Vitals

- The topic of compassion comes up a lot in my day-to-day at the hospital.

As physicians, we have to have difficult conversations all the time, with a patient, loved ones, in our healthcare circles.

So when headlines about physician-assisted suicide started popping up in my social feeds earlier this year, I wanted to learn more.

I had to learn more.

Simply put, physician-assisted suicide or assisted dying is where a physician facilitates upon request and approval, the ending of a suffering, most often terminal, patient's life through medical assistance.

I've learned that this statement without context can sound a little strange.

So I found some context and a little history.

I didn't have to go very far.

Our friends to the north, Oh Canada are at the front of this conversation.

Canada is debating whether to remove extra protections for people who want help in dying, but are mentally ill. Around the world, countries are looking at Canada to see how they can progress in their medical assistance in dying legislation.

Currently, there are 15 countries that in some shape or form permit medical assistance in dying.

But check this out, only eight of those countries, Austria, Belgium, Luxembourg the Netherlands, Spain, Switzerland, Columbia and as of 2021, Canada, removed the requirement of a terminal illness diagnosis in order to receive MAID.

And overwhelmingly, Canadians are in full support of physicians being able to offer this compassionate care.

Six in 10 Canadians support MAID however, only three in 10 support the 2024 removal of mental health exclusion.

But as the conversation about who gets to decide, patient autonomy and consent unfolds, how do we ethically discuss who gets to decide when it is their time to die and if the safeguards currently in place are enough to keep up with the evolution of the laws regulating this practice?

(gentle music) (air swooshes) When talking about this subject, you might hear terms thrown around interchangeably, physician-assisted suicide, assisted-death, physician aid-in-dying, dying with dignity, and medical assistance in dying or MAID.

They all refer to the same practice in theory, but it might be helpful to clear up what exactly assisted dying means and what it entails.

- When I'm talking about assisted dying, I'm talking about the legalized, compassionate end-of-life care that's provided by clinicians who safely and effectively end a person's life in specifically outlined and safeguarded circumstances, including the explicit request of a competent adult.

Our law in Canada is very clear.

You know, a person needs to have a serious and incurable illness.

They're already in an advanced state of irreversible decline and that they're suffering intolerably in a way that they determine themselves.

So all of that makes up a grievous and irremediable condition.

- In Canada, there are two forms of medical assistance that fall under the umbrella of MAID, euthanasia and assisted suicide or assisted dying.

With euthanasia, after a person has gone through the process of requesting and found eligible to receive MAID, a prescription will be administered by a physician through an IV.

Assisted suicide, however, the prescription is given to the patient and they take it self-administered through a drink.

But just know that there are fewer than seven deaths that were self-administered in 2021 across all of Canada.

If this is all sounding a little procedural, it's because it is.

There are safeguards in place that determine a person's eligibility to receive MAID and they have to meet certain criteria.

- They need, in terms of eligibility, they need to be over 18 years of age.

They need to be eligible for Canadian government-funded healthcare.

So you can't come from the United States and pay for this.

They need to make what we call a voluntary request.

So there's no sense of coercion of any sort.

It's the patient who's asking for it and the patient who wants it.

They need to have what we call a grievous and irremediable condition.

On top of that they need to have the capacity to make this request.

They understand what's wrong, they understand their treatment options, and they can reason those options and make a choice.

And, of course, they need to make a fully informed and capable decision giving informed consent.

A patient then has a process where they need to make a written request.

These are the safeguards we include that the request must be written, it must be signed, it must be dated, it must be witnessed.

And for patients who are not closer to end of life, who are not dying, you might say, there is an additional five other safeguards.

And just very briefly, they include that the assessment period for their eligibility has to be a minimum of 90 days.

There needs to be a person with expertise brought into the assessment.

If it's not one of the assessors, then a consultant who has expertise in the condition that's causing the patient's suffering, they need to give their input into that assessment.

And all the assessors need to have that information.

Patient needs to be made aware of all the resources, all the reasonably available resources and services that might reduce their suffering.

They need to be offered those resources and services.

And they need to give what we call serious consideration to accepting those resources and services.

- These criteria or safeguards are what's at the heart of the discussion surrounding assisted death, but not just in Canada.

Here in the US we've had our own controversial history with physician-assisted suicide.

In the mid 1990s, Dr. Jack Kevorkian sparked international headlines when he was convicted of murder after providing physicians-assisted suicide to over 100 patients.

It wasn't until 1997 that Oregon passed legislation permitting patients with a terminal illness, the right to assisted dying.

And then it wasn't until 2006 that the United States Supreme Court would vote to uphold Oregon's Death with Dignity Law.

Eventually, Dr. Kevorkian was released from prison, but was banned from providing PAS.

And now today, 10 states in Washington D.C. have legalized some form of MAID.

- Jack Kevorkian was purposeful in his challenge of the law.

You know, he, rather than working within the system to change that law, he chose to challenge the law by breaking it.

And that's not something that I would condone.

I think what we've seen in Canada is a 30-year debate about the topic.

We've seen a growing support by the public.

Certainly the national polls that were conducted before our law changed to allow for assisted dying during the first five years of legalized practice.

And in every year since our amendment that extended eligibility beyond the end of life context, we see consistent strong support for assisted dying in Canada and that continues to this day.

- That support has only become more prominent since Canada legalized MAID in 2016, but to patients that were terminally ill and within six months of dying.

In 2021, there were over 10,000 MAID provisions reported in Canada accounting for 3.3% of all deaths.

That's a sharp increase from 2020, approximately 32% more cases.

In total over 31,000 Canadians have received medical assistance in dying since 2016.

In 2021, Canada dropped the criteria for a terminal illness.

2% of the acted upon MAID requests in 2021 were non-terminal.

That same year, Canada explicitly excluded those suffering exclusively from intolerable mental health disorder as their only underlying illness from requesting and receiving MAID.

That exclusion was set to expire in 2023, but was then delayed for one more year until March 2024.

- I think the best way to think about the tension that exists is between respecting a patient's autonomy, the patient's right to make their own informed decision about their own care, and society's need or real responsibility to protect those who might be particularly vulnerable.

And I think there's often a perceived tension between those two, and sometimes there is.

But I actually don't believe there has to be a tension between the two.

I think that a rigorous system that's crafted with careful safeguards can actually accomplish both.

And that's I think what we've tried to do in Canada.

- I must say, I'm supportive of medical assistance in dying.

I've been directly involved, but I'm a former medical social worker, as well as being a bioethicist.

And I had grave doubts before it was even legalized as to whether we could really just parcel off these complex issues related to social determinants of health, people with disability, people with mental health disorders, whether we could really contain these things and be ethical about it.

I had great worry and others didn't.

But here we are.

- We discuss ethics a lot in the medical field.

Not surprising.

In the US the PAS laws are pretty straightforward with their own set of safeguards.

Those laws uniformly deny requests for anyone who isn't terminal.

However, in Canada, that's not the case.

With the mental health exclusion set to expire, some healthcare professionals have their doubts.

- But I must also say, you know, people don't always fully understand what it would be like to have a mental health disorder.

And they often see people, anyone with a mental health disorder as being sort of globally incapable of anything.

And that's not accurate either at all.

But the heart of the ethical challenge is can we say that the kind of suffering that comes forward when someone is facing an aggressive malignancy that's metastatic, you know, that, that is fundamentally different than the type of suffering that someone has 25 years into a mental illness where they are considered treatment recalcitrant.

And, you know, I do see a huge ethical challenge there to say one's acceptable and one's not.

And also the system is such if you do apply, you meet with a doctor, he or she interviews you extensively, and their determination is a definite no, there is nothing in Canadian law that says you can't go to the next doctor, and the next, and the next, and you can keep shopping around as much as you choose to.

- While the Canadians await the mental health exclusion to sunset, support for this provision is waning.

When Canada removed the foreseeable death requirement in 2021, 60% of Canadians polled supported this update.

However, only 31% said they supported restoring mental health as the sole reason for requesting MAID.

But as Canada continues to evolve their MAID laws, there are concerns that future expansion of MAID laws could encompass vulnerable populations, such as those looking to escape poverty, all of which would fall well outside the current safeguards.

- I mean, I think what's happening, and I don't necessarily love this, I think medical assistance in dying is becoming greatly integrated into Canadian culture in a general sense.

And I think within medical culture in Canada, I think we actually have probably made a mistake by considering medical assistance in dying as a treatment option 'cause treatment, you know.

And I think what's happened is it's, you know, rather than seeing it as something very serious as a last resort, calling something a treatment option has kind of normalized it, I think, probably a little too much.

I don't say this with pride, but I say that as a clinician who has, you know, experienced MAID directly and it has been a, some of the most compassionate measures that I've ever seen actually expressed in healthcare.

But as a social institution within Canadian society, wow.

You know, it's a much tougher question.

- Compassion is really about the ability to see suffering in someone else, but not just to see it, or to even experience it, but to actually have the desire to change that to help them.

So it's an ability to see someone suffering and the desire to change that for them.

And I think that's a lot of what we do in healthcare.

We all said interesting things when we went to our medical school interviews about why we wanted to be doctors.

But, you know, in essence, I think the vast majority of people do go into healthcare 'cause they wanna help people.

And I think this work is exactly that.

I mean, drilled down to its essence, I think offering assisted dying to patients is helping patients.

I think that's how they see it.

I think they see it as compassionate care.

(air swooshes) - There's a lot more to healthcare than just looking at a textbook and following a protocol.

A lot of it, if not the majority of it, is understanding the human element.

And that involves understanding someone's individual, cultural, religious, and spiritual identity, especially in times that are traditionally dark, like death and dying.

But I think these conversations add a necessary light, some optimism, and some compassion to that process.

(air swooshes) And that's it for this episode of Vitals.

Please share your thoughts, your comments, any personal stories you may have.

This is a heavy topic, physician-assisted suicide, and we want to hear from you.

Until next time.