Dying – and killing – in a ‘free and informed manner’

Bill 52 sets out rules for health officials to follow when medically assisted death is requested

QUEBEC — Quebec is taking a bold step, the first by a Canadian province, toward giving dying patients the right to a medically assisted death rather than accept excruciating pain.

It was four years ago that Véronique Hivon, now junior health minister in the Parti Québécois, initiated the process that led to her presentation Wednesday of Bill 52, An Act respecting end-of-life care.

Hivon said the procedure will be available only to Quebec residents, but that other provinces are watching Quebec’s approach.

And she is confident Bill 52 will not trigger Criminal Code sanctions, which she said only forbid assisted suicide.

“I want to repeat that euthanasia, for example, is not forbidden in the Criminal Code,” she told reporters. “There are general provisions and there is something specific about assisted suicide but nothing on euthanasia.”

Responsibility for health is within provincial jurisdiction, Hivon added. But the province is considering a directive to prosecutors, if necessary, instructing them not to prosecute doctors who help patients wanting to die.

Federal Justice Minister Rob Nicholson said in a statement that Ottawa will “review the implications of Quebec’s proposed legislation,” without saying the Conservative government will oppose the Quebec law.

A spokesperson for the Canadian Council for Religious Freedom, Father Geoffrey Korz, expressed concerns with the bill’s implications for healthcare workers in the province.

Forced participation ‘unconscionable’

“The government of Quebec has not offered protection of conscience to those healthcare workers in the province whose faith and conscience would not let them participate in the killing of another human being,” he said.

“It does not matter how ‘informed’ a patient might be. The idea that Premier Marois’ government would force a doctor or nurse to participate in such a process against their will is simply unconscionable,” he said.

“The idea that doctors and nurses who are trained to heal will now use the same instruments to administer poisons to their patients should stop Canadians in their tracks.”

But Minister Hivon explained that unlike the medically assisted death that the PQ is proposing, assisted suicide, which is legal in Oregon, consists of offering a prescription for a lethal dose of medicine that someone other than a doctor administers.

In the approach proposed in the PQ’s bill, patients must state their intentions in writing, a doctor must agree and a second doctor must confirm that medical aid to die is the only way to end the patient’s suffering.

As an opposition MNA in 2009, Hivon had proposed a special commission of the Quebec National Assembly to look into the idea. In a rare unscripted moment, then-premier Jean Charest agreed.

The all-party committee then travelled across the province, hearing from hundreds of witnesses, for and against, before unanimously endorsing a plan to allow patients to give their consent for a doctor to administer a life-ending injection as a last resort in cases where death was certain and normal palliative care was insufficient to ease the pain.

A panel of legal experts, headed by Jean-Pierre Ménard, a lawyer specializing in medical issues, reviewed the committee’s 2012 report, setting out the options for a dying patient, starting with a patient’s choice between refusing treatment or choosing palliative care, which is aimed at keeping a dying patient comfortable.

“The patient should have the right to autonomy in deciding, which includes the right to refuse, to interrupt or decline care, the right to palliative care, including terminal palliative sedation (in which a dying patient is sedated with drugs and deprived of food and water until they die), and correspondingly, the obligation of (medical) institutions to provide this care, and the right to medical assistance to die,” Ménard wrote.

Hivon’s bill follows Ménard’s prescription, touching on all the elements he raised, and recognizes “the primacy of freely and clearly expressing wishes with respect to care.”

Since the 1992 Quebec Superior Court case of Nancy B., a 25-year-old woman suffering from Guillain-Barré syndrome who won the right to die by disconnecting her respirator, Quebecers have had a clear right to refuse medical treatment.

Bill 52 reaffirms that right, adding that the attending physician must ensure a decision to refuse medical treatment is made freely, providing the patient first with all information needed for an informed decision.

Hivon said Quebec is upgrading its palliative care, with an emphasis on home care for the dying. Palliative care is also offered in hospices and some hospitals.

A $15-million investment, announced by Premier Pauline Marois in May, means that in two to three years, Quebec aims to be able to offer palliative care to all who need it, she said.

Bill 52 states that patients receiving palliative care must have a private room, and the hospice or other provider must have a code of ethics explaining the rights of patients and obligations of the institution.

Beyond refusal of treatment

Also under the proposed law, care facilities must report each year the number of end-of-life patients who received palliative care, the number receiving terminal palliative sedation, the number asking for medical aid in dying, as well as the number of times such aid was provided, the number of times it was refused and the reasons why.

But with regard to medically assisted death, Bill 52 goes a step further than the refusal of care. It states:

Medical aid to die means an injection that brings on death.

The patient, or, if the patient is incapacitated, the person authorized to consent, must be informed of the prognosis, the irreversible and terminal nature of the sedation and its expected duration, before signing consent in writing.

The patient must request medical aid to die themselves “in a free and informed manner,” signing a dated consent form. If the patient is not able to consent, a third person, not a minor or a member of the medical-care team, must give signed consent in the presence of a health professional who countersigns.

In order for another person to be authorized to consent, the patient in question must have put communicated their consent to medically assisted death before becoming incapacitated.

The patient must be 18 or over, suffering from an incurable disease, with an irreversible decline in health and must be suffering from “constant and unbearable physical or psychological pain which cannot be relieved in a manner the person deems tolerable.”

Significant sections of column are taken from an original National Post article, found here.