Autonomy for the individual, compassion for those who desire a good death, and respect for those who do not wish to participate in such practices.
Like many of the individuals involved in the medical assistance in dying (MAID) movement, I witnessed the horrible death of close relatives. In my case, one of these relatives died a lingering death from dementia and spent more than 1 year in the state commonly referred to as the infantile triad; namely, unable to speak, no awareness of who she was as a person, and incontinent of urine and feces. This is not the type of death that most Canadians, including me, would ever choose.
We know from surveys, including the Proust questionnaires published in the BCMJ, that most Canadians (and medical leaders) would prefer to die at home in their beds surrounded by their friends and family. My own father repeatedly asked me to help him die in the last 2 years of his life. The truth of the matter is that the vast majority of Canadians die in institutions after extensive medical interventions frequently without any family members or loved ones present.
Arguments have been made that if Canadians had universal access to palliative care that MAID would not be necessary. Although I and every person I know who is involved with the MAID movement is strongly in favor of universal and readily available palliative care, in the end all patients in palliative care will die, and it remains my view that it is the patient who should have control over the timing of his or her death—not a facility, an institution, or a doctor.
Elayne Shapray, one of the plaintiffs in the Carter v. Canada case, had worked as a volunteer in palliative care facilities, and when it came to her own death did not wish to die in a palliative care unit. After a heroic battle with multiple sclerosis she died this past spring with the assistance of a physician at a time and place of her choosing.
The fight to have patient autonomy as the primary principle in choosing an assisted death was first put forward by Sue Rodriguez before the Supreme Court of Canada in 1993. Despite there being no jurisdictions in which MAID was legal at the time, her request was denied by the surprisingly small margin of five to four.
When the same issues were again adjudicated by the Supreme Court of Canada in 2012, the court was unanimous (nine to zero) that it was a violation of Section 7 of the Canadian Charter of Rights and Freedoms to deny Canadians access to MAID under certain conditions—those conditions being that the individual was an adult, was competent, had an irremediable condition, and was enduring intolerable suffering as defined by the individual. “Irremediable” did not mean that the person had to accept every potential or possible treatment. We also know that the Carter ruling included individuals with a primary psychiatric diagnosis, as was adjudicated by the Alberta Court of Appeal in May 2016.
The Liberal government has now passed Bill C-14, which has narrowed the criteria established in the Carter case. The person must have a serious and incurable illness, they must be in an advanced state of irreversible decline, and their natural death must have become “reasonably foreseeable.” C-14 is already under court challenge in BC involving the case of a woman (age 25) with progressive muscular dystrophy. In my view, C-14 is not compliant with the Carter decision.
The principles I see underlying MAID are:
1. The autonomy of an individual in a free and democratic society to be able to make decisions concerning his or her death.
2. A compassionate attitude on the part of physicians to assist patients with a good death.
3. A respect for those individuals, both ordinary citizens and health care workers, who believe that they should not participate in such practices.
One of the unresolved areas of controversy is whether health facilities, primarily Catholic hospitals, which are funded entirely by public funds, should be able to opt out of providing services for MAID as they have with other publicly funded services such as abortion.
Fortunately in British Columbia we have physicians who have taken the lead in terms of providing MAID services across the province and in providing education for our colleagues who want to understand the issues and receive appropriate training. The story of MAID is unique to BC in that all of the patients, lawyers, and many of the judges involved in the Rodriguez and Carter cases are from British Columbia.
For physicians interested in providing MAID, I encourage you to review the policies of the College of Physicians and Surgeons of British Columbia and to consider joining the Physicians Advisory Council of Dying with Dignity Canada.
This article has been peer reviewed.
Dr Smith is a clinical professor emeritus with the Department of Psychiatry at the University of British Columbia. Dr Smith was an expert witness in the Carter v. Canada court case. He is on the board of Dying with Dignity Canada and the board of the World Federation of Right to Die Societies. He has testified before the House of Commons and the Senate in regard to Bill C-14.
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