Tom Koch, the research scientist specializing in ethics has studied how the situation of medical termination, which covers euthanasia and assisted suicide, has evolved in Canada since its legalization in 2016. His study deals in particular with the question of whether or not the concerns of those persons opposed to legalization (skeptics) have proved to be justified or unfounded. His approach is not philosophical, but based on facts.
He analyses two types of argument:
- The probable “slippery slope” effect resulting in the gradual relaxation of the eligibility conditions and consequent increasing number of deaths.
- The probability that euthanasia will supplant palliative care, especially in areas where palliative care is poorly developed.
First argument: The rapidly broadening of eligibility criteria and the increase in deaths
The yearly total of euthanasias has strongly increased over 5 years, increasing from 1,018 to 7,589. The author mentioned that this increase has continued through 2021. The last statistical report, released after this study, records 10,064 deaths in 2021, i.e. some 3.3% of Canadian deaths and an increase of 32% relative to the previous year.
The law governing “Medically assisted death” adopted in 2016, from the outset established broad and subjective eligibility criteria, especially as the doctor or paramedic calling on them may have an “erroneous understanding” of them, whilst remaining blameless, according to article 227(3). In order to qualify for euthanasia or medical termination, the person must be of age and “afflicted with serious and irremediable health problems“. This expression means in particular that “his/her sickness, ailment, handicap or advanced and irreversible decline in capacities are causing him/her intolerable persistent physical or psychological suffering which cannot be relieved under conditions which he/she considers acceptable” and that “his/her natural death has become reasonably foreseeable in view of the overall medical situation, without any forecast having been given on his/her life expectancy.” In addition to the opinion of a second doctor or paramedic, a time-delay of 10 days was necessary between the written request by the person and the application of euthanasia or medical termination. This time-delay could be shortened, only at the discretion of the medical team, if the death of the person or the loss of the capacity to provide an enlightened consent is imminent.” In the event of the person’s inability to sign and date the request, “a third party of at least 18 years of age and who understands the nature of the request for medical termination, may do so expressly on his/her behalf, in his/her presence and in accordance with his/her instructions.”
In 2021 a new law was adopted, law C7, which removed the short-term end-of-life criterion and the time-delay for application. In practice, this relaxation means that a physically handicapped or chronically sick person is now eligible for euthanasia. The law states that it is possible to carry out euthanasia on a patient who is unable to express his/her final consent (for example if unconscious) and whose death is reasonably predictable, in the event that he/she has made an anticipated statement to that effect, or if the self-administered lethal injection has failed.
The possibility of extending euthanasia to mental sickness is currently under discussion in Canada.
Since 2016, the eligibility criteria have been so relaxed that people who are merely worried about possible future illnesses may choose to end their life. The report mentions the case of a couple, reported in 2018: George and Shirley Brickendens (Grant 2018) who were granted euthanasia not on the grounds of pain or distress, but because they feared a future invalidating disease.
In a recent report at the World Lung Cancer Conference [1], Canadian research scientists reported that with the relaxation of medical termination criteria, “Patients are seeking this option despite the availability of more effective and better tolerable treatments.”
Second argument: Could euthanasia become a substitute for palliative care?
The other subject of concern was that euthanasia could become a substitute for palliative care and other support services. Palliative care, in this case is taken in its widest sense, to include not only the management of pain, but also the accompaniment of chronically ill patients in their living environment. This may include continuous care for those suffering from chronic disease (ALS, multiple sclerosis etc.) which, with appropriate medical care and social support, are not end-of-life conditions.
According to the author, the problem could be due in part to a lack of specialists able to explain and provide such therapies. Indeed, a report [2] by Health Canada 2020 on the reasons given by patients requesting medical termination, indicated that over 50% of respondents mentioned inadequate pain control or concern about the possibility that their pain could become uncontrollable. More than 50% also gave as a reason the generally inadequate control of other symptoms. Finally, over 35% gave as a reason the feeling of being a burden on family and friends.
Generally speaking, the level of specialist care and support services available in most Canadian States is inadequate. In 2016, the Canadian Society of Palliative Care Doctors [3] reported that “a mere 15% of patients requiring specialist palliative care, are able to receive it, and such care is often provided only for short periods before death”. A subsequent study in 2018 has shown the limited availability of palliative health care in most States. The Canadian Institute for Health Information (CIHI) reported [4] that according to the available data “few providers of health care in Canada are specialized in or practice essentially palliative care…”.
Evidently, the concerns of the “skeptics” were justified. Tom Koch thus questions the reality of the claimed autonomy and freedom of choice in the absence of high-quality accompaniment and medical care.
[1] Susman, E. 2021. Study sheds light on physician-assisted suicide in lung cancer patients. Medpage Today (Sept. 9). http://www.medpaget0day.com/meetingcoverage/iaslc/ 94429.
[2] Health Canada. (2021). Second annual report on medical assistance in dying in Canada 2020. Ottawa:Health Canada. https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annualreport-2020.html.
[3] CSPC. (2016). How to improve palliative care in Canada: A call to action for federal, provincial, territorial,regional and local decision-makers. Ottawa: Canadian Society of Palliative Care Physicians. http://www.cspcp.ca/wp-content/uploads/2016/11/Full-Report-How-to-Improve-Palliative-Care-in-Canada-FINAL-Nov-2016.pdf
[4] CIHI. (2018). Access to palliative care in Canada. Canadian Institute for Health Information.
