30 June 2012

Therapeutic Homicide?

With the recent Carter v Canada (Attorney General) 2012 BCSC 886 euthanasia decision in mind it is interesting to see 'Choosing when and how to die: Are we ready to perform therapeutic homicide?', an editorial [PDF] by Ken Flegel & John Fletcher in the Canadian Medical Association Journal regarding the Dying With Dignity report from the Quebec legislature earlier this year.

The authors comment that
the report calls for a change in thinking, arguing that there will still be cases where suffering is great, irreversible and unrelievable, such that the only option is actively helping a person to die. 
The recommendation [regarding physician-assisted death] is based on two legal considerations. First, the civil code recognizes the right of adult patients to make medical decisions concerning their care, even if refusing or stopping treatment may result in their death. Second, both the Quebec and Canadian charters of rights and freedoms enshrine the rights to personal dignity and integrity. These rights imply a respect for self-determination and a person’s physical and psychological well-being. These are powerful arguments and suggest that an individual should be able to make life’s important decisions in a free and unconditional way, including deciding when the struggle to stay alive should end. However, this line of reasoning only supports an individual’s right to end his or her own life. 
Proponents of “dying with medical assistance” must argue that a patient’s rights invoke a corresponding medical duty to provide the means if a patient cannot, and it follows that this should be done in a safe and expert way. Hence, the act of assisting death would need to move from the context of being criminal to being part of the continuum of end-of-life care. 
Many physicians and patients will find this a shocking prospect to consider. If their views are to prevail, they will need to argue why there should be limits to a person’s autonomy. Human dignity may imply certain rights and freedoms, but conflicts among people’s rights are hard to resolve. Frail, dependent patients often feel a burden to their families or caregivers, and the unspoken possibility of a quick resolution to their predicament may complicate an already stressful situation. Removing the legal barrier to ending another’s life may ensure the self-dignity of those who wish to die, but may distress and remove the self-dignity of more people who wish to live.
The salient recommendations of the Quebec report are -
12  The Committee recommends that persons diagnosed with an incurable disease be given an information guide on their rights and the available services and resources. 
13 ... that relevant legislation be amended to recognize medical aid in dying as appropriate end-of-life care if the request made by the person meets the following criteria, as assessed by the physician: 
• the person is a Québec resident according to the Health Insurance Act;
• the person is an adult able to consent to treatment under the law;
• the person himself or herself requests medical aid in dying after making a free and informed decision;
• the person is suffering from a serious, incurable disease;
• the person is in an advanced state of weakening capacities, with no chance of improvement;
• the person has constant and unbearable physical or psychological suffering that cannot be eased under conditions he or she deems tolerable. 
14 ... that relevant legislation be amended to include the following guidelines: 
• all requests for medical aid in dying must be made in writing by way of a signed form;
• the request must be repeated within a reasonable period of time, depending on the type of disease;
• the attending physician must consult with another physician on whether the request meets the eligibility criteria;
• the physician consulted must be independent of the patient and the attending physician, and be competent with respect to the disease in question;
• the attending physician must complete a formal declaration of medical aid in dying. 
15 ... that a body be created to control and evaluate medical aid in dying and whose responsibilities would be to: 
• verify whether acts of medical aid in dying were carried out according to the conditions provided by law;
• publish an annual report, including statistics, on acts of medical aid in dying;
• publish, every five years, a report on the implementation of medical aid in dying provisions. 
16 ... that the appropriate National Assembly committee examine the five-year report of the control and evaluation body. 
17 ...  that relevant legislation be amended to recognize that an adult with the capacity to consent is entitled to give an advance directive for medical aid in dying in the event he or she becomes irreversibly unconscious, based on scientific knowledge. This advance directive for medical aid in dying: 
• must be given in a free and informed manner;
• is legally binding;
• must take the form of a notarized act or an instrument signed by two witnesses, including a commissioner of oaths;
• may mention the name of one or more trusted persons who will ensure the directive is known. 
18 ... that relevant legislation be amended to include the following guidelines: 
• the attending physician must consult another physician to confirm the irreversible nature of the unconsciousness;
• the physician consulted must be independent of the patient and the attending physician. 
19 ... that the ministère de la Santé et des Services sociaux: 
• take the necessary measures to ensure the advance directive for medical aid in dying appears in a person’s medical file and is recorded in a register;
• ensure that physicians check for the existence of such a directive in patient medical files or in the register;
• ensure that each establishment’s service quality and complaints commissioner periodically verifies compliance with advance directives for medical aid in dying. 
20 ... that the Attorney General of Québec issue directives (in the form of “guidelines and measures”) to the Director of Criminal and Penal Prosecutions to ensure that a physician who provides medical aid in dying in accordance with the criteria provided by law cannot be prosecuted. 
21 ... that the Collège des médecins du Québec amend its Code of Ethics so that physicians may provide medical aid in dying in accordance with the criteria provided by law while confirming their right to conscientious objection and their obligation, in such a case, to refer their patient to another physician. 
22 ... that the Ordre des infirmières et infirmiers du Québec amend its Code of Ethics to allow its members to help provide medical aid in dying in accordance with the criteria provided by law while, however, confirming their right to conscientious objection.