CMA’s “third way” may be a third rail

Responding to articles by CMA officials (BMJ 2019; 364)

Sean Murphy*

British Medical Journal

It is disconcerting to find that the CMA’s President-Elect thinks that Canadian law “does not compel any physician to be involved in an act or procedure that would violate their values or faith.” The state medical regulator in Canada’s largest province has enacted policies that do just that, requiring physicians who refuse to kill their patients to find a colleague who will. These policies do have the force of law, and objecting physicians were forced to launch an expensive constitutional challenge to defend themselves. The Protection of Conscience Project and others have intervened in the case to support them; the CMA has not.

Further, the Canadian Medical Association’s assertion that it has successfully adopted a “neutral” position on euthanasia and assisted suicide (EAS) is challenged in a World Medical Journal article by seven Canadian physicians. “For refusing to collaborate in killing our patients,” they write, “many of us now risk discipline and expulsion from the medical profession,” are accused of human rights violations and “even called bigots.” . . .


Murphy S. CMA’s “third way” may be a third rail. Rapid Response to articles by CMA officials (BMJ 2019; 364).

Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada

Emmanuelle Bélanger, Anna Towers, David Kenneth Wright, Yuexi Chen, Golda Tradounsky, Mary Ellen Macdonald

Journal of Medical Ethics

Abstract

Objectives: In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?

Methods: We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.

Results: Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients’ autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.

Conclusions: This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.


Bélanger E, Towers A, Wright DK, Chen Y, Tradounsky G, Macdonald ME. Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada. J Med Ethics 2019;45:48-53.

L’euthanasie au Canada: une mise en garde

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

L'euthanasie au Canada: une mise en garde

Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français

Euthanasia in Canada: a Cautionary Tale

Rene Leiva, Margaret M. Cottle, Catherine Ferrier, Sheila Rutledge Harding, Timothy Lau, Terence McQuiston, John F. Scott*

World Medical Journal

We are Canadian physicians who are dismayed and concerned by the impact  – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public  – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . .


Leiva R, Cottle MM, Ferrier C, Harding SR, Lau T, Scott JF. Euthanasia in Canada: A Cautionary Tale. WMJ 2018 Sep [cited 2020 Jan 14]; 64:3 17-23.

Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

G. Bravo, C. Rodrigue, M. Arcand, J. Downie, M.-F. Dubois, S. Kaasalaine, C.M. Hertogh,S. Pautex, L. Van den Block

Geriatric Nursing

Abstract

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.


Bravo G, Rodrigue C, Arcand M, Downie J, Dubois M-F, Kaasalaine S, Hertogh CM,  Pautex S, L. Van den Block L. Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs. 2018 Jan 3. pii: S0197-4572(17)30319-1. doi: 10.1016/j.gerinurse.2017.12.002.

Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada

Madeline Li, Sarah Watt, Marnie Escaf, Michael Gardam, Ann Heesters, Gerald O’Leary, and Gary Rodin

NEJM

Abstract
After Canada legalized medical assistance in dying (MAiD), the University Health Network in Toronto implemented a hospital-based MAiD program. UHN offers a framework for assessing patients for and providing MAiD while respecting the rights of patients and staff.


Li M, Watt S, Escaf M, Gardam M, Heesters A, O’Leary G, M.B., Rodin G. Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada. N Engl J Med 2017; 376:2082-2088 May 25, 2017 DOI: 10.1056/NEJMms1700606

Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections

Dylan Dahlgren, Fred Koning, John Sloan, Timothy Christie

Bioethique Online

Abstract

Background: The Supreme Court of Canada (SCC) has ruled that the federal government is required to remove the provisions of the Criminal Code of Canada that prohibit medical assistance in dying (MAID). The SCC has stipulated that individual physicians will not be required to provide MAID should they have a religious or conscientious objection. Therefore, the pending legislative response will have to balance the rights of the patients with the rights of physicians, other health care professionals, and objecting institutions.

Objective: The objective of this paper is to critically assess, within the Canadian context, the moral probity of individual or institutional objections to MAID that are for either religious or conscientious reasons.

Methods: Deontological ethics and the Doctrine of Double Effect.

Results: The religious or conscientious objector has conflicting duties, i.e., a duty to respect the “right to life” (section 7 of the Charter) and a duty to respect the tenets of his or her religious or conscientious beliefs (protected by section 2 of the Charter).

Conclusion: The discussion of religious or conscientious objections to MAID has not explicitly considered the competing duties of the conscientious objector. It has focussed on the fact that a conscientious objection exists and has ignored the normative question of whether the duty to respect one’s conscience or religion supersedes the duty to respect the patient’s right to life.

Christie T, Sloan J, Dahlgren D, Konging F.  Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections.  BioéthiqueOnLine, 2016, 5/14

The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada

Amir Attaran

The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada

In February 2015, the Supreme Court of Canada unanimously ruled in Carter v. Canada (Attorney General) that the Canadian Charter of Rights
and Freedoms (the “Charter”) protects the right of every competent, consenting adult suffering from a grievous and irremediable medical condition to
choose death, assisted by a physician.1 The Court’s decision to quash the sections of the Criminal Code that criminalize physician-assisted dying is in
abeyance until June 2016.2

Trouble is, not many physicians seem willing to assist. In a survey of its members, the Canadian Medical Association found that, at best, only 29 per
cent would consider a patient’s request for medical aid in dying, while a staggering 63 per cent would refuse outright (and even more say they would refuse
if the patient were not terminally ill).3 Further, among that majority of doctors who would refuse, most also believe that the system should require
them to do nothing to help patients die—not even refer the patient to a more willing doctor.4 No doubt there are fissures within the profession — family doctors appear to be more willing to assist dying, and Christian doctors less willing — but overall, it is clear that a majority of Canadian doctors
polled refuse to participate in physician assisted dying.5

. . . This article argues that whether doctors do or do not have the right to refuse to treat patients on conscientious or religious grounds is neither a difficult nor a novel legal issue. Patients and doctors have clashed on this issue before, and when they have, tribunals and courts have overwhelmingly sided
with the patients over the doctors. . .

. . .Equality law therefore greatly limits, but does not wholly abolish, the ability of doctors to opt out of giving medical services. For example, while
a doctor clearly would be justified to opt out of physician-assisted dying if he or she lacks the clinical skills to administer it safely—equality law does
not override the standard of care and fiduciary duty owed to the patient—it is extremely doubtful that a suitably skilled doctor could opt out just because of his or her conscientious or religious objection to assisting death, and that is because doing so would discriminate against the patient.


Attaran A. The Limits of Conscientious and Religious Objectionto Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada. Health Law Can. 2016 Feb;36(3):86-98.

Emerging assault on freedom of conscience

Stephen J. Genuis

Canadian Family Physician

Discussion on physician autonomy at the 2014 and 2015 Canadian Medical Association (CMA) annual meetings highlighted an emerging issue of enormous importance: the contentious matter of freedom of conscience (FOC) within clinical practice. In 2014, a motion was passed by delegates to CMA’s General Council,and affirmed by the Board of Directors, supporting the right of all physicians, within the bounds of existing legislation, to follow their conscience with regard to providing medical aid in dying. The overwhelming sentiment among those in attendance was that physicians should retain the right to choose when it comes to matters of conscience related to end-of-life intervention. Support for doctors refusing to engage in care that clashes with their beliefs was reaffirmed in 2015. However, a registrar from a provincial college of physicians and surgeons is reported to have a differing perspective, stating “Patient rights trump our rights. Patient needs trump our needs.1

So, do the personal wishes of doctors hold much sway in Canadian society, where physicians are increasingly perceived as publicly funded service providers? Should the colleges of physicians and surgeons have the power to remove competent physicians who refuse to violate their own conscience?

And what about FOC in a range of other thorny medical situations unrelated to physician-assisted dying?

Genuis SJ. Emerging assault on freedom of conscience.  Canadian Family Physician April 2016 vol. 62 no. 4 293-296  [Full text]

Controversy over doctors’ right to say “no”: The most controversial issues relate to abortion referrals or prescribing birth control

Wendy Glauser

Canadian Medical Association Journal

Religious groups, doctor’s organizations, ethicists and abortion rights advocates are raising concerns around the review of an Ontario policy that outlines, among other things, physicians’ right to object to patients’ requests for services on moral grounds.

The College of Physicians and Surgeons of Ontario’s Physicians and Ontario Human Rights Code is up for its five-year review, with both public and expert opinion being sought. . .


Glauser W. Controversy over doctors’ right to say “no”: The most controversial issues relate to abortion referrals or prescribing birth control. CMAJ September 16, 2014 186:E483-E484; published ahead of print August 18, 2014