Protection of Conscience Project
Abstract
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
- “Emergency” requests
- CPSO position
- Requests for “emergency continuation”
- Expedited EAS and ER presentation
- Issues
- Recommendations
- Policy clarification
- Measures to prevent urgent requests and conflict
II. Falsifying death certificates
- Classification of death
- Cause of death
- Falsification of causes of death
- Issues
- Falsification “inappropriate”
- Falsification reflects corruption
- Deception undesirable
- Falsification breeds mistrust, may fuel Covid controversy
- Falsification wrong in principle
- Falsification compromises health statistics
- Recommendations
- Accommodate objecting practitioners and coroners
III. Criminal law limits on College policy
- Requirement to conform to criminal law
- Criminal law and eligibility
- EAS when patients are believed eligible
- EAS when patients are believed ineligible
- Patient ineligibility must lead to practitioner refusal
- Eligibility and “irremediable” medical conditions
- Revisiting Carter
- Conflation of irremediability and patient freedom
- Irremediability and mental illness
- Determining irremediability
- Limits on College authority
- Counselling suicide
- Issues
- Recommendations
- Re: practitioners
- Re: persons in authority