The fight for the right to die

Canada’s first assisted-suicide law draws fire in Quebec

Quebec Minister Véronique Hivon. (Fred Lum / The Globe and Mail / CP)

Quebec is on the cusp of allowing its doctors to actively participate in the death of terminally ill patients by way of lethal injection. Long the crucible of the country’s thorny ethical questions, abortion included, the province would be the first in Canada, and one of the few places in the world, where such a thing would be legal. And the proposed law pits Quebec against the federal government, which considers legal injection to be assisted suicide, a violation of the Criminal Code.

The bill, which received all-party consent upon its introduction this past summer, provides the legal framework by which a doctor may provide “end-of-life care” to a terminally ill patient. The patient must be of legal age, suffer an “incurable serious illness” and “irreversible decline in capability” resulting in “constant and unbearable pain.”

If Quebec’s legislation passes—it was adopted in principle this past week, and barring an election will likely become law—it will be “a template for the rest of the country,” said Wanda Morris, executive director of Dying With Dignity, a British Columbia-based right-to-die group. “If Quebec does this, and people see that it works and are happy with it, then I think much of the country would look to it and say that is something we need.”

The right for a terminally ill patient to choose his or her own time and means of death has broad support in the province, which is arguably the most socially liberal in the country. A recent Environics poll suggested 79 per cent of Quebecers support euthanasia, compared to 68 per cent in the rest of the country. Quebec’s college of physicians was an early backer of the right-to-die legislation, and it has the support of its associations of medical specialists and general practitioners—though, notably, not of its palliative caregivers, the very people charged with caring for the terminally ill.

Parti Québécois MNA and junior health minister Véronique Hivon spearheaded the legislation in 2009, and spent much of the last four years in consultation with doctors, patients, ethicists and the general public before introducing the bill in June. “An act respecting end-of-life care” (the official name of the bill) is a first in many ways. It not only lays the legal groundwork for doctor-assisted suicide, it equates the practice with “terminal palliative sedation,” a practice in which a terminally ill patient is induced into a coma, alleviating their pain while they die. Though TPS, as it’s known, is a medically accepted practice, few jurisdictions legislate how it can be used.

“The proposed law is meant for the five to eight per cent of patients who, despite the best palliative measures, still suffer from unendurable pain,” Hivon told Maclean’s. TPS doesn’t work for every patient, she says. “It works well for cancer patients, but not for sufferers of Lou Gehrig’s disease, for example. As well, there are many terminally ill patients who suffer pain even after being induced into a coma. This legislation integrates all types of end-of-life care, so we can best care for the suffering of all patients.”

The proposed law has several levels of checks to ensure a patient is giving clear-minded consent to death and is not being coerced, Hivon says. Under the legislation, a patient would sign and date a consent form in the presence of a physician to begin the process of what it calls “medical aid in dying.” (A third party can do so if the patient is physically incapable.) This physician would then ensure the patient meets the criteria set out in the legislation, and fulfills eight further requirements, including having made the decision “freely and without any external pressure.” The opinion of another physician is then sought; if this physician agrees, the patient’s wishes are granted, and “the physician must administer such aid personally and take care of the patient until their death.”

Quebec’s right-to-die bill faces potential legal hurdles, though Hivon is confident the law is on the Quebec government’s side. “It is amongst the most well thought out and structured bills we’ve had,” Hivon said. “It isn’t euthanasia, it’s medical aid in dying.” Because the law frames the issue of doctor-assisted dying as part of a continuum of care, Hivon believes the proposed law avoids the criminal definition of assisted suicide, which is an indictable offence according to the Criminal Code.

Yet the difference between allowing someone to die and actively inducing death through lethal injection is ethically fraught. “Yes, there’s a difference, but the end result is the same,” Hivon says. Many palliative caregivers beg to differ. Balfour Mount is the Montreal physician who invented the field. (He came up with the term “palliative care” in 1974.) For the 74-year-old survivor of esophageal cancer, the question of intent is critical. “With TPS, sedation is used as a point of going to sleep. The aim is to alleviate pain, not to kill the person,” Mount says. “Through palliative measures, we can control most physical suffering. If the suffering isn’t physical, if the patient is depressed, that can be treated as well. If the anguish continues, we would ask if the person would prefer to just go to sleep. That doesn’t need a change in legislation.” Opponents such as Mount and the Quebec-based Physicians’ Alliance for the Total Refusal of Euthanasia further argue that Quebec’s law will normalize assisted suicide—and, inevitably, make it an accepted substitute for palliative care. “It’s cheaper to kill patients than care for them,” said the Alliance’s Catherine Ferrier.

As with most contentious social issues, camps on either side come armed with duelling research, statistics and thinly veiled insults of their opponents. Even language is a minefield in which every word is loaded. Right-to-die proponents eschew terms like “euthanasia” and even “doctor-assisted suicide” while its opponents say expressions such as “dying with dignity” and “assisted dying” remove any suggestion of the act’s implicit barbarity. It also pulls at the heartstrings. Shortly before his death in September, noted microbiologist Dr. Donald Low made a widely publicized video pleading for right-to-die legislation in Canada.

The video and the Quebec bill were shots in the arm for Canadian right-to-die advocates, who are smarting from a recent B.C. Court of Appeal decision reversing a lower court’s ruling in favour of assisted suicide. “I love what Quebec has done,” says Morris, who sees it as part of a “worldwide phenomenon” pushing the issue to the forefront.

Proponents, Morris says, are Baby Boomers who’ve seen their parents suffer through the last chapter of their lives and want nothing of the sort themselves. “Boomers have always been in control. We don’t just go to the doctor, we go to the Internet to see what has to say. We do our own research. It’s a natural extension of that. When we look at the current options for dying, we say ‘I think we need a different one.’ ”

The feds have already come down squarely against Quebec’s right-to-die bill, setting the stage for a legal battle between Quebec and Ottawa. A court would have to decide whether the act of helping a patient along to his or her final resting place is a criminal matter or, as Quebec maintains, a relatively simple medical procedure.

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