Webcast archive: Safeguards in the College of Physicians’ guide

This week, we continue our discussion on the Quebec College of Physicians guide to MAID.

In this episode of Euthanasia & Disability, Amy Hasbrouck and Christian Debray discuss:

  • Too little, too late: Safeguards in the College of Physicians’ guide to MAID

Please note that this text is only a script and that our webcast contains additional commentary.

SAFEGUARDS: TOO LITTLE, TOO LATE:  THE COLLEGE OF PHYSICIANS GUIDE TO MAID

  • A few weeks ago when we talked about the Québec physicians’ guide to Medical Aid in Dying, we promised we would get back to it in more detail.  Today, we return to the guide.
  • It can be hard to talk about the safeguards in the guide because:
    • It’s hard to describe something that isn’t there.
    • The authors assume that safeguards are not necessary.
    • Though all of the decisions are left up to one doctor, the responsibility for protecting people in vulnerable circumstances rests with society as a whole.
  • Some of the typical problems as found in the Québec plan include
    • Safeguards are seen as working against the person’s interest (mentioned on pp. 21, 31).
    • Dying is portrayed as “relief” from suffering, (see pp. 17, 30, 31).
    • Standards are relaxed over time (pp. 26, 54).
    • All decisions are concentrated in the hands of one doctor. (pp. 27, 28).
    • By taking a strictly medical approach, the program does not address the primary reasons people ask for assisted suicide:
      • Loss of autonomy
      • Loss of ability to do the things the person enjoyed
      • Perceived loss of dignity
      • Loss of control of bodily functions
      • Feeling like a burden
      • Pain or concerns about pain
  • The effects of prejudice and discrimination
    • Examples of “psychological suffering” that merits euthanasia includes (p. 15):
      • Total dependence.
      • Desperation when faced with a no-win situation.
        • These are caused by badly managed services and supports.
        • These could apply to a survivor of domestic violence.
    • The assumption that living with dying is intolerable.
  • The Application Process
    • Lacks provisions for accessibility
      • Sign language interpreters & Scribes (p. 14)
      • Print materials in alternative formats
    • No protection against family members with financial interests who witness or write forms. (p. 14)
    • Nothing prevents a doctor from falsifying documents.
    • There don’t appear to be any barriers to applying multiple times (p. 30, 34) or “doctor shopping.”
  • Preventing Abuse
    • Doctors lack training to detect signs of abuse
    • Neither a psycho-social evaluation, nor a home visit is required.
    • “Conversations with families” are not mandatory (p. 18).
    • There is no provision for intervention where abuse is detected.
  • Competency determination
    • Appears to be only medical judgment rather than the legal decision (as provided for in the Civil Code of Québec) (p. 28).
    • Choosing to undergo a medical procedure is not the same as choosing to end one’s life.
    • The Guide does not mention “depression” or mandate a psychological assessment.
  • “Free and informed” choice
    • Information is not the same as options (p. 22).
    • Options offered are exclusively medical and don’t address social or discrimination issues.
    • The “choice” to die is an illusion where the person doesn’t have a choice of where or how to live. (p. 16).
  • “End of life” definition
    • Criteria are entirely subjective.
    • Range from two months to eight years (p. 16, 18).
    • The College of Physicians did not focus on the stage that occurs a few days before natural death (p. 17).
  • “Treating physicians”
    • Decision is made and procedure done by treating physician (p. 14)
      • What happens to the 25% of Québécois do not have a primary care doctor?
      • Does this include specialists, or only generalists?
    • Pressure on “treating physicians” not to refuse to provide euthanasia is very intense, invoking guilt, professionalism and responsibility.
    • All decisions and power are in the hands of the treating physician, others are merely advisors.
  • “Interdisciplinary teams”
    • Are suggested, but apparently not required (p. 15).
    • Teams are required for coaching the doctor (p. 29), but not for working with the person making the request.
    • The multidimensional approach recommended is not guaranteed where “resources are not available” (Speech by P. Couillard, 4 June 2014).
  •  “Medical Judgments”
    • Euthanasia is more than just a medical issue (§ 3.4.2, p. 23).
      • Capacity is a legal matter,
      • Mental health and family supports are social issues.
    • Describing pain as “impossible to relieve” shows ignorance of palliative techniques (p. 24).
    • Requiring the doctor to “assure himself” of compliance creates a low standard of objectivity (p. 27).
  • Doctors should develop expertise and proficiency
    • There is no indication as to how doctors will be trained. (p. 24).
    • The guide estimates that they will perform euthanasia less than once per year provides insufficient opportunity to “practice” (p. 12).
    • Things don’t always go as planned when performing euthanasia (p. 32)
    • There is insufficient research to reliably predict what will happen in all cases (p. 33).
  • Doctors’ Conscience Rights
    • It appears doctors must determine eligibility, regardless of their beliefs about euthanasia (p. 24).
    • Must make a referral to another physician for euthanasia
    • Multiple passages discourage doctors from following their conscience and refusing to kill (p. 24, 25)
    • Doctors who don’t want to kill can’t consult (p. 29).
  • Other Issues
    • The length of “reasonable delay” (waiting period) is not defined, (p. 28)
    • Doctors must indicate underlying illness, not euthanasia, as cause of death on the death certificate (p. 49).
    • As we mentioned last summer regarding the regulations for forms doctors must turn in, it appears that the actual medical record will not be sent to the Commission on end of life care.  Instead, forms and reports filled out by the treating physician can only be compared against the report of the second physician for accuracy.
  • Problems Unique to Québec
    • Québec continues to perpetuate the Big Lie – That everyone supports euthanasia (p. 12)
      • A report by Living with Dignity in 2012 showed that majority of Commission witnesses opposed AS/E.
      • An Ipsos poll sponsored by Living with Dignity in 2013 showed many confused “Medical Aid in Dying” with “palliative care.”
    • Despite freedom of conscience provision in the law (§ 72) for hospices, Québec government is threatening to withhold funding from hospices that refuse to euthanize.  One hospice has already yielded before the threat.
    • The method of administration
      • Prepare the intravenous site
      • Inject a tranquilizer
      • Induce an artificial coma using barbiturates
      • Inject a neuromuscular blocker to stop the heart and respiration.
    • Nurses
      • must help doctors at several stages, including setting up the IV.
      • The guide does not state that nurses have conscience rights to refuse.
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