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November 7, 2015

Assisted dying in Quebec

Reuel S. Amdur

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Quebec will begin providing euthanasia and assisted suicide for patients beginning this December (2015). The province took considerable time to "get it right." The bill was first introduced by Parti Québécois Member of the Quebec National Assembly Véronique Hivon in 2013, under a PQ government.

However, it was finally passed under a Liberal government in 2014.  It underwent 18 months of all-party analysis and development, involving international travel to visit jurisdictions with such legislation.

This February, the Supreme Court reversed its 1993 decision in the Sue Rodriguez case, where she, suffering from ALS (Lou Gehrig’s disease), was denied a right to physician-assisted death.  The Court this time tossed out the ban on euthanasia, giving Parliament one year to bring in new legislation.  Otherwise, Canada would lack a legal framework.  Either each province may adopt its own regulations or doctors will act on their own judgment.

So what was the Harper government’s reaction to the Court’s decision?  The Tories are clearly unhappy with it. They set up a panel to advise on the issue, appointing panel members known for their opposition to assisted dying.  They let it be known that they will ask the court for more time to bring in legislation, after the election, should we continue to be bound by the Tories.  It seems doubtful that the court would agree to such stalling.

Quebec’s law applies to persons covered by its health insurance, Quebec residents.  The person must be 18 or older and capable of giving consent, be at the end of life, suffering from a serious and incurable illness, in an advanced state of irreversible decline in capacities, and experiencing “constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable.”

The administration of the services must be by a physician.  It may not be passed on to a nurse or other health care worker.  There are of course detailed requirements regarding record-keeping and assurance that action taken is in accord with the patient’s wishes.

The physician is in the centre of all of this.  He is the one who checks with the patient and administers the medication.  The doctor-oriented approach is part of the current Liberal government’s orientation, with Philippe Couillard, the Premier, a brain surgeon.  He has appointed a number of physicians to prominent posts in his government.

In Oregon, the patient must self-administer the lethal dose, for example, mixed in apple sauce.  Interestingly, as a result many of the suicide doses remain unused.  Patients keep them at hand “just in case.”  There is, however, a drawback.  The person must be physically able to take the medication.  No one can put it in his mouth.  There is a low level of uptake on the law in Oregon and an even lower level of follow-through to death.  In 2014, 155 prescriptions were issued, resulting in 105 deaths.  The legislation in that state was adopted in 1997.  Hence, the slippery-slope fear was not fulfilled in Oregon.

The story in the Netherlands is rather different.  Euthanasia in that country has a history dating back to 1973, when, faced with a case, a court set down criteria, further clarified in the following decade.  Actual legislation did not come in till 2002.  Since that time, there have been a number of disturbing cases and cases in which the required documentation was lacking.  Dutch writers Henk ten Have and Jos Welie cite instances where people were terminated without consultation and consent, where a politician with no medical or psychological disability opted to die because he was just tired of living, and many cases where formal reports were neglected.  Their account is found in their book Death and Medical Power (2005).

The Dutch slippery slope might be the consequence of a long period of gestation during which a certain latitude developed.  The implication for Canada is that the foot-dragging of the Harper government on this issue and the lack of federal leadership is more likely to lead to the slippery-slope phenomenon.

Our two Dutch authors note that, in an experiment, when patients were given palliative care as an alternative, most withdrew their request for euthanasia.  Those who did not had to leave the hospice to receive their euthanasia. That experience points to a problem in Quebec.

The hospices in Quebec have announced that they will not make provision of euthanasia available in their facilities.  In any case, there is a shortage of hospices in the province.  Nevertheless, those choosing death may need to move out of their hospice, not a comforting situation for them.

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