Posts Tagged ‘Euthanasia’

Around and about

December 19, 2019

A few interesting articles that have come my way in the past month or so:

  • At The New Atlantis, Aaron Kheriaty reviews the recent history of the spread of assisted suicide and euthanasia, with a special eye on how medical societies have aided and abetted the process by assuming a stance of neutrality toward these “procedures”.
  • In physics news, a new experiment in Germany has put an improved upper limit on the mass of neutrinos. For a long time it was thought they might be massless, like photons, but the discovery of neutrino oscillations implied that they must have some non-zero, albeit very tiny mass, and this new result assures us that they weigh no more than about 1/500000 of the mass of an electron. Still, this has interesting implications for cosmology.
  • Also in the physics world: the first detection of gamma-ray bursts by a ground-based telescope. Gamma-ray bursts are amazing astrophysical events that can release in 1 second as much energy as our sun will generate in its entire lifetime.
  • Some months ago, we read The Tale of Genji. A manuscript of a very early copy of a portion of the book was recently discovered.
  • A few years ago a big media splash was made by a study which found that children with religious upbringings were less generous then their unchurched counterparts. Since religion poisons everything, this result was reasonable, right? But it turned out that the data showed no such thing, and the study has been retracted. In fact, the associations of religiosity in childhood with psychological and social health measures generally run the other way.
  • Daniel Kennelly writes an engaging essay marking the 60th anniversary of A Canticle for Leibowitz.
  • At the New York Review of Books, Matthew Aucoin writes a fascinating account of Verdi’s two late Shakespearean masterpieces, Otello and Falstaff.

For an envoi, here is Desdemona’s “Willow Song” from Otello, sung by Rosanna Carteri in a 1950’s television production:

A constitutional right to palliative care

June 6, 2016

Starting today physicians in Canada can commit acts of assisted suicide and euthanasia without facing criminal penalties. The deeply flawed law proposed to regulate these “procedures” is still under debate in the Senate, so the present legal framework is murky. Looking for a silver lining in these dark clouds, I propose an argument I’ve not seen elsewhere.

In Carter v Canada the Supreme Court of Canada claimed to discover a right to assisted suicide (and euthanasia?) in the Canadian Charter of Rights and Freedoms, and more specifically in Section 7, which reads

Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.

Initially — and perhaps also persistently — it seems mysterious that the Court would seek to ground a right to death in a constitutional provision protecting the right to life, but here is the Court’s reasoning in the Carter decision:

The right to life is engaged where the law or state action imposes death or an increased risk of death on a person, either directly or indirectly. Here, the prohibition deprives some individuals of life, as it has the effect of forcing some individuals to take their own lives prematurely, for fear that they would be incapable of doing so when they reached the point where suffering was intolerable. The rights to liberty and security of the person, which deal with concerns about autonomy and quality of life, are also engaged. An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.

Focusing for a moment on the first part of the argument: the Court claims that a prohibition on assisted suicide violates the right to life because it forces some people to kill themselves before they otherwise would were assisted suicide permitted.

Let’s try to put this into the form of a syllogism:

(a) Forcing someone to kill himself violates his right to life.
(b) Failure to provide assisted suicide forces someone to kill himself.
(c) Therefore, failure to provide assisted suicide violates the right to life.

This reasoning is obviously tendentious — premise (b) is false — but for the moment let’s take it for granted. I want to suggest that this same reasoning implies that Canadians enjoy a constitutional right to palliative care.

The argument is simple: absent effective palliative care some individuals will be “forced” to kill themselves — whether directly or through activation of our newly-minted right to assisted suicide — earlier than they would had they access to palliative care. Therefore failure to provide such palliative care to Canadians violates their right to life. In the syllogism above, just replace “assisted suicide” with “palliative care”.

The other arguments deployed by the Court in the section above, pertaining to the rights to liberty and security of the person, are just as relevant to the case of palliative care: without access to palliative care Canadians cannot truly “make decisions concerning their integrity and medical care” (for at least one option for which they might decide is unavailable), and failure to provide palliative care abandons patients “to endure intolerable suffering” and so “impinges on their security of the person”.

Today only 16-30% of Canadians have access to palliative care.

Euthanasia update

April 14, 2016

Today the Liberals tabled their proposed legislation to regulate assisted suicide and euthanasia in Canada. I wrote about this issue a few weeks ago when a Parliamentary Committee issued a set of appalling recommendations to those drafting the law, and I had intended to return to the topic occasionally, but, alas, blogging is only my fourth job, and sometimes I don’t find the time.

The good news is that the proposed law ignores most of the recommendations from the Parliamentary Committee. It’s still a terrible law, inasmuch as it legalizes assisted suicide and euthanasia, but it is not as terrible as it might have been, and that is a significant victory. Almost all of the commentary in Canada’s leading papers over the past few weeks was critical of the original recommendations, and perhaps that helped. Many people have been working hard over the last month or two to convince Parliament to introduce safeguards and restrictions into the law, and they deserve some credit for the fact that we’re staring down a law that’s not quite as dire as it might have been.

The proposed law differs from the recommendations insofar as it restricts these “procedures” to adults, disallows advance directives, requires a minimum waiting period (15 days) except in exceptional circumstances, and places stricter requirements on who would be eligible (tending toward only terminal patients, although it doesn’t say so directly). The law — which I have not actually been able to find yet — is apparently silent on the issues of who will be coerced into participation and to what extent, leaving those details up to the provinces or the regulatory medical Colleges. The proposed law does apparently specify that regulations should “respect the personal convictions of health care providers.” What that will mean in practice is hard to say.

So, overlooking the fact that such a law cuts the heart out of the medical profession, undermines the oath each physician took, concedes that people have a constitutional right to require another to commit a grave evil, is confused about whether suicide is good or bad, accepts that killing is an acceptable response to suffering, and provides for a group of Canadian citizens to legally kill another group of Canadian citizens, we can be fairly pleased with this development.

UPDATE: Andrew Coyne, writing for The National Post, has been one of the most astute commentators on the euthanasia ruling and legislation. His column today is no exception. He argues that once one concedes that killing people (or helping them kill themselves) can be an act of beneficence it becomes impossible to impose restrictions on the practice. This is not even a slippery slope argument; it’s just a logical one:

For the logic of assisted suicide permits no other outcome. Once suicide has been accepted, as a formal matter of law, not as something we should wish at all times to prevent, but as relief from intolerable suffering; once it has been established that an individual has a right to such relief, not by his own hand but by another’s; once assisting in suicide has been transformed from a crime into a public service, there is no grounds to limit that relief, that right or that service to some sufferers and not to others.

I believe he is right about that. The sad game is, very probably, up. All in time.

A vulnerable persons standard

March 2, 2016

In an effort to get more and better safeguards for vulnerable patients into the forthcoming assisted suicide/euthanasia legislation, a Vulnerable Persons Standard was launched yesterday.

This Standard is consistent with the Carter ruling that legalized these “procedures” in Canada, but it proposes much tighter restrictions and better oversight in order to provide protection for patients who might request assisted suicide or euthanasia “when what they want and deserve is better treatment – to have their needs for care, respect and palliative and other supports better met.”

For those of us who are opposed to assisted suicide and euthanasia, this Standard can only be a half-measure. It cannot prevent all such “procedures”, but it may prevent some. Under the straitened circumstances imposed by the Supreme Court I see it as a morally praiseworthy initiative.

It has already attracted the support of numerous medical and legal organizations. (Full disclosure: my wife is one of the advisors to the Standard.)

Read the Standard here.

Pundits weigh in

March 2, 2016

Last week I wrote about the recommendations to Parliament made by a committee of MPs to guide legislation of assisted suicide and euthanasia in Canada. As I said then, the recommendations are irresponsible in the extreme. In the past few days, a number of responses to the Committee’s report have appeared in Canada’s leading newspapers, and I think it is worth drawing attention to them.

The Toronto Star, which is Canada’s largest left-leaning paper, was gently but unequivocally critical of the recommendations, seeing them as needlessly inflammatory and potentially dangerous:

Given the fraught nature of this file, compassion and caution, not compulsion, should be the government’s watchword as it goes ahead. A physician’s first duty is, after all, to do no harm.

A Toronto Star columnist, Thomas Walkom, also highlighted the apparent unwillingness of the Committee to consider the implications of its recommendations for the vulnerable. “Death, it seems, is easier.”

And just today — and frankly rather astoundingly — the Toronto Star has run an op-ed by Thomas Cardinal Collins, Archbishop of Toronto, arguing for conscience protections for doctors:

When the state goes beyond its legitimate but limited role and suppresses conscience rights, I am reminded of a man whose employer told him to do something against his conscience. He courageously replied: “You employ me; you don’t own me.”

Just before the recommendations were issued last week, the Globe & Mail ran a prescient column by Margaret Somerville of McGill University, who has been one of our leading public voices urging skepticism about the putative goods of assisted suicide and euthanasia. She focused on the Liberal Party’s plan to whip the vote on the grounds that assisted suicide and euthanasia are allegedly “Charter issues”:

This “hide behind the Charter” strategy resonates with an “obedience to higher orders” defence to wrongdoing (“it wasn’t my decision, I was forced to do it”), which the law has never accepted as valid.

Also in the Globe & Mail, constitutional lawyer David Baker and University of Toronto professor Trudo Lemmens have written a scathing critique of the Committee’s work:

Essentially all disabilities can be included in the open-ended criteria for access, extending the law beyond the persons with irreversibly declining capacities at the end-of-life that the Supreme Court ruled upon, and disregarding the court’s determination that “psychiatric disorders” were expressly excluded, as well as children, even if children would only have access three years after the new legislation is introduced. The committee further recommends access by advanced directive for people suffering from dementia, which most agree would create a practical and ethical minefield.

In the National Post, Andrew Coyne puts the Committee’s report in context, arguing that each step in the process of legalization of assisted suicide and euthanasia has extended the conditions under which it would be permitted:

So the court not only opened the door to assisted suicide, but opened it a little wider than it had been asked to. Nonetheless, it remained confident that the door would open no further. Indeed, the ruling arguably depended on it. The Crown’s case for retaining the prohibition, after all, had rested on the concern that the logic of assisted suicide would not permit it to be limited to the sort of narrow circumstances the court had in mind. Expert testimony was called on the experience in Belgium and other countries, where eligibility for assisted suicide has been extended to children, the mentally incompetent, and others.

The court found this sort of “anecdotal” evidence unpersuasive. These countries, it said, had a very different “medico-legal culture” than ours. In Canada, the “risks” of legalized killing could be limited “through a carefully designed and monitored system of safeguards.”

That was a year ago. The court’s ruling has not yet taken effect, and already we have the report of an all-party joint committee on “physician-assisted dying” recommending legislation that would go far beyond what the court prescribed.

Meanwhile, the Canadian Medical Association has expressed its disappointment with the Committee’s failure to recommend protections for health-care workers who refuse to participate in death-dealing. The CMA has consistently been strong on this point, opposing also the provincial medical colleges, such as those for Ontario and Saskatchewan, who have abandoned conscientious protections for their physicians.

There have been some hear-no-evil, see-no-evil responses to the Committee’s work as well, but all in all I take the above commentary to be broadly encouraging. There may yet be the will to override the Joint Committee’s awful recommendations.

Unassisted, Canada commits moral suicide

February 26, 2016

Last year the Supreme Court of Canada, in Carter v Canada, struck down legal prohibitions of physician-assisted suicide and euthanasia, alleging to have discerned a right to such procedures lurking somewhere in the background, unnoticed until now, of the Canadian Charter of Rights and Freedoms. The Court ordered Parliament to draft legislation to regulate these procedures, and gave it a deadline. Today the Special Joint Committee on Physician-Assisted Dying tabled its recommendations to Parliament, and, my friends, the situation is about as bad as it could be.

Two weeks ago, before the recommendations were public, our Prime Minister announced that all members of the ruling Liberal Party would be required to vote in favour of the legislation, whatever it turned out to be. This was the first indication that it was going to be very bad indeed.

As for me and my house, we have been fighting this every step of the way — writing editorials, writing letters, making phone calls, drafting submissions, attending meetings — and I must say that the Committee’s report is profoundly disappointing.

First a word about language. As usual with issues of this sort, euphemisms abound. The Committee adopts the phrase “medical aid in dying” to cover both assisted suicide and euthanasia, preferring it to “physician assisted dying”, which had been used by the Supreme Court. Both are highly objectionable, and for the same reason: they blur the distinction between palliative care, assisted suicide, and euthanasia. In this post I shall use the acronym ASE for assisted suicide and euthanasia.

The report makes 21 recommendations to legislators. Among them are:

  • ASE for minors. “Mature minors,” to be sure. The meaning of this phrase is unclear. It is worth noting that this recommendation is in direct conflict with the Supreme Court ruling, which restricted access to ASE to adults.
  • ASE for non-terminal conditions. Adopting the vagaries of the Supreme Court nearly word for word, the Committee recommends only that patients have a “grievous and irremediable condition”. The Committee actually recommends against Parliament clarifying what that phrase might mean.
  • ASE for psychiatric patients. There has been great concern over how patients suffering from psychiatric disorders might be treated under the incoming law. The Committee recommends both that psychiatric patients have access to ASE, and that psychological suffering be a legitimate criterion for accessing ASE.
  • No required waiting period. The Committee recommends that “guidelines” for “a period of reflection” be “flexible”. This puts at risk patients suffering acutely or terrified by a recent diagnosis.
  • No advance oversight. The Committee recommends against a review process where eligibility under the law could be assessed. This recommendation, if adopted, will make it very difficult to know if the law is being abused.
  • Public funding? This one is unclear. The Committee recommends that only individuals who are insured under Canada’s health care system have access to ASE — in other words, no euthanasia tourism — but it does not directly say that the procedures themselves should be insured.
  • Coercion of conscientious objectors. This is an issue that has been fiercely contested in the past couple of years in Canada, as many physicians have been fighting to carve out a space for themselves to practice medicine without being undermined by this assault on the principles of their profession. There are two targets here: individual physicians, nurses, and pharmacists on one hand, and Catholic hospitals on the other. Last year the College of Physicians and Surgeons of Ontario, which regulates the practice of medicine in Ontario (where I live), changed their policies on conscientious objection, henceforth requiring physicians to either provide the objectionable procedure or provide an “effective referral” to someone who would. But those who provide an “effective referral” — meaning a referral to someone who will do the procedure, and a referral for that express purpose — are complicit. Again, many physicians fought that policy change at the time, partly on the very grounds that the Supreme Court was about to rule on ASE, to which the new policy would apply. Those physicians were told they were alarmist and that everything would be fine. Now the Joint Committee has adopted exactly the same language as the Colleges did: “effective referrals” are to be required “at a minimum”. I’ve not seen that last phrase used in this context before, and I really wonder why it was included. It is very troubling. Also troubling is that institutions will not be permitted to abstain from performing ASE. If a patient is worried about being subjected to pressure to consent to ASE, there will be no safe hospital in Canada.

The report is also notable for what it does not recommend. It does not recommend a mandatory psychiatric assessment for those requesting ASE. It does not recommend that the cause of death (ASE) be put on the death certificate — though it does recommend that statistics on ASE be collected, so perhaps the legislation itself will mandate the former in order to facilitate the latter. It does not recommend that the next of kin of a patient who requests ASE be notified. It does not recommend that patients have access to palliative care before becoming eligible for ASE. All of these safeguards were advanced during the consultation process, but were apparently rejected by the Committee.

One safeguard which the Committee does recommend is that ASE can only be provided if two physicians sign off on it. But it could be any two physicians, not necessarily ones who know the patient well, and not necessarily the first two physicians consulted. In other words, patients can shop for physicians who will sign off.

All in all, an appalling set of recommendations that bodes exceeding ill. If these recommendations are adopted by Parliament — and they almost certainly will be — Canada will have the most radical ASE policies in the world. In particular, the requirement that conscientiously-objecting physicians provide an “effective referral” is not in force in any other jurisdiction, much less “at a minimum”.

We’ve got a bona fide fight on our hands.

The sole bright light is that a small group of four Committee members (including a vice chair) issued a dissenting opinion which is stapled to the back of the Committee’s official report. It is sensible and humane and I recommend that you read it.

**

If anyone is interested in learning about how Canada got into this mess, I recommend reading “A Right to Voluntary Euthanasia? Confusion in Canada in Carter,” John Keown’s scholarly overview of the court cases, and the principle arguments deployed therein, that eventually led to the Supreme Court’s decision last year. Or, if you prefer, here is a lecture in which he covers much of the same ground.