Unlike other Canadian provinces, Quebec codes of ethics for health care professionals are enacted by provincial statute. Quebec is also unique in having a provincial euthanasia law, which includes a protection of conscience provision for health care professionals specific to that service.
Freedom of conscience for services other than euthanasia
Physicians
The Code of Ethics for Physicians1 and the gloss on the Code by ALDO Quebec,2 an authoritative document, require objecting physicians to advise patients of the consequences of not receiving the contested service, and “offer to help the patient find another physician.” They are not obliged to help the patient find someone willing to provide the contested service. Objecting physicians are normally quite willing to explain how patients can find other physicians or health care professionals. . . [Full text]
Quebec’s euthanasia law, the Act Regarding End of Life Care (ARELC), permits two kinds of euthanasia, distinguished here as reportable and non-reportable euthanasia.
Reportable euthanasia is identified as “medical aid in dying” in ARELC.1 Only physicians may administer a lethal substance, and only to a legally competent person who is at least 18 years old, meets other criteria and personally gives informed consent. Physicians must conform to procedural guidelines and reporting requirements. Most people probably believe that this is the only type of euthanasia authorized by the law.
Non-reportable euthanasia is not explicitly identified in the law, but is permitted for legally incompetent patients (including those under 14 years old) who are not dying. Substitute decision makers acting under the authority of Quebec’s Civil Code2 can order them to be starved and dehydrated to death. There are no procedural guidelines, no reporting requirements, and it appears that the order can be carried out by anyone responsible for patient care.3 All of this was incorporated into ARELC by a revision of the original text.
Note that section 50, the protection of conscience provision in ARELC for health care professionals, pertains ONLY to reportable euthanasia. The Act does not recognize the possibility of conscientious objection by health care professionals unwilling to participate in euthanasia by starvation and dehydration. . . [Full text]
The MAiD Act is a procedure-specific law applying only to euthanasia and assisted suicide. It protects all regulated professionals who refuse to provide or “aid in the provision” of the procedures from professional disciplinary proceedings and adverse employment consequences because they have refused. They remain liable for other misconduct in relation to the refusal.
The Act protects those who refuse for any reason; refusal need not be based on any specific ground. Hence, it equally protects refusal for reasons of personal discomfort, distaste or fear and refusal based on moral or ethical objections.
“Aid in the provision” is not defined. A narrow reading could limit protection against coercion to acts closely associated with the administration of a lethal substance, like inserting an IV line or dispensing lethal drugs. A broad reading could extend it to include facilitation by referral or other means. However, based on the Janaway2 and Doogan3 cases in the United Kingdom (in which the key term, “participate,” was restricted to “hands on” activity), a narrow reading of “aid in the provision” is possible.
Professional obligations in relation to refusal are untouched by the law. Regulators remain free to specify obligations that do not prevent or conflict with refusal to provide or aid in the provision of euthanasia and assisted suicide. Based on a narrow interpretation of “aid,” this could include facilitation by referral to an EAS practitioner. This would be unacceptable to objecting professionals who consider that to entail complicity in killing patients.
Alert from a growing number of Canadian physicians
News Release
Physicians’ Alliance Against Euthanasia
Montréal, March 9, 2020 – The Physicians’ Alliance against Euthanasia has received reports that unwilling physicians are being pressured and bullied to participate in Medical Assistance in Dying (MAiD): euphemism for euthanasia and assisted suicide. Fearing reprisals, physicians have asked that no information that could identify them be disclosed.
The pressure has been intense for many physicians, especially amongst palliative specialists, some leaving even before this latest development. Descriptions were made of toxic practice environments and fear of discipline by medical regulators.
“The anxiety, fear, and sadness surrounding my work bled into my family life, and I ultimately felt that I could not manage practicing palliative care at this stage of my life.” (Former palliative care physician, March 2020)
In different locations across Canada over the last months to weeks there has been a change in certain hospital MAiD policies. The change seems intended to provoke crisis or confrontation: to force objecting physicians to facilitate MAiD, or to have to refuse — and face contrived allegations of “obstructing access.”
Reports consistently focus on the MAiD providers refusing to accept full responsibility for the death of the patient and forcing other physicians to share responsibility for the death. If the physician asks to withdraw from care and allow the MAiD provider to take over as before, the MAiD provider resists assuming the natural pattern of care.
The reports we are hearing from distressed physicians describe deliberate disruption of arrangements that were previously working satisfactorily and that had permitted patients to have access to MAiD while still allowing for conscience objectors to not be involved in facilitating the patient’s death. This bullying and betrayal of collegial relationships can poison practice environments and compromise patient care. Such behavior should not be tolerated by health care administrators in Canada.
Canadian physicians having similar stories of bullying are encouraged to contact the by email: info@collectifmedecins.org.
Vancouver — Delta Hospice officials were shocked and outraged this week by the Fraser Health Authority’s blatant move to cut off all discussions and close the facility because it wants the hospice to provide MAiD (Medical Assistance in Dying) at every facility. The Irene Thomas Hospice is dedicated to allowing patients access to expert symptom management for physical, emotional and spiritual distress. It provides comfort, meaning dignity and hope as one dies a natural death.
Angelina Ireland, President of the Delta Hospice, said the Fraser Health Authority and the British Columbia Minister of Health abruptly cancelled the Hospice’s contract on Tuesday without even acknowledging or responding to the hospice’s offer to a reduced level of government financing of the facility by $750,000 per year in order to meet the 50% funding level for exemption from providing MAiD.
“The actions of the Ministry reveal that the issue of MAiD vs. palliative care is an agenda-driven policy rather than one that ensures access to skilled and compassionate palliative care for eligible patients in distress, and their families,” she said. “And it’s all about dollars. It is easier and cheaper for the government to provide euthanasia rather than continue with palliative care. Basically, they are saying that no palliative care facility in BC has a right to exist unless it also provides euthanasia.”
Faced with the government’s decision and refusal to consider other options such as decreased provincial funding, Ms. Ireland said the hospice will look at all of its legal and other options to continue to exist and serve patients and families in their final days, as they have always done.
The decision is particularly baffling, she said, since access to MAiD for those who request it is available at many locations in the lower mainland, including Delta Hospital right next door to the hospice. That, in her mind, reinforces the view that this is not about patients or families, but rather about a social policy agenda.
“MAiD is a separate public health care stream, distinct and apart from palliative care. If the government wants to open MAiD facilities that’s their option, but they must not be allowed to download it onto the backs of private palliative care facilities.”
“Palliative care physicians and nurses believe in the philosophy of specialty palliative care and practice as defined by the World Health Organization (WHO), which maintains that palliative care provides relief from pain and other distressing symptoms and which affirms life and regards death as a normal process. At no point does WHO include euthanasia as an aspect of palliative care!”
Forced closure of the facility ignores the fact that this is a privately owned hospice built on land leased from the government, employs more than fifty people and has contributed significantly to BC’s public health care system.
“This is an invasion of the historic medical discipline of palliative care. The Canadian model is respected around the world. The government and the health authority are running roughshod over that principle and reputation.”
Ms. Ireland expressed hope that “even at this late date” Fraser Health Authority and the BC Ministry of Health will come to the table and discuss the issues, including the financial offer. “Our deepest concern is with those patients and families who have entrusted their final days to us. We want to make sure those days are filled with comfort and peace. That is still our goal.”
The Ministry and the Authority have both publicly stated they plan to take control of the premises currently occupied by the Hospice. The Delta Hospice Society built the Irene Thomas Hospice without taxpayer funds, at the cost of approximately $9,000,000. The Society has operated the Irene Thomas Hospice for 10 years, providing more than 700,000 hours of volunteer labour and $30 million to the public health care system. For the government to step in and seize this private property is “a scandalous appropriation of private assets,” said Ireland.
On Saturday April 4, a Rally for Delta Hospice will be held in front of the Legislative Buildings at noon. Speakers include Dr. Margaret Cottle (palliative care physician) and Dr. Will Johnston (family physician and obstetrician) along with MP Tamara Jansen and Alex Schadenberg of the Euthanasia Prevention Coalition.
-30- For further information, contact: Angelina Ireland. President Delta Hospice irelandangelina@gmail.com
