Final uncertainty

The February 2015 Supreme Court of Canada decision in Carter v. Canada will soon result in legal and regulatory changes to how we, as physicians, can legally assist patients, who are experiencing “grievous and irremediable” pain and suffering, with the process of dying. Many of us will applaud the fact that our terminal patients have been granted the right of self-determination to end life as an option to palliative care. For many patients, the knowledge of that option may be comfort enough. However, the decision does not limit physician-assisted dying to terminally ill patients, and here many of us will have a high degree of trepidation—despite arguments from public figures such as Stephen Hawking that “to keep someone alive against their wishes is the ultimate indignity.”

Physician-assisted dying has, until recently, been one of those unspeakable acts that could only be discussed with our closest colleagues, not for fear of being found in breach of the law or being labeled Kevorkian but because it is so contrary to the core of our professional practice, which is to preserve both the quality of life and life itself.

How many of us have sat with families by the bedside of our terminally ill patients whispering the welcome of death? Until now it has only been acceptable to take a passive approach to the termination of life, either through withdrawal of treatment and life support or conscious over-palliation. One could argue that this amounts to nothing but moral refuge from an active physician-assisted dying process. However, at the time of writing, this process is still fraught with many uncertainties:
•    What, precisely, is meant by “grievous and irremediable,” and who decides the threshold for physician-assisted dying eligibility?
•    Could the term “adult” be interpreted to include mature minors?
•    How and where will physician-assisted dying be delivered and what safeguards must a physician apply?
•    Will standards be uniform across Canada?
•    Will physician-assisted dying need to be recorded on the death certificate?
•    Will the patient’s life insurance be protected?
•    How will the rights of physicians who conscientiously object be protected?

In addition to answers to the questions set out above, many of us will be looking for associated assurances:
•    Will the requirement for patients to remain mentally competent at all times accelerate requests for physician-assisted dying to preempt loss of competence?
•    Will those who are ill and dying feel pressured to choose a physician-assisted death to lessen the burden on their families?
•    Will there be assurance of good access to palliative care and that physician-assisted dying will not become a cheap and quick alternative?

This is one of the most controversial and professionally challenging issues of our careers and currently well beyond the skillset of individual practitioners. Its implementation will require a continuum of supports and services. Let’s hope these services and supports accompany regulations and guidance before the Supreme Court–imposed deadline of 6 June 2016.   
—WRV