Requesting euthanasia in anticipation has now become possible in Quebec
Since 30th October 2024, it has become possible in Quebec to apply for medical assistance in dying (MAiD) i.e. euthanasia, in anticipation.
This measure introduced in Quebec is included in a law extending MAiD as it was adopted in June 2023. Two other measures in the law have already been introduced:
• The obligation for palliative care centres to provide MAiD since the beginning of 2024;
• The availability of MAiD for cases of serious physical deficiency from the spring of 2024.
In practical terms, what is meant by a request for MAiD in anticipation ?
It enables sick patients to submit an application to consent in advance for MAiD. They will be able to have MAiD administered once they have become inapt. In order to be eligible for such an anticipated request, the patient must have been diagnosed with a serious and incurable disease, leading to inaptitude such as a neuro-degenerative disorder like Alzheimer’s or multiple sclerosis. At the moment when the patient submits the request, in a free and enlightened frame of mind, the person must be:
• adult,
• able to consent to treatments, i.e. MAiD which Canadian law considers as a treatment,
• covered in the eyes of the law by health insurance.
The Quebec law is different from the Canadian federal law. Its particularity is that it includes euthanasia in “end-of-life care”, which includes palliative care, MAiD and advance medical directives, as distinct from anticipated requests for MAiD. Advanced medical directives allow, for example the refusal of certain treatments in the future but they cannot be used for requesting medical assistance in dying.
What are the stages for a request for MAiD in anticipation?
1. Completion of a form
In the form, which is available from a doctor or a specialist practitioner nurse, the person describes the clinical conditions associated with the diagnosed illness which would justify the triggering of the validation of MAiD in the event that the person is unable to provide such consent. The patient may also designate one or two people of confidence whose role will be to ensure that the wishes expressed by the patient in the application for MAiD in anticipation are known and fulfilled.
According to the “Vivre dans la dignité” (living with dignity) network, “There will not be any lists of inadmissible motives. Everything will be left to the better judgement of the various parties (patient with a neuro-degenerative disease diagnosis, a competent doctor, a person of confidence and, for those who so wish, a solicitor).” The Quebec Minister for Health and the Aged, has listed some examples of motives which would be considered to be acceptable:
“When, for example, I no longer recognise my own children, when I become unable to feed myself, when I become unable to walk unaided, to go to the toilet, when I have physical suffering, that I appear anxious, then at that stage, I wish to be evaluated to receive medical assistance in dying.”
2. Examination of the person having submitted a request for MAiD in anticipation
This examination is conducted when a person of confidence, or any other person under certain circumstances specified by law, believes that the person exhibits clinical conditions associated with the disease and described in the application or is enduring persistent and unbearable physical or psychological suffering.
The practitioner responsible for evaluating the patient considers the clinical conditions mentioned in the application form and checks that the patient is enduring persistent and unbearable physical or psychological suffering. This question of suffering has caused some debate in Quebec inasmuch as practitioners consider that the advanced decline due to a disease like Alzheimer’s automatically causes intolerable psychological suffering.
According to them, there can be no “happy dementia”, in the sense that the disease always masks intrinsic suffering, an associated psychological suffering. Others on the contrary, claim that in the event of “happy dementia”, MAiD cannot be authorised.
3. Administration of MAiD
Although the law provides that the expression of a refusal gesture will arrest the administration of death, it also enables anticipation of such refusal in the form by a request for sedation prior to euthanasia.
MAiD, the endless extensions?
In Quebec, opinion polls are favourable to the request in anticipation. People suffering from the early stages of Alzheimer’s are pushing for the introduction of the measure. Nevertheless, geriatricians and carers working for example in homes for people suffering from Alzheimer’s, are less keen, being well aware that such requests will be difficult to apply. It is important to understand that there is no need to be a specialist in neuro-degenerative disorders in order to accompany the 1st stage of the form which lists the clinical conditions.
Quebec has joined the Netherlands, up till now the only nation to offer requests for euthanasia in anticipation for those unable to provide consent but who are still conscious. Nevertheless, several questions remain:
• What are the protocols for the lethal injection to inapt patients who do not expect their living days to be ended?
• Will there be any prior studies into the consequences to be expected on the families and the medical staff?
• What will be the next frontiers when there is already talk of extending the law on euthanasia yet again to cover mature minors and cases of those who are tired of living?
In less than 10 years, the law in Quebec is constantly worsening. The introduction of a request for euthanasia in anticipation is particularly alarming. According to the “Vivre dans la dignité” citizens’ network : “It is help for living” which people need, “not medical assistance in dying under the disguise of compassion.”
