Submission to the College of Physicians and Surgeons of Ontario Re: Medical Assistance in Dying (2022)

Protection of Conscience Project

Abstract

Protection of Conscience Project
Protection of Conscience Project

The College of Physicians and Surgeons of Ontario (CPSO) has invited comment on a draft revision of its euthanasia/assisted suicide policy, Medical Assistance in Dying (CPSO MAID 2022). The focus of this submission is on issues related to the exercise of freedom of conscience by practitioners who refuse to do what they believe to be unethical or immoral in relation to euthanasia and assisted suicide (EAS, “medical assistance in dying”, MAID).

The CPSO has indicated that it does not consider EAS requests to be emergencies. However a source cited in CPSO MAID 2022 indicates otherwise, and CPSO MAID 2022 is silent on the issue. CPSO MAID 2022 should explicitly confirm CPSO statements that MAID is not a treatment option in an emergency, requests for MAID are not emergencies, and physicians are never required to assess patients for or provide the service.

Failed self-administration of lethal EAS medication can bring patients to hospital emergency rooms. Requiring EAS practitioners to be present and remain with patients self-administering EAS drugs until death ensues would prevent this and other problems, like delayed discovery of corpses in circumstances that would trigger police and coroner investigations.

CPSO MAID 2022 requires EAS practitioners to falsify death certificates. This is contrary to accepted international standards and can be considered deceptive, unethical or professionally ill-advised. EAS practitioners unwilling to falsify death certificates should not be compelled to do so.

Practitioners who believe that a patient is ineligible for MAID must refuse to provide euthanasia or assisted suicide or do anything to facilitate the services. Prominent medical practitioners insist that it is impossible to establish that mental illness is irremediable. The CPSO has no basis to proceed against them if they refuse to do anything to further an EAS request based on mental illness alone.

Patients can sign a waiver authorizing euthanasia if they lose capacity to consent before the time appointed for the procedure. They may later express ambivalence, or having apparently lost capacity, express ambivalence about proceeding with euthanasia at the appointed time. However, the benchmark set by the Criminal Code is refusal. EAS practitioners may legally proceed if the patient expresses only ambivalence. CPSO MAID 2022 should provide ethical direction or guidance in relation to the response expected from EAS practitioners in such circumstances.


TABLE OF CONTENTS
I.    Avoiding conflicts in urgent situations
 II.    Falsifying death certificates
III.    Criminal law limits on College policy
IV.    Criminal law and ethical norms
Appendix “A”: Summary of Recommendations

New South Wales’ Voluntary Assisted Dying Act (2022) No. 17

Impact on freedom of conscience for health care practitioners and institutions

Sean Murphy

Protection of Conscience Project
Protection of Conscience Project

Executive Summary
New South Wales’ Voluntary Assisted Dying Act 2022 No. 17, drafted and introduced by Independent MLA Alex Greenwich, closely resembles Queensland’s Voluntary Assisted Dying Act 2021. It will legalize euthanasia and assisted suicide (termed “voluntary assisted dying”) in the Australian state when it comes into force in January, 2023. This review considers the impact the Act may have on health care workers and institutions opposed to euthanasia or assisted suicide (EAS) for reasons of conscience. Part I outlines the main features of the law, providing a context for discussion of provisions relevant to freedom of conscience in Part II (Individual Freedom of Conscience) and Part III (Institutional & Collective Freedom of Conscience).

Overview
Eligibility

People seeking euthanasia/assisted suicide (EAS)  must be adults with an advanced, progressive disease or medical condition that is causing suffering (of any degree or kind) and that is expected to cause death within 12 months (in the case of neurodegenerative conditions) or within 6 months in all other cases.  They must be acting voluntarily, without pressure or duress, and be capable of making and communicating medical decisions.  They can be mentally impaired or have dementia or a disability, but EAS cannot be provided for mental impairment, dementia or disability alone.  Decision-making capacity is presumed in the absence of evidence to the contrary if a patient appears to understand the consequences of a decision.  The Act acknowledges that capacity can be temporarily or permanently lost. It imposes residency requirements that can be waived for compassionate reasons.

Practitioners

Only EAS-trained medical practitioners with least ten years general practice experience or specialist credentials can act as EAS coordinators and consultants.  Other EAS trained medical practitioners and  nurse practitioners may administer euthanasia.

Discussion with patients

It appears that NSW legislators muddled the wording of the provision about discussions with patients while attempting to modify the comparable provision in Queensland’s Voluntary Assisted Dying Act 2021.  All health care workers, contracted care service workers and medical practitioners can initiate discussion about or suggest euthanasia/assisted suicide to patients, even if patients have not expressed an interest, as long as they provide other information required by the Act.  If a patient asks about EAS, contracted care service workers and health care workers other than medical practitioners can provide EAS information, but need not provide information about available options or suggest that the patient talk to a medical practitioner.  However, none are required to suggest or initiate discussion about EAS.

The EAS process

The EAS process begins with a “clear and unambiguous” first request to a medical practitioner made personally by a patient (not a third party).  After discussing alternative options, the medical practitioner must accept or reject the request and promptly notify the patient.  A practitioner who rejects a request must advise the patient that others may be able to assist, and must provide  information about them or the Voluntary Assisted Dying Care Navigator Service.  An EAS-qualified medical practitioner who accepts a request becomes the coordinating practitioner, responsible for supervising the EAS request, assessment and administration process.

A medical practitioner who accepts a request must assess the patient’s eligiblity.  Patients deemed eligible must be referred to a consulting practitioner to confirm the assessment, and can be referred repeatedly to consulting practitioners until eligibility is confirmed.  Referrals to specialists are optional, and their opinions are not binding. 

A patient deemed eligible by two medical practitioners and who wishes to proceed must make a second EAS request, then a written declaration witnessed by two people, and a final request.  Finally, with the coordinating practitioner’s assistance, me must make an administration decision: to opt for assisted suicide or euthanasia. Assisted suicide is less reliable than euthanasia, and experience elsewhere demonstrates that very few choose assisted suicide when both euthanasia and assisted suicide are available. 

The second request, final request, and administration decision could all occur during the same consultation, although a final request cannot be made until the day after the completion of the second (consulting) assessment, and cannot normally be made within five days of a first request; the latter requirement can be waived if the patient may lose capacity or die before EAS can be provided. 

Subject to Australian national laws, the Act explicitly allows the use of audiovisual communication for first and final requests and administration decisions. The Act does not explicity prohibit audiovisual communication for EAS assessments.  Australia’s Criminal Code currently prevents this.  Should the Code be amended to allow it, videoconferencing for first and final requests and administration decisions would immediately be allowed, and it appears that professional regulators in New South Wales would be able to permit videoconferencing for EAS assessements.

Providing EAS

Coordinating practitioners must be authorised by the Voluntary Assisted Dying Board (the Board) to prescribe a lethal substance for each patient, whether it is to be practioner-administered or self-administered.  A practitioner providing euthanasia must have an adult witness present and ensure that the patient has decision-making capacity and is acting voluntarily.  A patient can self-administer lethal medication at any time and place, without notifying anyone. Neither a witness or confirmation of decision-making capacity or voluntariness is required.  It is thus possible for death by self-administration to occur in public or inconvenient places or remain undiscovered for some time.  If the patient is incapacitated but does not die after being administered or ingesting the lethal substance, it does not appear that an additional lethal dose can be given to kill the patient unless the patient regains capacity and consents.

The wording of the Act seems to leave open the possibility that a friend, family member, agent or contact person could put the substance to or into the mouth of a patient who needs help to self-administer it, which, in some circumstances, would be indistinguishable from administering it. A required statutory instruction to patients that they are not obliged to self-administer the lethal substance could contribute to this outcome.

Death certificates

The Act requires the cause of death be falsified by reporting it as the disease or medical condition for with EAS was approved. Falsification of the cause of death on death certificates is contrary to international standards for identifying causes of death that are acknowledged by the Australian government.  Falsification of death certificates contributed to the murder of over 200 patients by a British medical practitioner and led to unfavourable comments by the chairman of the subsequent inquiry into the murders.

Voluntary Assisted Dying Care Navigator Service

The New South Wales government will establish the Voluntary Assisted Dying Care Navigator service to assist those seeking “support, assistance and information” about EAS services.  VADCNS will be a service dedicated to enabling euthanasia/assisted suicide, so it will not be equivalent to a service providing information and assistance related to a variety of government and health services. 

Institutions (“entities”)

Institutions are categorized as “residential facilities” like nursing homes, hostels, group homes, etc. operated by “relevant entities” (excluding individuals) and “health care establishments” like hospitals or hospices operated by “health care entities” (including individuals).  They may decide not to provide EAS related services and information.

The Act imposes obligations on residential facilities and health care establishments if a person in their care requests EAS information or services that they do not provide.  They must allow a VADCNS employee or someone else “reasonable access” to anyone in their to provide EAS information. 

Generally speaking, governing entities are expected to facilitate the transfer of patients in health care establishments to and from a location where EAS services can be provided. 

On the other hand, they are expected to allow all EAS services in residential facilities for all permanent residents, and for all occupants who are not permanent residents if an EAS practitioner decides that transferring them “would not be reasonable in the circumstances.”

Oversight

The operation of the Act is to be overseen by an appointed Voluntary Assisted Dying Review Board. It must approve each EAS application and residency exemption, maintain a list of registered health practitioners willing to be involved in EAS services and monitor and report annually upon the operation of the Act.  The Supreme Court of New South Wales is empowered to review and overturn decisions about residency, capacity, and voluntariness (not diagnosis or prognosis). Coordinating practitioners may refuse to continue if the Court overturns a decision about capacity or voluntariness, but must then transfer the patient to the consulting practitioner or someone eligible to act as coordinating practitioner.

Illusion of neutrality

The Act identifies eleven principles underpinning the statute and seems to give equal weight to all of them.  Six are irrelevant to conflicts of conscience in relation to supporting or participating in euthanasia/assisted suicide and five are subject to morally partisan interpretations. This enables an adjudicator to impose subjective and contested views about the meaning and importance of each principle during an ostensibly neutral “rights balancing” analysis. No one should be under the illusion that the principles identified in the Act can be fairly and objectively applied in a “rights balancing” exercise when there is fundamental disagreement about what they mean.

The provision of euthanasia or assisted suicide under the Act is not considered palliative care, which is clearly distinguished as an alternative option.  People hold different views about the moral acceptability of euthanasia and assisted suicide and whether or not the procedures are forms of health care or medical practice.  However, the Act assumes that euthanasia and assisted suicide are morally acceptable forms of healthcare and must be characterized as death by natural causes rather than homicide or suicide. This does not demonstrate respect for different views.  On the contrary: it effectively imposes a chokehold on public discourse, suppressing the words needed those opposed to the Act to express their reasoning.


Individual Freedom of Conscience
Conflicts of conscience

The health care professions are not divided into sharply defined groups of objecting and non-objecting practitioners.  The position of many practitioners depends upon the nature of the illness or condition, opinions about decision-making capacity, voluntariness, or other issues they consider relevant.

The broader the grounds for euthanasia and assisted suicide, the more likely it is that conflicts of conscience will arise. By restricting eligibility to competent adults with terminal illnesses or conditions, and by explicitly ruling out EAS for disability, dementia or “mental health impairment” alone, the Act reduces the number of practitioners likely to experience conflicts of conscience when it comes into force.

Capacity assessments

The ability of practitioners to perform capacity assessments for euthanasia and assisted suicide is disputed, and assessment of limited, fluctuating and episodic capacity can be particularly troublesome. Patients could be deemed capable of choosing euthanasia/assisted suicide even if they are considered incapable of challenging medical decisions about alternative treatments and palliative care. The burden of illness may make it easier to understand the EAS process than alternative treatment options, and to choose what is more easily understood rather than what might offer significant symptom relief. Even practitioners willing to facilitate euthanasia for clear-headed patients may not be confident that they can safely act upon a request made when the clouds of major depressive disorder part for a time, or if the patient recovers what another colleague considers “enough” capacity to make a valid request.

Risk assessments by EAS supporters, uncommitted practitioners and EAS opponents may reflect significantly different views about life-or-death decisions based on different underlying philosophical or ethical views. A priori biases in favour of an outcome cannot be avoided in EAS assessments.

Overturning practitioner decisions

The New South Wales Supreme Court can overturn a coordinating practitioner’s conclusion that a patient is ineligible for EAS because of involuntariness or lack capacity.  This can cause a problem for practitioners who are certain of their conclusion because, though they can withdraw, the Act requires them to transfer the patient to a colleague willing to continue the EAS process.  They may well consider this unacceptable, and it is completely unnecessary.  The Act should be amended to require the Voluntary Assisted Dying Board to find a new coordinating practitioner should the coordinating practitioner withdraw in these circumstances.

Protection for objecting practitioners

All health care workers, contracted care service workers and medical practitioners can initiate discussion about or suggest euthanasia/assisted suicide to patients, even if patients have not expressed an interest, but they are not required to do so.  By explicitly making discussion optional, the Act supports both practitioners who want to initiate discussion about EAS and those who think it best to let patients take the lead, responding to their enquiries or apparent interests. 

All registered health practitioners who conscientiously object to EAS may refuse to participate in any part of the EAS process and refuse to be present when EAS is provided.  The wording of the relevant provision is ambivalent, but the Act does not require objecting practitioners to do anything other than record the refusal and the reason for it in the patient’s medical record and report the refusal and reason for it to the Voluntary Assisted Dying Board.  Further, objecting practitioners who refuse to do something (such as referral) are protected from disciplinary action by regulators if they act in good faith and reasonably believe that the refusal is in accordance with the Act.  Hence, the starting point for objecting practitioners pressured by regulators or others to do more should be that the Act not only does not require it, but (interpreting the ambivalent provision in a fully protective sense) affirms that they need not do so.

Protection for other care workers

The protection for individual freedom of conscience offered by the Act is limited to registered health care practitioners.  No protection is provided for the many people involved in the provision of health care, personal care and aged care who are not registered health practitioners, even though the Act explicitly recognizes their work.  For example, nothing in the Act prevents employers from requiring a personal care worker or social worker to actively support the provision of EAS or to be present when lethal medication is administered.

Falsification of death certificates

Regardless of their views about euthanasia and assisted suicide, some medical practitioners are likely to object to falsifying the cause of death in death certificates. They may be uncomfortable about lying or dissembling to families about how their loved ones died or concerned that falsifying records and lying is likely to undermine the trust essential to the practice of medicine. Others may have principled objections to falsifying documents, lying, dissembling and other forms of deception under any circumstances. Finally, some may consider falsification ill-advised because it is likely to compromise important epidemiological data.  If the state insists that death certificates must be falsified, the Act should be amended to make a medical member of the Voluntary Assisted Dying Review Board responsible for completing EAS death certificates (assuming that a Board member’s objection to doing so would also be accommodated).


Institutional & Collective Freedom of Conscience

Factors relevant to moral decision-making by entities/collectives are not necessarily identical to those concerning individuals, and the concept of individual freedom of conscience is applied analogically to collectives, so some differences are to be expected.  This paper presumes that entities/collectives are entitled to rely upon constitutional guarantees of freedom of conscience, notwithstanding differences between individuals and collectives in the exercise of that freedom. Individuals and entities/collectives are equally concerned to avoid complicity in perceived wrongdoing. This obviously includes taking part directly in what they deem to be a wrongful act, but also causally contributing to by collaboration or contingent cooperation.

The Act does not admit the possibility of conscientious objection by entities/collectives. Consistent with this, the Act acknowledges the need to respect individuals’ culture, religion, beliefs, values and personal characteristics, but not those of entities/collectives.  It imposes a number of constraints and requirements on objecting entities/collectives specifically to compel their cooperation and even collaboration, some of which go beyond legal constraints arising from legal occupancy status.  Refusal to participate in or facilitate killing people for moral reasons is placed on the same level as refusals based on pragmatic considerations like lack of trained personnel or management of institutional branding.  The Act thus implies that guarantees of freedom of conscience or religion are irrelevant to decision-making by entities/collectives about involvement in killing people, and, if they defend refusals on that basis, the Act puts them at a disadvantage. 

The Act is is concerned with two kinds of institutions: “residential facilities” like nursing homes, hostels, group homes, etc. operated by “relevant entities” (excluding individuals), and “health care establishments” like hospitals or hospices operated by “health care entities” (including individuals).  Regardless of structure, an “institution” in the sense relevant here always manifests a collective enterprise by individuals, so the term “entity/collective” is used here to keep this in mind.

Participation, cooperation, collaboration

The Act does not require entities/collectives to provide euthanasia or assisted or even to provide information about the procedures, so it does not threaten institutional freedom of conscience in relation to direct participation in EAS services.  Instead, the Act is designed to enable the state to compel unwilling entities/collectives to cooperate and perhaps collaborate in killing people in their care or helping them kill themselves, and to disadvantage any that resist by appeals to freedom of conscience.

However, patients and practitioners cannot proceed with EAS in an objecting institution unless they notify insititutional authorities at each stage in the EAS process.  This is fortunate, because providing EAS services in a private apartment in a residential facility would be radically different from providing them behind a curtain in a room shared with others, and the Act does not distinguish between the two situations.  Nothing in the Act prevents objecting entities/collectives from imposing conditions on EAS-related activities that they are required to permit once they have been notified.

EAS information

Objecting entities/collectives must allow all institutional occupants access to EAS information.  They could direct all patient enquiries about EAS to staff members trained to provide patients with information necessary to enable informed decision-making without compromising institutional moral integrity.  Hence, the cooperation required in providing information about EAS does not appear to undermine institutional freedom of conscience. 

First and final EAS requests

The Act leaves room for objecting entities/collectives to direct staff to fully and compassionately explore and document first requests, refuse those found to be clear and unambiguous, and provide information enabling patients to seek EAS elsewhere.  They can thus comply with a number of the Act’s provisions without compromising institutional moral integrity.  However, the Act also requires objecting entities/collectives to allow EAS practitioners to accept first and final requests from anyone in their health care establishments and residential facilities.  Accepting requests (i.e., agreeing to act upon them), especially final requests, is more directly supportive of and causally related to euthanasia and assisted suicide than merely receiving and responding to requests, and thus more likely to be problematic for objecting entities/collectives.

Declarations, EAS assessments, administration decisions, and administration of lethal substance

Moreover, the Act demands that objecting entities/collectives allow EAS practitioners to provide all EAS assessments, consultations and euthanasia/assisted suicide for permanent residents in residential facilitiesContingent cooperation of this kind is likely to be problematic, especially in relation to patients who share rooms with others.  If EAS practitioners cannot attend, objecting entities/collectives must “take reasonable steps to facilitate the transfer” EAS candidates to a location where they can receive EAS services, including lethal injection.  This suggests that active collaboration might be expected, and it goes well beyond merely granting the equivalent of a residential tenancy right to service delivery at home.  Landlords are not forced to help tenants travel to see EAS practitioners who can’t make home visits.

Objecting entities/collectives may refuse to allow the EAS process for institutional occupants in health care establishments and residential facilities only if, once more, they “take reasonable steps to facilitate” transfers to enable the procedures elsewhere.  If that means initiating rather than simply cooperating in a transfer requested by others, the purported compromise may amount to a choice between two objectionable alternatives.  In addition, the Act allows legal action against objecting entities/collectives that require transfers from their health care establishments for EAS procedures (including euthanasia and assisted suicide) if transfer “would not be reasonable in the circumstances.” It also enables patients and EAS practitioners to veto transfers of institutional occupants from residential facilities, thus forcing objecting entities/collectives to cooperate.

Credentials (privileges)

The Act’s demands that qualified practitioners be allowed to provide EAS services to patients in facilities poses a dilemma for objecting entities/collectives in granting credentials.  Granting credentials for EAS would explicitly affirm the acceptability of euthanasia/assisted suicide and authorize the procedures, thus contradicting their moral commitments.  However, granting credentials may be necessary to avoid legal liability, and it may be the only way for objecting entities/collectives to impose enforceable conditions and restrictions on provision of the service in order to protect other patients, staff and mitigate harm to institutional moral integrity.

Bias

The provisions of the Act suggest that NSW legislators not only believe that it is morally acceptable to kill patients or help them kill themselves in accordance with their law, but are unable to imagine or unwilling to concede that others could reasonably and collectively hold and live in accordance with the contrary view, and should be entitled to do so in a democratic state. This demonstrates a lack of moral imagination or unreflective and entrenched authoritarianism inconsistent with the best traditions of liberal democracy.


TABLE OF CONTENTS
Preface
PART I:    OVERVIEW
PART II:    INDIVIDUAL FREEDOM OF CONSCIENCE
PART III:    INSTITUTIONAL & COLLECTIVE FREEDOM OF CONSCIENCE

Conscience Clauses, Health Care Providers, and Parents

Nancy Berlinger

Conscience Clauses, Health Care Providers, and Parents

Extract
Conscientious objection in health care always affects someone else’s health or access to care because the refusal interrupts the delivery of health services. Therefore, conscientious objection in health care always has a social dimension and cannot be framed solely as an issue of individual rights or beliefs. . . . Conscience rights are also limited by the foundational duty of care, which must be maintained through referrals and transfers so that a refusal to provide a service does not result in abandonment of a patient. . . Physicians who work in the 11 U.S. jurisdictions that permit terminally ill people, under certain conditions, to request a prescription of lethal medication with the goal of ending their lives may also have mixed emotions and intuitions about participating in medical aid-in-dying. . . Conscientious objection to providing or participating in certain activities on principle should not be used to avoid patient care that a professional finds stressful, or as a remedy for the common problem of moral distress.


Berlinger N. Conscience Clauses, Health Care Providers, and Parents [Internet]. Garrison, NY: The Hastings Center; 2022 May 31.

(Editorial) Assisted dying: a question of when, not if

Richard Hurley, Tessa Richards, Fiona Godlee

British Medical Journal, BMJ
British Medical Journal

Extract
Doctors’ views on assisted dying are split, and most doctors’ organisations take no position on the issue; a few—including the BMA—oppose legalisation. Their stance matters: lawmakers and judges regularly seek, and listen to, their views. The BMJ has called for the professions’ representatives to take a position of neutrality—neither in support nor opposition—on the grounds that doctors should not obstruct a decision that is for society and parliament to make.

Engaged neutrality is far from an abdication of responsibility. It honours the diversity in professionals’ opinion. We believe that it also enables organisations to facilitate and fully engage with much needed societal conversations about death and what it means to die well.

Neutral organisations can be closely involved in drafting laws and guidelines, which would be impossible if they opposed their existence. They can lobby for the interests of doctors who do not wish to participate, as well as of doctors who do. . .


Hurley R, Richards T, Godlee F. (Editorial) Assisted dying: a question of when, not if. Br. Med. J. 2021;374(2128)

End-of-Life Options Act Fails to Protect Conscience Rights

Andrew S. Kubick

Ethics & Medics
Ethics & Medics

Extract
The New Mexico Senate passed the Elizabeth Whitefield End-of-Life Options Act on March 15 by a vote of twentyfour to seventeen. That vote followed a February vote of thirty-nine to twenty-seven in the lower chamber. Now with the stroke of Governor Michelle Lujan Grisham’s pen, New Mexico has become the ninth state in the United States to enact a physician assisted suicide law. (The practice also is legal in Washington, DC.) The End-of-Life Options Act is incompatible with the moral teachings of Catholicism (along with several other religions). A provider who embraces the Catholic faith will be faced with the following ultimatum: You can either write a prescription for a lethal dose of a sedative or refer the patient to a physician who will then write it, or you can suffer the professional consequences of conscientiously objecting to both of those options. It is clear upon review of the End-of-Life Options Act that it fails to fully protect the conscience rights of providers. . .


Kubick AS. End-of-Life Options Act Fails to Protect Conscience Rights. Ethics & Medics 2021 Jun; 46(6): 1-2.

Equality of Autonomy? Physician Aid in Dying and Supported Decision-Making

Megan S Wright

Arizona Law Review
Arizona Law Review

Extract
Abstract

. . . This Article is the first to address whether terminally ill persons with cognitive impairments should be able to access PAID [Physician Aid In Dying] through supported decision-making. If provided with decision-making support, terminally ill persons with cognitive impairments may be able to elect PAID intentionally, voluntarily, and with understanding; that is, despite their impairments, such persons may be capable of autonomous end-of-life decision-making. This Article thus argues that the principle of equality demands that the law not exclude terminally ill supported persons with decisional impairments from PAID. This Article also argues that supported decision-making is a superior means for terminally ill persons with decisional impairments to access this end-of-life option compared to advance directives, which have numerous and well-documented problems. . .


Wright MS. Equality of Autonomy? Physician Aid in Dying and Supported Decision-Making. Arizona Law Review. 2021;63(157):158-197.

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer

BMJ Supportive & Palliative Care
BMJ Supportive & Palliative Care

Abstract
Background
The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.

Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.

Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.

Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.

Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.


Groenewoud AS, Atsma F, Arvin M, Westert GP, Boer TA. Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation BMJ Support Palliat Care. 2021 Jan 14:bmjspcare-2020-002573. doi: 10.1136/bmjspcare-2020-002573. Epub ahead of print. PMID: 33446488.

The Declaration of Geneva: Conscience, Dignity and Good Medical Practice

Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva

World Medical Journal
World Medical Journal

Extract
Since 1948 the Declaration of Geneva (the Declaration) has insisted that physicians must practise medicine “with conscience and dignity.” In 2017 this provision was modified by adding, “and in accordance with good medical practice” [1].

Good medical practice in Canada is said to include providing euthanasia and assisted suicide or arranging for someone else to do so. From this perspective, physicians who cannot in conscience kill their patients or collaborate in killing are not acting “in accordance with good medical practice,” and – some might say – the revised Declaration.

However, this merely literal application of the text cannot be correct, since the WMA later reaffirmed its support for physicians who refuse to provide or refer for euthanasia and assisted suicide even where they are considered good medical practice [2]. A reading informed by the history of the document is necessary and consistent with the care taken in its revision [1]. This yields a rational and coherent account of the relationship of conscience and dignity to medical practice.


Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR, Leiva R. The Declaration of Geneva: Conscience, Dignity and Good Medical Practice . WMJ [Internet]. 2020 Aug; 66(4): 43-47.

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues

Leonie Herx, Margaret Cottle, John Scott

World Medical Journal
World Medical Journal

Extract
This paper will balance recent portrayals in the popular and medical media that imply only a positive impact as a result of the introduction of euthanasia into Canada’s health system [3–4]. Evidence will be presented to demonstrate that there are significant negative and dangerous consequences of this radical shift for medicine, and particularly for palliative medicine. These include the widening and loosening of already ambiguous eligibility criteria, the lack of adequate and appropriate safeguards, the erosion of conscience protection for health care professionals, and the failure of adequate over- sight, review and prosecution for non-compliance with the legislation. Indeed, what we have seen over the past four years is that “the slope has in fact proved every bit as slippery as the critics had warned” . . . Euthanasia is not the panacea that proponents promise. Its legalization and subsequent rapid normalization have had serious negative effects on Canadian medicine and on Canadian society as a whole. We urge the WMA and our colleagues around the world to look beyond the simplistic media reports and to monitor developments in Canada carefully and wisely before making any changes in their own country’s legal frame- work for medical practice.


Herx L, Cottle M, Scott J. The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues. World Medical Journal020. 2020;66(2):28-37.

(Correspondence) Organ Donation after Medical Assistance in Dying — Canada’s First Cases

Ian M. Ball, Andrew Healey, Sean Keenan, Fran Priestap, John Basmaji, ,Kimia Honarmand, ,Jeanna Parsons Leigh, ,Sam Shemie, ,Prosanto Chaudhury,,Jeffrey M Singh, Jeffrey Zaltzman,Stephen Beed, Matthew Weiss

New England Journal of Medicine, NEJM
New England Journal of Medicine

Extract
The provision of organ donation after medically assisted euthanasia involves unusual challenges, including first-person direct consent, navigation of a new legislative landscape, and incorporation of the legislated requirements of euthanasia into the donation process. Ethical issues involving the well-being of health care workers and conscientious objection have also been raised.

Medical assistance in dying followed by organ donation is new to North America. It is evolving, and if offered to potential donors it provides them with the opportunity to fulfill their dying wishes. Secondarily, this process may make more organs available to patients on transplant waiting lists. There is substantial room for enhanced education of both the public and health care workers and for the evolution of clinical practice. National level, prospective data will be necessary to assess this evolving area of care.


Ball IM, Healey A, Keenan S, Priestap F, Basmaji J, Honarmand K et al. Organ Donation after Medical Assistance in Dying — Canada’s First Cases. N Engl J Med. 2020;382(6):576-577.