Patient choice will override physicians’ assessment
The Canadian Parliament is debating a major expansion of the country’s 2016 euthanasia act. Critics say that the amendments will make Canada’s law the most permissive in the world.
Bill C-7 intends to give access to “Medical Assistance in Dying” (MAiD) to people whose natural death is not reasonably foreseeable. It establishes more relaxed eligibility rules for those who are near death, including a form of advance directives, and more stringent rules for those who are not.
Writing in Policy Options, Trudo Lemmens, Mary Shariff and Leonie Herx contend that C-7 endorses an ablist prejudice that life with a disability has less dignity or is less worth living. It transforms MAiD “from a procedure to facilitate dying into a terminal therapy for life’s suffering”.
The particular effect they zero in on is that the Bill abrogates a doctor’s traditional “standard of care”, which obliges “physicians to apply their skills and intricate knowledge to a patient’s particular clinical circumstances.” Instead patient choice becomes the criterion for deciding whether or not he or she is eligible for MAiD.
That physicians need to obtain “informed” consent from the patient before engaging in MAiD is obviously key. But they must also generally act according to the “standard of care” which is based on evidence-informed standards, shared among professionals and in line with their acquired clinical expertise.
The fact that a patient ultimately consents to a treatment proposed by a physician does not dislodge this a priori standard. It is part of medical practice that physicians can present only those medical treatment options that are reasonably and objectively indicated based on the “standard of care.”
They use the example of a hip replacement to illustrate the problem. Before surgery, which is risky and painful, a doctor will advise a patient to modify his lifestyle or to use pain medication. He doesn’t reach for a scalpel immediately.
But C-7 effectively allows a patient to self-diagnose his “enduring and intolerable suffering” and to prescribe the remedy, death. This is obviously a very tricky problem for patients with mental disorders.
This is a stunning reversal of the central role of the medical and legal concept of the standard of care. It lifts “informed consent” up to the status of the sole arbiter of what constitutes proper medical practice. This development is also internationally unprecedented. Even the three most permissive MAiD regimes in the world — Belgium, the Netherlands, Luxembourg, the only ones that currently permit physician-provided ending of life outside the end-of-life context — treat MAiD rightly as the last resort, available when no other options are seen to remain.
The authors caustically observe that Canadian doctors have surrendered their professional integrity.
By supporting Bill C-7, medical organizations are handing over to patients the determination of professional standards. They are thereby also abandoning their commitment to patients to provide the best evidence-informed care, based on the concept of “informed consent” that we also know is rarely if ever fully realized in practice.
Parliamentary critics are also alarmed at the haste with which the law is changing. “Colleagues, how did we get to this point, where we are debating an overhaul of our entire regime a few short years after its enactment and before we have even undertaken a parliamentary review?” asked Opposition Senate leader Don Plett this week. “As has been said before, we are here because of a lower court decision made by one judge, in one province and because the government chose not to defend its own legislation.”
Michael Cook is editor of BioEdge
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