically as to why it was deemed necessary.

My analysis is based on:

  1. The societal conditions which have fostered demand for ‘assisted dying’.
  2. Actions in other jurisdictions
  3. Carter and Quebec Bill 52
  4. Political considerations
  5. Current medical practice

Leading to a series of recommendations regarding:

  1. Legislation and regulation
  2. The role of professional regulatory agencies
  3. Medical professions education and practice
  4. Public education
  5. Health care delivery and palliative care

Given the burden of public opinion, and the legal steps already taken, a process for assisted dying is required. However, those legal and regulatory steps should only be considered a necessary and defensive first step in a two stage process.

The larger goal, the second step, is to drive the improvement of care, and thus minimize assisted dying.

Assisted Death: The Risks and Benefits of Tribunal Approval
By Mark Handelman
Should every request for physician-assisted death require approval from some kind of independent tribunal? The benefits include consistent interpretation of statutory or judge-created guidelines from hospital to hospital, accurate reporting of assisted deaths, a process that protects vulnerable patients and health practitioners, and assurance to the public that the process has sufficient safeguards. On the other hand, such a process might cause delays for persons suffering intolerably. Accessibility might be a problem and there is the risk that the patient’s personal health information becomes fodder for media sensationalism. The author weighs these risks and benefits and concludes that a tribunal approval process is a transparent system capable of helping the law clearly gel in a way that provides guidelines, encourages trust in the healthcare process generally and the assisted death process specifically.

Québec’s Medical Aid in Dying, An Inspiration for Other Canadian Jurisdictions?
By Daniel Boivin and Julie Barrette
Soon, physicians across Canada will be permitted to assist patients in dying, provided certain conditions are met. Physicians in the province of Québec can already provide this service since December 10, 2015. While Québec has been studying the question of legislating medical aid in dying since 2009, the rest of the country must come up with legislation on this issue within the next few months. This article suggests that other Canadian jurisdictions, federally and provincially/territorially, may find inspiration in the extensive work done in Québec leading to its end of life legislation, including on the issues of identifying proper safeguards to protect vulnerable people and eligibility criteria that could be put in place in these jurisdictions. The Québec model could be particularly useful in regard to the approach to balancing physicians’ rights of conscience with patients’ constitutional right to access medical aid in dying

Federal and Provincial Responsibilities to Implement Physician Assisted Suicide
By David Baker, Rebeka Lauks and Gilbert Sharpe
In the most significant constitutional decision of the last generation, Carter v. Canada, the Supreme Court of Canada reversed itself and decided that it was possible for Parliament to enact safeguards that would be adequate to protect persons who are vulnerable in times of weakness, then proceeded to declare that Canadians were entitled to a s. 7 Charter right to physician assisted death. David Baker and Gilbert Sharpe accepted the challenge issued by the Court and drafted a Bill to amend the Criminal Code in a manner they believed would strike a constitutional balance between providing access to the right declared by the Court and protecting the vulnerable. This article represents their attempt, along with co-author Rebeka Lauks, to explain many of the key provisions in their draft. Amongst the most noteworthy are their attempts to ensure that those choosing PAD are informed about quality of life, as well as treatment choices; to define vulnerability and to install safeguards adequate to protect persons while vulnerable and finally a prior review process that would ensure both ready access to the Charter right declared by the Court and consistent and transparent application of the law. The authors have attempted to establish an alternative model to that currently in effect in the Benelux country which they regard as having been ineffective in achieving any of these objectives.