Quebec Update (July 2013)

In March of 2012, Dying with Dignity, the report of a nine-member select

committee, was tabled in the Quebec National Assembly. The result of two years
work and extensive public consultation, the report contained 24 unanimous
recommendations on end of life issues, palliative care and euthanasia. While it
recommended that access to palliative care services be improved in Quebec it
also proposed that “medical aid in dying” be legalized to allow another option in
the continuum of end of life care. It found that Quebec is a secular society in
which autonomy is a universally accepted value and respect for life is now
relative.

Legislation implementing the recommendations of the report was tabled in the

Quebec legislature on June 12, 2013. The legislation defines “end of life care” as
“palliative care provided to persons at the end of their lives, including terminal
palliative sedation, and medical aid in dying.” It requires that every medical
institution in the province provide “end of life care”. The following criteria must be
met for a patient to obtain medical aid in dying:

(1) be of full age, be capable of giving consent to care and be an insured person
within the meaning of the Health Insurance Act
(2) suffer from an incurable serious illness;
(3) suffer from an advanced state of irreversible decline in capability; and
(4) suffer from constant and unbearable physical or psychological pain which
cannot be relieved in a manner the person deems tolerable.

The patient must request medical aid in dying themselves, in a free and informed
manner. Two physicians would be required to declare that these criteria are met.
Note that there are no criteria for terminal palliative sedation.

If physicians refuse to grant the request for physician assisted death, for any
reason other than the patient does not meet the criteria, they will be required to
transfer the form to the director of professional services of their institution or
health authority who will be required to find a doctor who will assess the request.

This legislation is controversial as the criminal law is a matter of federal

jurisdiction, and the government of Canada has declared its opposition to any
changes in the Criminal Code that would permit this initiative. A Quebec panel of
legal experts has suggested that Quebec could bypass the provisions of the
Criminal Code using the provincial jurisdictions of provision of health care and
administration of justice. Such legislation could result in a legal battle between
the governments of Quebec and Canada. Members are encouraged to write the
federal Attorney General to encourage him to challenge the legislation in the
event it is passed. One option for the Quebec government would be to instruct
their crown prosecutors not to prosecute cases in this area.

The report and the response of the government are disturbing for Christians in
general, and especially for Christian physicians in Quebec. Various groups have
spoken out against the legalization of physician-assisted death in that province,
including the organization Living with Dignity which is affiliated with the national
Euthanasia Prevention Coalition. (http://www.vivredignite.com/index.html) In
addition, a group called the Physicians Alliance for the Total Refusal of
Euthanasia, was formed and held a press conference on February 19th to
express physician’s concerns about the Dying with Dignity report. They are an
alliance of Quebec physicians who oppose legalization of euthanasia and
assisted suicide. One of their programs is a declaration of their commitment to
protect life,that all physicians may sign even if they do not work in Quebec.
http://www.totalrefusal.blogspot.ca/p/the-physicians-alliance.html Reports
indicate that 60% of the briefs and representations to the select committee were
opposed to legalization. Palliative care physicians are especially concerned
about the report’s characterization of “physician aid in dying” as just one
additional option in a continuum of palliative care therapies.

The objections to the recommendations of the Quebec report are the same as
those described in the June 2012 issue of Focus with reference to the Carter
case. CMDS members who are psychiatrists tell us that it is extremely difficult to
determine how cognitive impairment or depression in those who are experiencing
a serious, incurable disease affects their capacity to consent to premature death.
Physicians who are involved in end of life care know that the risk of coercion and
undue influence, both subtle and overt, is significant – from family, caregivers
and society in general. There is currently tremendous pressure in all of our
hospitals for services as the baby boom generation matures, and government
healthcare budgets experience what seems to be uncontrollable expansion. The
health care system operates within an ethos of saving life. What will happen
when society deems intentionally ending one’s life to be as virtuous as fighting
for one’s life? Can two different ethics be supported simultaneously, or will one
eventually win out over the other? (For an interesting discussion on how these
conflicting ethics might play out in medical school education see Dr. Donald
Boudreau of McGill University School of Medicine.
http://www.vivredignite.com/en/media/euthanasia_assisted_suicide.html)

The history of the legalization of abortion in Canada may provide a cautionary

note in this discussion. In 1969 legislation was passed in Parliament, which
legalized abortion only for therapeutic reasons. By 1988 this legislation was
struck down by the Supreme Court of Canada, partly because it was not being
implemented consistently across the country. By 2006 a CMAJ guest editorial
advised that it was not ethical for physicians to refuse to refer for abortion. (Our
members were among the most vocal critics of this article. The ensuing
controversy resulted in a clarification of this point by the CMA in favour of
conscientious objectors.) Nevertheless it is instructive to see that in two
generations we have migrated from tolerating the procedure in exceptional
circumstances, to full legalization, to people accusing conscientious objectors of
discrimination.
The experience of other jurisdictions that have already legalized physician-
assisted death is not reassuring. Credible research has uncovered numerous
examples of underreporting and non-compliance with protocols. A study of the
Flanders area in Belgium indicated that 32% of euthanasia cases were life-
ending acts without specific request of the patient. A 2010 British Medical Journal
study found that 47.2 % of physician-assisted deaths went unreported in
Flanders, and that that number was 20% in the Netherlands. In most
jurisdictions, physician self-reporting is the only method of official oversight.
Despite the aspirations of the report to develop an audit system in Quebec, the
practical challenges of “after the fact” investigating and the associated costs
would seem to foreclose on this aspect of the proposal as an effective option.

Christ explicitly incorporated the Ten Commandments into his teaching and
required adherence from his followers. (Lk. 18:20) As Jesus is the Son of God
and the fullness of the revelation of the Father, we know that these moral laws
apply to every human being. The person who takes a human life, even with the
consent of the patient, is saying that life in some cases is not worth living. This is
contrary to what we Christians know that God has said about each and every
human life. Once this line is crossed, where does it end?

Obviously, we cannot force others to follow our faith, even though we have a
deep commitment to its ultimate truth. What is open to us, however, in a
democratic society, is to join with other like-minded people to defeat this proposal
to safeguard the dignity of those vulnerable individuals who may be coerced into
ending their lives prematurely.

This includes finding ways to share with others that the sacredness of human life
is guaranteed by God and cannot be taken away by any legislative act or
committee report. This is an important challenge for all of us, as it impacts our
whole society, and the abiding ethos of the whole system of health care.