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Updated: 2 months 5 days ago

Dutch Court decision on 'coffee euthanasia' opens the door to dubious practices

Fri, 2020-05-01 18:22
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Netherlands Supreme Court recently approved euthanasia for incompetent people with dementia who had made a previous request for euthanasia.

The case concerned the euthanasia death of a woman with dementia, who had stated in her power of attorney document that she wanted euthanasia but when the doctor came to inject her she resisted. The doctor attempted to sedate the woman by putting the drugs in her coffee but she continued to resist so the doctor had the family hold her down while the doctor lethally injected her.

In January 2017, a Netherlands Regional Euthanasia Review Committee decided that the doctor had contravened the rule of law but that she had done it in "good faith."

According to Reuters, the Supreme Court found that:
The Dutch Supreme Court on Tuesday ruled that doctors could legally carry out euthanasia on people with advanced dementia who had earlier put their wishes in writing even if they could no longer confirm them because of their illness. The ruling is a landmark in Dutch euthanasia legislation which up to now had required patients to confirm euthanasia requests. This had not been considered possible for mentally incapacitated patients like advanced dementia sufferers. “A doctor can carry out an (earlier) written request for euthanasia from people with advanced dementia,”Theo BoerProfessor Theo Boer, a former member of a Netherlands Regional Euthanasia Review Committee (2005 - 14), wrote about his concerns about the Supreme Court decision that were published by Trouw in the Netherlands (google translated).

Boer describes the case in Trouw:
The Supreme Court recently ruled on coffee euthanasia. A 74-year-old patient with dementia had stated in a living will that she wanted euthanasia if she ended up in a nursing home. When that indeed happened and she became incapacitated, she gave varying signals: most of the time she didn't want to live, but sometimes she was having a good time. Although the doctor had put something calming in her coffee, the woman resisted during the euthanasia. The Supreme Court ruled that the doctor had acted correctly by taking the patient's advance directive as a compass.Boer expresses his concern that the number of euthanasia deaths for people with advanced dementia will increase and he questions how these decisions will be made based on the fact that these people are incompetent. He then expresses his concern for what he calls, "dubious euthanasia." He writes:
This also increases the risk of dubious euthanasia. Because people with advanced dementia are by definition not competent (many are even aphrodisiac), the practical request for euthanasia comes from the family. The doctor (nursing home doctor or doctor of the Expertise Center for Euthanasia) may be independent, but he will rely heavily on their judgment when weighing the agony of suffering. After all, the doctor usually did not know the patient before. That opens the door to framing. Despite good intentions, family value judgments ("I would never want to be demented," "What kind of life is that?") Take on a strong role. It cannot be excluded that financial and emotional considerations are a motivating force.Boer than expresses that the Dutch Supreme Court decision proves that there is not a "border" to euthanasia even as other countries, when debating euthanasia, social distance themselves from the Dutch euthanasia program.

Boer concludes by pointing out that this decision will likely lead to a new opportunities to expand euthanasia. Based on "legal equality and compassion" why would euthanasia be limited to people with dementia who previously requested euthanasia when people who did not request euthanasia also suffer?

The only bright line is rejecting euthanasia. Once it is legal it is unfair or it lacks "compassion" to deny it to others, who are also "suffering."
Categories: Discussion

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues

Wed, 2020-04-29 21:46
This article was published in the World Medical Journal. (Link - page 28 - 39)

Written by: Dr Leonie Herx, Dr Margaret Cottle and Dr John Scott.

In June 2016, Canada legalized euthanasia and assisted suicide, which legislators referred to collectively as “Medical Assistance in Dying” (MAiD). In Sept 2018, an article was published in this journal summarizing the early impacts of legalized euthanasia on Canadian medicine [1]. In October 2019, the World Medical Association (WMA) reaffirmed its opposition to euthanasia and assisted suicide [2]. We propose in this article to update colleagues around the globe on consequences of the rapid expansion and cultural normalization of the practice of intentional termination of life in Canada. 


Dr Leonie HerxThis paper will balance recent portrayals in the popular and medical media that imply only a positive impact as a result of the introduction of euthanasia into Canada’s health system [3–4]. Evidence will be presented to demonstrate that there are significant negative and dangerous consequences of this radical shift for medicine, and particularly for palliative medicine. These include the widening and loosening of already ambiguous eligibility criteria, the lack of adequate and appropriate safeguards, the erosion of conscience protection for health care professionals, and the failure of adequate oversight, review and prosecution for non-compliance with the legislation. Indeed, what we have seen over the past four years is that “the slope has in fact proved every bit as slippery as the critics had warned” [5]. We also seek to reaffirm the vision of the physician’s role “to cure sometimes, to relieve often and to comfort always.” 

How Many People Undergo Euthanasia in Canada? 

Dr John ScottIn just under four years, the number of euthanasia deaths has rapidly increased in Canada. New statistics released by the federal government on February 24, 2020, show that 13,000 people have died by euthanasia since the legalization of the practice, which represents approximately 2% of all deaths in Canada. The government estimated that there were 5,444 deaths in 2019 and 4,438 deaths in 2018 from euthanasia [6]. In comparison, Statistics Canada reported 1,922 deaths in motor vehicle accidents for 2018, the latest year for which statistics are available [7]. Euthanasia proponents argue that the Canadian death rate should stabilize at a level comparable to other jurisdictions with equivalent legislation, such as the Netherlands where euthanasia now accounts for 4.9% of deaths [8]. However, it is troubling that Canada’s rate has increased more rapidly than other permissive jurisdictions over a similar initial time period, and that our rates are quickly approaching current rates in the Netherlands and Belgium, where euthanasia has been legal for almost 20 years. 

Expansion of Euthanasia Practice and Legislative Changes 

Dr Margaret CottleIn addition to the increasing numbers of cases, there is also an expanding range of indications approved for euthanasia. In four years, Canada has moved from approving euthanasia for so-called “exceptional” cases to euthanasia being treated as a normalized, almost routine, option for death. 

Ongoing court challenges to legislative requirements for euthanasia have resulted in its approval for individuals with chronic illnesses such as osteoarthritis, dementia, and physical disability [9, 10, 11, 12]. Media reports point to less restrictive interpretations of eligibility criteria by assessors and providers of euthanasia without intervention from the courts [13, 14]. These precedent-setting cases have produced what euthanasia providers themselves call “not an expansion of our law” but “a maturing of the understanding of what we’re doing” [12]. This, in turn, has led providers to approve cases they would not have previously approved due to earlier fears of criminal prosecution [15]. Although reports of criminal code and regulatory body violations have been well documented [16, 17], no charges have ever been laid. 

In September 2019, a Quebec Superior Court ruling on the Truchon case [11] struck down a central euthanasia criterion for “reasonably foreseeable natural death” (RFND) which may soon open up euthanasia to those with chronic conditions, disabilities and mental health issues as a primary diagnosis. The Federal Government is committed to expanding the legislation and, on February 24, 2020, tabled a new bill in Parliament to respond to the Truchon case ruling to remove the requirement for RFND [18]. In the near future, euthanasia in Canada will almost certainly be open to any person who feels their suffering cannot be addressed except through intentional termination of life. As mandated by the 2016 legislation, the Canadian government is continuing to explore the additional inclusion of those with mental health issues as a primary diagnosis, “mature minors” (i.e. children), and euthanasia by advance directive (for those who may lose decisional capacity at some point in the future) as part of a parliamentary review expected to begin by June 2020 [19]. 

Even those who support euthanasia in some circumstances are voicing concerns over the rapid expansion of the procedure in Canada, and a problematic lack of proper, robust analysis of its utilization [20]. Many who care for citizens with mental health issues are extremely concerned, not only that psychiatric conditions may be considered “irremediable” by some, but also that if psychiatric indications are permitted as the sole reason for euthanasia, these patients could possibly have euthanasia performed almost immediately, whereas the wait time can be years for specialized, lifesaving psychiatric interventions and care [21]. The lack of access to psychiatric care in Canada is also putting patients who are facing an end of life diagnosis in an even more dire situation [22], given the high risk for suicide in this population [23, 24]. 

Euthanasia deaths are now serving as a growing source of organ and tissue donations in Canada [25]. Unlike other countries, Canada is the first jurisdiction to allow non-patient-initiated discussion of organ donation for those approved for euthanasia. In other jurisdictions where euthanasia is legalized, including the Netherlands and Belgium, only patient-initiated organ donation discussion is allowed, while in some jurisdictions, including Switzerland and some U.S. states, subsequent organ donation is not possible following assisted suicide. Having the potential to alleviate the suffering of another person in need or to leave a legacy appears to be a powerful motivator in the decision for organ donation as part of death by euthanasia [25]. One individual who donated her organs after euthanasia stated, “I thought the knowledge of having full autonomy by way of MAiD was comforting, but, when the possibility of organ donation was added to it, the sense of elation is the only appropriate word for me.” [25]. Given that most requests for euthanasia are due to existential suffering, in particular feeling a burden to others and loss of meaning and purpose in life [26], the potential “good” of organ donation may be a persuasive incentive for some who may otherwise not have chosen to hasten their death. 

Euthanasia providers are now making recommendations to add drugs (e.g., potassium chloride) to the existing regimen which will cause rapid cessation of cardiac activity and reduce the potential for ischemic damage to organs to be transplanted. The rationale for the change is that it “allows organs to be donated in the best condition possible” [27]. Questions are also being raised about starting organ procurement processes prior to death being determined which would also allow organs to be donated in “the best condition possible” [28]. There are a number of difficult issues that arise when considering organ donation in these circumstances, including conscientious objection of team members involved in transplantation, the “dead donor” rule, and informing potential recipients of the source of the organs to be transplanted. 

More evidence of the normalization of euthanasia can be seen in the recent set of tips published on how to prepare children for a euthanasia death of a loved one. The author, Co-Chair of the Ontario College of Family Physicians Palliative/End of Life Care and MAiD Collaborative Mentoring Network,  recommends, “if the adults surrounding them normalize MAID [sic], so will the children” [29]. Medical literature regarding children, death and grieving was used to extrapolate approaches to the euthanasia context. Tip #5 states that these conversations can easily be had with children as young as four years old. Tip #6 suggests that euthanasia providers should offer to show your equipment (syringes, stethoscope, IV  supplies). For example: “I have a tray with the things I will use to help your loved one die. These include medications and syringes. I am going to leave them on the table and if you would like to take a look you can. I will stand beside the table and you can ask me any questions” [29]. 

Euthanasia Due to Lack of Access to Care or Lack of Perceived Quality of Life 

Examples are mounting of Canadians requesting euthanasia because of lack of access to care, such as long-term care or disability supports [30, 31]. A significant number of reports have documented cases in which individuals have been told by health care professionals and others to consider euthanasia as an “answer” to a perceived poor quality of life or a lack of health care resources to meet their needs. Motivation for these decisions and suggestions appears to include the cost of care or specialized supports [32, 33]. 

Following the Quebec Superior Court ruling on the Truchon case [11], over seventy Canadian disability allied organizations came together out of concern for the equality rights of vulnerable Canadians, and signed an open letter asking the federal government to appeal the court ruling to the Supreme Court of Canada [34]. A similar open letter [35], urging an appeal in the same case, was signed by over 350 physicians from all specialties across Canada. No appeal was made. These disability experts and physicians argued that the removal of the end of life criterion (RFND) means that disability-related suffering, largely caused by lack of support and societal inequality, justifies the termination of a person’s life. When the legislation is amended, this will effectively enshrine in Canadian law the principle that a person’s life can be ended based on disability alone, further stigmatizing and devaluing the lives of those living with disabilities. 

Disability advocates continue to express alarm at the evolving situation in Canada, and Catherine Frazee (former Human Rights Commissioner in Ontario and retired professor in Disability Studies) points to the hidden message being conveyed by government, that expanding medically assisted death so that it is not only for those who are dying, but also, exclusively, for those who have some illness, disease or disability, makes us a ‘special case’ for ending a difficult life. This categorically sends one and only one message: we are not needed. Whatever gifts we bring to the world, gifts of mind and heart and body, are not of such value that Canada will fight for us to live [36]. 

International attention was garnered last year when the UN’s Special Rapporteur on the Rights of Persons with Disabilities traveled to Canada in the spring of 2019. In her end-of-mission statement, Ms. Devandas Aguilar stated that she is “extremely concerned about the implementation of the legislation on medical assistance in dying from a disability perspective…” and she urged Canada to do more to “…ensure that persons with disabilities do not request assistive [sic] dying simply because of the absence of community-based alternatives and palliative care” [37]. 

“Safeguards” for Euthanasia 

The Supreme Court of Canada, in the case of Carter v. Canada (2015), that originally led to the decriminalization and subsequent legalization of euthanasia, stated that a “carefully designed and monitored system of safeguards” would limit risks to vulnerable persons [38]. The safeguards in the subsequent 2016 legislation [39] include a mandatory ten-day reflection period between the request and the euthanasia procedure, the independent nature of the two eligibility assessors, the requirement for decisional capacity of the patient at the time of the request and at the time of the procedure, protection against coercion by requiring two independent witnesses, and a rigorous system of monitoring and review. 

Currently, the ten-day reflection period is often waived, and the newly proposed legislation would formally repeal this requirement [18]. In one cohort study of euthanasia deaths in Ontario, 26% of euthanasia deaths had the ten-day reflection period expedited [40]. In Quebec, it has been reported that 60% of euthanasia cases had the ten-day reflection period waived and, of these cases, 48% did not meet the criminal code criteria for removal (i.e., imminent risk of death or imminent loss of decisional capacity) and 26% had no documented reason for waiving the reflection period [41]. 

Compliance reports from Quebec have also documented concerns about the “independent nature” of assessors [17]. In our personal experience, the assessors are in reality not always independent. Assessors are often colleagues belonging to a small community of providers who practice euthanasia. The second assessor can see the first assessor’s report prior to seeing the patient or writing their own report. There are also no data about how often a second assessor disagrees with a first assessor, or how many different assessors an individual seeks out, since there is no limit to the number of assessments that can be obtained. An individual patient only needs two approved assessments. A study from Belgium, which deals with euthanasia for psychiatric reasons, suggested that 24% of cases involved disagreement amongst consultants, highlighting the challenge of discordant assessments [42]. Although the current and proposed initial amendments to the euthanasia legislation in Canada (response to the Truchon case) do not permit euthanasia for psychiatric reasons alone, this indication is under formal review [19] and there is considerable public pressure for its legalization from those who wish to see this expansion [43]. 

We also note that it is difficult, even in person, to determine decisional capacity or possible coercion, especially if a case is complicated. In Canada, both telemedicine (video) and telephone (voice) are allowed to be used for euthanasia assessments. Determination of a person’s decisional capacity is not straightforward and may require advanced skills and tools [44], but there are no formal requirements for training to assess decisional capacity and no requirement for psychiatric consultation in complex cases. Many physician colleagues, ourselves included, report personal experiences with patients who, in their opinion, lacked decisional capacity at the time of the euthanasia assessment and/or at the time of the procedure, and still received euthanasia even though formal documented concerns had been raised with the euthanasia providers. 

Monitoring requirements include only basic demographic information and are reviewed in retrospect [45]. Information about race, education, socioeconomic status, and language abilities is not collected, and there is no direct oversight or mechanism to stop the procedure if red flags are raised. 

A group representing euthanasia providers, the Canadian Association of MAiD Assessors and Providers (CAMAP) has been calling for the abandonment of the requirement for two independent witnesses (established to ensure protection against coercion). They contend that this requirement is a bureaucratic frustration that blocks patient access. New legislation proposes to reduce the number of witnesses to one and would make it legal for that witness to be the patient’s paid personal care worker or health care provider [18]. There is also a reasonable concern that the blanket misapplication of the so-called “duty to inform” may soon suggest to all physicians that they are required to offer euthanasia as an option in every serious illness. If this is the case, it will be impossible for physicians to avoid the appearance, if not the reality, of coercion for vulnerable patients who may already feel they are a burden to others. Even supporters of euthanasia have already acknowledged there is no reliable way to measure coercion [46]. 

Concerned Canadians continue to work together to address the issue of safety for vulnerable citizens. The Vulnerable Persons Standard (VPS), initially developed in response to the Carter v. Canada decision, is an internationally recognized evidence based framework “that provides clear and comprehensive guidance to law-makers by identifying the safeguards necessary to protect vulnerable persons within a regulatory environment that permits medical assistance in dying” [47]. The VPS was developed by a large body of advisors with expertise in medicine, ethics, law, public policy and the needs of vulnerable persons. Despite the fact that the VPS has received strong, broad-based, continuing support, it has been completely ignored by every level of government. 

It is also important to note that, during the legalization process, access to palliative care was positioned as a “safeguard” for euthanasia. However, in reality, less than 30% of Canadians have access to any form of palliative care and less than 15% have access to specialized palliative care [48]. Many, including Shariff and Gingerich, have questioned if euthanasia can truly be an informed choice if there is no meaningful access to palliative care [49]. 

Although economic considerations may not currently be driving the normalization and expansion of euthanasia in Canada, it cannot be denied that the procedure is significantly cheaper than rigorous, traditional palliative care. The financial savings of euthanasia for the health care system in Canada have already been reported [50] and with an aging demographic and diminishing fiscal resources, the option to save money in this way may become increasingly acceptable to health care decision makers. 

Confusion Between Palliative Care and Euthanasia 

Another ongoing issue is the confusion and conflation of euthanasia with palliative care. The use of the euphemistic terminology of Medical Assistance in Dying to refer to euthanasia in Canada has exacerbated this confusion in both the public and health care spheres. Canadian palliative care organizations have argued against the use of such language, affirming that palliative care provides support or “assistance» in dying to help people live as fully as possible until their natural death, but does not intentionally hasten death [51]. This assertion is also supported by the longstanding World Health Organization definition of palliative care [52]. 

In spite of clear and repeated distinctions made by national palliative care organizations and the Canadian Medical Association [53–56], there are ongoing efforts by some euthanasia providers to incorporate euthanasia within the scope of practice of palliative care, and to co-opt palliative care language to describe their euthanasia practice, “as one of the many items in the palliative care basket” [57, 58]. Linking the two practices in this way misleads other health care professionals and the public regarding palliative care. The 2019 Canadian Guideline for Parkinson Disease is a recent example [59]. Palliative care was commendably presented as one of the five key recommendations for the approach to care for persons with Parkinson Disease. However, euthanasia (as “MAiD“) was listed directly under the banner of palliative care support and was the only specific measure listed!

National Canadian palliative care organizations have expressed concern that this confusion and conflation of euthanasia and palliative care perpetuates the myth that palliative care hastens death and that misconception may prevent patients from seeking timely palliative care interventions which improve quality of life and, in some cases, enable people to live longer [60]. The Canadian Society of Palliative Care Physicians has stated that “patients and families must be able to trust that the principles of palliative care remain focused on effective symptom management and psychological, social, and spiritual interventions to help people live as well as they can until their natural death.” [53]. 

Dr. Balfour Mount, the “father” of palliative care in Canada, recently stated that 

Canadian legislation utilizes the euphemism ‘medical assistance in dying’ (MAiD) to define euthanasia/assisted suicide and that language has caused confusion concerning its distinction from Palliative Care. For over four decades, Palliative Care has been providing expert medical management to assist and support those who are dying without hastening death or administering a lethal dose of drugs to end life. The MAiD euphemism confuses and causes fear in our patients and the general public regarding the practice of Palliative Care and the nature of Palliative Medicine [61].

Impact on Palliative Care 

The 2016 Federal legislation positioned euthanasia (MAiD) as a health care right under the Canada Health Act, and so it must be publicly funded and accessible to all Canadians [39]. Palliative care, however, is not afforded such status and there is no similar requirement for it to be funded and accessible to Canadians. This is highly inequitable since almost 98% of deaths in Canada are not through euthanasia [6]. 

Euthanasia proponents continue to co-opt the vocabulary and tools of palliative care to create a new discipline of “end of life medicine” with a radically different philosophy, intention and approach that embraces hastened death as the “most beautiful death” [3]. Under this banner of “end of life care,” existing palliative care resources are being used in some jurisdictions to provide euthanasia, effectively reducing already limited resources for palliative care. This is the case in Ontario where, in some regions, the community Hospice Palliative Care Nurse Practitioners were given the additional role of providing euthanasia [62–63]. The assessment for and provision of euthanasia by physicians in Ontario are billed to the Ministry of Health using palliative care billing codes, despite the objections of palliative care physicians [64]. The very distinct and disparate goals and procedures followed by euthanasia teams and palliative care teams make it reasonable and advisable to separate the two practices. This separation should be accepted without acrimony or contention as it is in the best interests of patients, their families and the teams themselves. 

The impact of normalized euthanasia on our day-to-day clinical work in palliative care has been profound. When someone expresses a desire to die or a desire for hastened death (for example, “I just want this to be over…”), there can now be a knee-jerk reaction to consult the euthanasia team as a first response and neglect what palliative care has to offer. Until now, the standard of care has been to engage the patient in serious dialogue, to try to understand the nature of their suffering and grief expression more fully, and to determine what supports might be helpful. In palliative care, it is universally accepted that expressing a desire to die and talking about hastening death are most often normal expressions of grief, loss and coming to terms with one’s mortality in the face of a life-threatening condition. Such expressions of distress need to be explored and supported with skilled palliative care interventions to better understand the nature of the suffering and how to address this, and/or to accompany the person in their suffering. There are many holistic, dignity-conserving palliative care interventions such as Dignity Therapy [65], developed by renowned Canadian palliative care psychiatrist Dr. Harvey Chochinov, which are aimed at restoring purpose, meaning, and reframing hope in the face of the losses that accompany life threatening illnesses. Such therapies help a person and their loved ones to focus on living, even while dying, and provide support to accompany people on their journey, so they do not feel abandoned or alone. 

There is no mandatory palliative care consultation prior to euthanasia. The only requirement is that a patient is aware of all options for care (informed of all means to relieve suffering, including palliative care). Awareness is not the same thing as meaningful access, and what a person understands palliative care to be may influence the person’s understanding of what palliative care has to offer. The Chief Coroner of Ontario, who receives all reports of euthanasia cases in the province, has identified that it is very difficult to evaluate the quality/suitability of the palliative care being offered to patients who receive euthanasia [66]. Our own personal experience is that many patients and health care professionals, including some euthanasia providers, do not fully understand palliative care and its extensive array of therapeutic interventions. 

It is also our experience that, although palliative care teams offer to provide ongoing palliative care for patients who request a euthanasia death, a number of these patients reject palliative care involvement. These patients often refuse many of the medications offered for optimizing symptom management, citing fear that the medications will cause them to lose decisional capacity and therefore their eligibility to receive euthanasia. Tragically and paradoxically, this may result in the last days of life awaiting a euthanasia death being more highly symptomatic, and patients may have euthanasia without ever having a proper trial of excellent palliative care, even where it is available. A Quebec study found that in patients requesting euthanasia, 32% of those who received a palliative care consultation had it requested less than seven days before euthanasia provision and another 25% of palliative care consults were requested the day of or the day after the euthanasia request [41]. With the removal of the ten-day reflection period from euthanasia request to delivery of the procedure in the proposed revision for euthanasia legislation [18], the reality of a meaningful palliative care consultation seems even less likely. 

Downar et al (2020) state that 74% of euthanasia cases in Ontario had palliative care involved, however, the reporting measures used during the study period do not allow for a detailed evaluation of the quality of medical care provided, including palliative care, as it is not within the legislated requirements for oversight by the Office of the Chief Coroner to review or collect this information [66]. It is thus not possible to delineate or evaluate either the quality or quantity of palliative care involvement, when it occurred in relation to the request for euthanasia (the study only documented that there was involvement at the time of request), which palliative care team member provided it (e.g. physician, nurse, or social worker, etc.) or whether there was any meaningful involvement by a specialist palliative care team. A number of detailed responses outlining the significant problems with the conclusions made in this paper have already been published online [40]. 

Strong lobbies are pushing for euthanasia to be available in every palliative care unit and hospice in the country [67]. In many areas, euthanasia is required to be provided in all settings of care in order to avoid the withdrawal of public funding. Hospice societies who fundraise to build the buildings and co-support the day-to-day costs of specialized hospice care are also being mandated to provide euthanasia on site or face closure. Hospices and faith-based institutions are criticized for “blocking access” to euthanasia, even where access is documented to be excellent [68]. 

Protection of Conscience for Physicians 

Participation in euthanasia is also a great concern for physicians who are professionally and/or morally opposed to it. Some physician regulatory bodies require participation via a mandatory referral for euthanasia by physicians unwilling to provide the procedure themselves. For some physicians, such an obligation makes them complicit in an act they find not clinically indicated, unethical, or immoral. This happens in Ontario, Canada’s largest province, where the College of Physicians and Surgeons of Ontario has mandated such an “effective referral” requirement [69]. Physicians who decline to do this could face disciplinary action such as the loss of the license to practice medicine. The Ontario courts have agreed that the requirement for referral violates the conscience/religious rights of physicians (which are protected under the Canadian Charter of Rights and Freedoms) but justifies the referral requirement to “ensure access» to euthanasia for patients, despite no documented lack of access in Ontario [70]. This is the very first time in Canada that the burden of ensuring access to other parts of the health care system has rested on the individual physician. 

As previously discussed, euthanasia proponents are now suggesting that doctors must introduce euthanasia as an option to all potentially eligible patients as a so-called “duty to inform” [71]. However, in no other clinical situations are physicians required to discuss all potential options and procedures if they determine that those options are not medically indicated [72–74]. 

Some euthanasia providers are now refusing to become the “Most Responsible Physician” (MRP) via a transfer of care prior to or during the euthanasia procedure. One of the authors on this paper has directly experienced this at their local hospital. Personal written communications have also reported this practice happening at other hospitals across Canada. In addition, some euthanasia providers are refusing to accept patient transfers from palliative care units and hospices. These strategies profoundly damage collegiality and may force physicians unwilling to collaborate in euthanasia (professionally or morally) into an ethical crisis, compelling them either to remain the MRP, formally approving euthanasia and responsible for all aspects of care for the patient and family, or to refuse to approve it and face contrived accusations of having obstructed patient access. 

Palliative care clinicians have a high level of burnout [75–76], and the perceived lack of control over the scope of practice and forced participation in something that goes against their convictions about the very core of their vocation may be contributing to increasing moral distress and moral injury. This is reflected in colleagues who come to us on a daily basis to share experiences of repeated distress from euthanasia cases. Even colleagues who support euthanasia in some circumstances have reported experiencing this serious distress at times. Moral distress and moral injury manifest as early retirements, leaves of absence, and career changes by physicians who will no longer provide palliative care due to the expectation that euthanasia is included in the scope of practice. Additional moral distress is experienced by some palliative care leaders when health region administrators arbitrarily put euthanasia administration and oversight into the “end of life care” portfolio. The probable loss of palliative care physicians from the workforce at a time when even more clinicians are needed is in part a direct consequence of such stressful situations and heavy-handed measures. 

Proponents of euthanasia use the phrase “my life, my death, my choice,” which calls solely on the principle of autonomy as justification for euthanasia [77]. But, in Canada, the delivery of euthanasia is anything but an autonomous act. By design, it involves one or more other individuals. Many individuals and health care and community services commonly participate in each death, sometimes against their better judgment and possibly even against their will. 

While palliative care has so far been on the forefront of the euthanasia experience, the coming expansion of the legislation that will allow euthanasia for suffering due to any illness, condition or disability, will have a much broader impact on physicians from all medical disciplines, as well as on other health care professionals. There will be very few areas of medicine that euthanasia does not touch. 

In less than four years since the legalization of euthanasia in Canada we have witnessed:
  • rapid increase in rate of death by euthanasia (now estimated to be 2% of all deaths and expected to rise further) – a rate of growth over 3 years that has surpassed all other permissive jurisdictions 
  • the loosening of eligibility criteria by assessors and courts and the weakening of safeguard mechanisms in existing legislation 
  • the imminent expansion of euthanasia through legislative revision, despite strong opposition from citizens in the disability community, mental health professionals, palliative care clinicians and public policy leaders 
  • the failure of federal and provincial governments to designate palliative care as a right and to provide access to palliative care that is at least as robust as access to euthanasia 
  • the confusion and conflation of palliative care with euthanasia; and 
  • the erosion of conscience protection for physicians and other health care professionals leading to coerced participation and demoralization. 
These formidable challenges faced by physicians and patients in our difficult Canadian experience should not lead to discouragement but should instead inspire a reaffirmation of the commitment to traditional, whole-person medicine. Patients, loved ones, clinicians, and even society in general are all deeply enriched when palliative teams use our expertise to show compassion through excellent clinical care in an on-going, committed relationship with each patient, no matter how difficult the circumstances or how complicated the issues. Suffering — pain, fear, loss of control, sense of burden—is not solved by hastened death, but by this excellent care, delivered in a community and a society that honours and protects our most vulnerable citizens at the most difficult times in their lives. Euthanasia is not the panacea that proponents promise. Its legalization and subsequent rapid normalization have had serious negative effects on Canadian medicine and on Canadian society as a whole. We urge the WMA and our colleagues around the world to look beyond the simplistic media reports and to monitor developments in Canada carefully and wisely before making any changes in their own country’s legal framework for medical practice.

Authors’ Affiliations (Institutional affiliation are provided for identification purposes only and do not imply endorsement by the institution)

Leonie Herx MD PhD CCFP (PC) FCFP Chair, Division of Palliative Medicine Associate Professor, Department of Medicine Queen’s University Kingston, Ontario, Canada

Margaret Cottle MD CCFP (PC) Assistant Professor, Division of Palliative Care Faculty of Medicine, University of British Columbia Vancouver, British Columbia, Canada

John F. Scott MD MDiv Associate Professor, Division of Palliative Care, Department of Medicine, University of Ottawa Ottawa, Ontario, Canada

References 
1. Leiva R, Cottle M, Ferrier C, Rutledge Harding S, Lau T, McQuiston T, et al. Euthanasia in Canada: a cautionary tale. WMJ 2018 Oct; 64 (3):17-23 [cited 2020 Feb 29]. Available from: Available from: https://www.wma.net/wp-content/uploads/2018/10/WMJ_3_2018-1.pdf 
2. World Medical Association. WMA Declaration on Euthanasia and Physician-Assisted Suicide [Internet]. 2019 Nov 13 [cited 2020 Feb 29]. Available from: https://www.wma.net/policiespost/declaration-on-euthanasia-and-physicianassisted-suicide/ 
3. Buchman S. Why I decided to provide assisted dying: it is truly patient centred care. BMJ. 2019 Jan 30;364:l412. 
4. Smith R. Learning from Canada about assisted dying. BMJ Blogs [Internet] 2020 Jan [cited 2020 Feb 29]. Available from: https://blogs.bmj. com/bmj/2020/01/22/richard-smith-learningfrom-canada-about-assisted-dying/ 
5. Coyne A. Globe and Mail [Internet]. 2020 Jan 17 [cited 2020 Feb 29]. Available from: https://www.theglobeandmail.com/opinion/article-onassisted-suicide-the-slope-is-proving-every-bitas-slippery-as/ 
6. Government of Canada. An Act to Amend the Criminal Code (medical assistance in dying) Technical Briefing. 2020 Feb 24. 
7. Government of Canada. Canadian Motor Vehicle Traffic Collision Statistics: 2018 [Internet]. 2019 Dec 19 [cited 2020 Feb 29]. Available from: https://www.tc.gc.ca/eng/motorvehiclesafety/ canadian-motor-vehicle-traffic-collision-statistics-2018.html 
8. Statistics Netherlands. StatLine. Deaths by medical end-of-life decision; age, cause of death [Internet]. 2019 Aug 9 [cited 2020 Feb 29]. Available from: https://opendata.cbs. nl/statline/#/CBS/en/dataset/81655ENG/ table?ts=1581825997592 
9. Germano D. Judge rules Ontario woman meets requirements for medically assisted death. CTV News [Internet]. 2017 Jun 19 [cited 2020 Feb 29]. Available from: https://www. ctvnews.ca/health/judge-rules-ontario-womanmeets-requirement-for-medically-assisteddeath-1.3467146 
10. The Superior Court of Ontario. A.B. v. Canada (Attorney General), 2017 ONSC 3759 [Internet]. 2017 Jun 19 [cited 2020 Feb 29]. Available from: http://eol.law.dal.ca/wp-content/uploads/2017/06/20170619152447518.pdf 
11. The Superior Court of Quebec. Truchon c. Procureur général du Canada, 2019 QCCS 3792 (CanLII) [Internet]. 2019 Sept 11 [cited 2020 Feb 29]. Available from: http://canlii.ca/t/j2bzl 
12. Canadian Broadcasting Corporation. B.C. man is one of the first Canadians with dementia to die with medical assistance [Internet]. 2019 Oct 27 [cited 2020 Feb 29]. Available from: https://www. cbc.ca/radio/thesundayedition/the-Sunday-edition-for-october-27-2019-1.5335017/b-c-manis-one-of-the-first-canadians-with-dementia-todie-with-medical-assistance-1.5335025 
13. Grant K. Medically assisted death allows couple married almost 73 years to die together. Globe and Mail [Internet]. 2018 Apr 1 [cited 2020 Feb 29]. Available from: https://www.theglobeandmail. com/canada/article-medically-assisted-deathallows-couple-married-almost-73-years-to-die/ 
14. Favaro A, St. Philip E, Slaughter G. Family says B.C. man with history of depression wasn’t fit for assisted death. CTV News [Internet]. 2019 Sep 24 [cited 2020 Feb 29]. Available from: https://www.ctvnews.ca/health/family-says-bc-man-with-history-of-depression-wasn-t-fitfor-assisted-death-1.4609016 
15. Bryden J. BC woman who challenged right-todie laws gets medically assisted death. Canadian Broadcasting Corporation [Internet]. 2017 Sep 18 [cited 2020 Feb 29]. Available from: https:// www.cbc.ca/news/canada/british-columbia/ assisted-dying-law-canada-moro-1.4294809 
16. Huyer D. Office of the Chief Coroner Memorandum [Internet]. 2018 Oct 9 [cited 2020 Feb 29]. Available from: http://www.mcscs.jus.gov.on.ca/english/Deathinvestigations/OfficeChiefCoroner/Publicationsandreports/MedicalAssistanceDyingUpdate.html 
17. Government of Quebec. Commission sur les soins de la fin de vie : Rapport annuel d’activités 1er juillet 2017 – 31 mars 2018 [Internet]. Quebec: Bibliothèque et Archives Canada; 2018 [cited 2020 Feb 29]. Available from: http://www.assnat.qc.ca/Media/Process.aspx?MediaId=ANQ. Vigie.Bll.DocumentGenerique_141357 
18. House of Commons of Canada. Bill C-7. An Act to amend the Criminal Code (medical assistance in dying). First Reading [Internet]. 2020 Feb 24 [cited 2020 Feb 29]. Available from: https://www.parl.ca/DocumentViewer/en/43- 1/bill/C-7/first-reading 
19. Department of Justice Canada. Government of Canada proposes changes to medical assistance in dying legislation (Internet). 2020 Feb 24 [cited 2020 Feb 29]. Available from: https://www.canada.ca/en/department-justice/ news/2020/02/government-of-canada-proposes-changes-to-medical-assistance-in-dyinglegislation.html 
20. Gaind KS. MAiD: Enlightened empathy or misguided myopia? [Internet] 2020 Feb 13 [cited 2020 Feb 29]. Available from: http:// www.canadianhealthcarenetwork.ca/physicians/ discussions/maid-enlighted-empathy-or-misguided-myopia-58237 
21. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canadian Broadcasting Corporation [Internet]. 2020 Feb 11 [cited 2020 Feb 29]. Available from: https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mentalhealth-1.5452676) 
22. The Canadian Mental Health Association (CMHA). Mental health in the balance: Ending the health care disparity in Canada [Internet]. 2018 Sept [cited 2020 Feb 29]. Available from: https://cmha.ca/wp-content/uploads/2018/09/ CMHA-Parity-Paper-Full-Report-EN.pdf 
23. Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide? South Med J. 2015 Oct;108(10):599-604. Kolva E, Hoffecker L, Cox-Martin E. Suicidal ideation in patients with cancer: a systematic review of prevalence, risk factors, intervention and assessment. Palliative Support Care. 2019 Sep 26:1-14. 
24. Deachman D. Medically assisted deaths prove a growing boon to organ donation in Ontario. Ottawa Citizen [Internet]. 2020 Jan 6 [cited 2020 Feb 29]. Available from: https://ottawacitizen.com/news/local-news/medically-assisteddeaths-prove-a-growing-boon-to-organ-donation-in-ontario 
25. Rodríguez-Prat A, Balaguer A, Booth A, Monforte-Royo C. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open [Internet]. 2017 Sep 29 [cited 2020 Feb 29]; 7(9): e016659. Available from: https://bmjopen.bmj.com/content/7/9/ e016659 doi: 10.1136/bmjopen-2017-016659 
26. Ball IM, Martin C, Sibbald R. Potassium chloride for medical assistance in dying followed by organ donation. Can J Anesth/J Can Anesth [Internet]. 2020 Feb 20 [cited 2020 Feb 29]. Available from: https://doi.org/10.1007/ s12630-020-01603-w 
27. Ball IM, Sibbald R, Truog RD. Voluntary Euthanasia – implications for organ donation. N Engl J Med 2018 Sep 6;379(10):909-911. 
28. Woolhouse, S. This changed my practice: Preparing children for the medically assisted death of a loved one. University of British Columbia Continuing Professional Development (Internet). 2020 Feb 26 [cited 2020 Feb 29]. Available from: http://thischangedmypractice.com/ preparing-children-for-death-of-a-loved-one/ 
29. Canadian Broadcasting Corporation. B.C. man with ALS chooses medically assisted death after years of struggling to fund 24-hour care [Internet]. 2019 Aug 13 [cited 2020 Feb 29]. Available from: https://www.cbc.ca/news/canada/ british-columbia/als-bc-man-medically-assisted-death-1.5244731 
30. Hamilton Spectator. Hamilton senior in unbearable pain wants assisted dying to save her from nursing home [Internet]. 2019 Jan 21 [cited 2020 Feb 29]. Available from: https://www. thespec.com/news-story/9131260-hamiltonsenior-in-unbearable-pain-wants-assisted-dying-to-save-her-from-nursing-home/ 
31. CTV News. Chronically ill man releases audio of hospital staff offering assisted death [Internet]. 2018 Aug 2 [cited 2020 Feb 29]. Available from: https://www.ctvnews.ca/health/chronically-ill-man-releases-audio-of-hospital-staffoffering-assisted-death-1.4038841 
32. Canadian Broadcasting Company. Doctor suggests assisted suicide to mother of child with several medical conditions [Internet]. 2017 Jul 24 [cited 2020 Feb 29]. Available from: http:// www.cbc.ca/player/play/1007608899964/ 
33. Open Letter: Advocates Call for DisabilityRights Based Appeal of the Quebec Superior Court’s Decision in Truchon & Gladu [Internet]. 2019 Oct 4 [cited 2020 Feb 29]. Available from: https://cacl.ca/2019/10/04/advocates-call-fordisability-rights-based-appeal-of-the-quebecsuperior-courts-decision-in-truchon-gladu/ 
34. Open Letter from Physicians Calling for an Appeal of the Quebec Superior Court Decision in Truchon & Gladu [Internet] 2019 Oct 9 [cited 2020 Feb 29]. Available from: https://static1.squarespace.com/static/56bb84cb01dbae77f988b71a/t/5da8e4cd272dc53dc71a2a64/1571349710134/Op en+Lettter+_+Updated+_+Re+_+Physicians+Cal l+for+Appeal+of+the+Quebec+Superior+Court’s +Decision+in+Truchon+%26+Gladu.pdf 
35. Frazee C. Opening Remarks. End of life, Equality and Disability: a National Forum on Medical Assistance in Dying [Internet]. Ottawa: The Canadian Association of Community Living and Council of Canadians with Disabilities; 2020 Jan 30 [cited 2020 Feb 29]. Available from: https://cacl.ca/2020/02/14/end-of-life-equalityand-disability-a-national-forum-on-medicalassistance-in-dying-maid-livestream/ 
36. United Nations Human Rights Office of the High Commissioner. End of Mission Statement by the United Nations Special Rapporteur on the rights of persons with disabilities, Ms. Catalina Devandas-Aguilar, on her visit to Canada [Internet]. 2019 Apr 12 [cited 2020 Feb 29]. Available from: https://www.ohchr. org/EN/NewsEvents/Pages/DisplayNews. aspx?NewsID=24481&LangID=E 
37. The Supreme Court of Canada. Carter v. Canada (Attorney General), 2015 SCC 5, [Internet] 2015 Feb 6 [cited 2020 Feb 29]. Available from: https://scc-csc.lexum.com/scc-csc/scc-csc/en/ item/14637/index.do 
38. Parliament of Canada. Bill C-14 [Internet]. 2016 Jun 17 [cited 2020 Feb 29]. Available from: https://www.parl.ca/DocumentViewer/en/42- 1/bill/C-14/royal-assent 
39. Downar J, Fowler RA, Halko R,  Davenport Huyer L,  Hill AD, Gibson JL. Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ [Internet]. 2020 Feb 24 [cited 2020 Feb 29]; 192 (8) E173- E181. Available from: https://www.cmaj.ca/content/192/8/E173/tab-e-letters DOI:https://doi. org/10.1503/cmaj.200016 
40. Seller L, Bouthillier M, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. Journal of Medical Ethics 2019; 45:106-111. 
41. Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients with Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362–368. 
42. Scully J. Why medical assistance in dying must treat mental and physical illness equally. Canadian Broadcasting Corporation (Internet). 2020 Feb 27 [cited 2020 Feb 29]. Available from: https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mentalhealth-1.5474025 
43. Kolva E, Rosenfeld B, Saracino R. Assessing the Decision-Making Capacity of Terminally Ill Patients with Cancer. Am J Geriatr Psychiatry. 2018 May;26(5):523-531. 
44. Government of Canada. Regulations for the Monitoring of Medical Assistance in Dying: SOR/2018-166 [Internet]. 2018 Jul 27 [cited 2020 Feb 29]. Available from: http://www.gazette.gc.ca/rp-pr/p2/2018/2018-08-08/html/ sor-dors166-eng.html 
45. Downar, D. Voluntary Assisted Dying: the Canadian Perspective [Internet]. Presented at: Voluntary Assisted Dying Implementation Conference; 2019 May 8-10; Melbourne, Australia [cited 2020 Feb 29]. Available at: https://www2.health. vic.gov.au/Api/downloadmedia/%7B1135F6C0- F463-42D9-8039-A47E6AF0A788%7D 
46. Vulnerable Persons Standard [Internet]. 2017 Sep 28 [cited 2020 Feb 29]. Available from: http://www.vps-npv.ca/ 
47. Canadian Institute for Health Information. Access to Palliative Care in Canada [Internet]. Ottawa: CIHI; 2018 [cited 2020 Feb 29]. Available from: https://www.cihi.ca/sites/default/files/ document/access-palliative-care-2018-en-web. pdf 
48. Shariff MJ, Gingerich M. Endgame: Philosophical, Clinical and Legal Distinctions between Palliative Care and Termination of Life. Second Series Supreme Court Law Review [Internet]. 2018 Jun 21 [cited 2020 Feb 29]; 85: 225-293. Available from: https://papers.ssrn.com/sol3/ papers.cfm?abstract_id=3191962 
49. Trachtenberg AJ, Manns B. Cost analysis of medical assistance in dying in Canada. CMAJ 2017 Jan 23;189:E101-5. 
50. Canadian Hospice Palliative Care Association and Canadian Society of Palliative Care Physicians Joint Call to Action [Internet]. 2019 Nov [cited 2020 Feb 29]. Available from: https:// www.cspcp.ca/joint-statement-from-chpcaand-cspcp-regarding-palliative-care-and-maid/ 
51. World Health Organization. WHO Definition of Palliative Care [Internet]. [cited 2020 Feb 29]. Available from: https://www.who.int/cancer/palliative/definition/en/ 
52. Canadian Society of Palliative Care Physicians Key Messages: Palliative Care and Medical Assistance in Dying [Internet]. 2019 May [cited 2020 Feb 29]. Available from: https:// www.cspcp.ca/wp-content/uploads/2019/05/ CSPCP-Key-Messages-PC-and-MAiD-May2019-FINAL.pdf 
53. Canadian Society of Palliative Care Physicians. Key Messages: Physician-Hastened Death [Internet]. 2015, Oct [cited 2020 Feb 29]. Available from: http://www.cspcp.ca/wp-content/ uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf 
54. Canadian Hospice Palliative Care Association. Policy on Hospice Palliative Care and Medical Assistance in Dying [Internet]. 2019 Jun [cited 2020 Feb 29]. Available from: https://www.cspcp.ca/wp-content/uploads/2019/12/CHPCAPosition-Statement_MAiD_June2019.pdf 
55. Canadian Medical Association. CMA Policy: Palliative Care [Internet]. 2016 [cited 2020 Feb 29]. Available from: https://www.cma.ca/sites/ default/files/2018-11/cma-policy-palliativecare-pd16-01-e.pdf 
56. Kutcher M. Navigating MAiD on PEI. Canadian Medical Association [Internet]. 2018 Nov 19 [cited 2020 Feb 29]. Available from: https:// www.cma.ca/dr-matt-kutcher 
57. Buchman S. Bringing Compassion to Medicine and to the CMA. Canadian Medical Association [Internet]. 2019 Oct 12 [cited 2020 Feb 29]. Available from: https://www.cma.ca/drsandy-buchman 
58. Grimes D, Fitzpatrick M, Gordon J, Miyasaki J, Fon EA, Schlossmacher M et al. Canadian guideline for Parkinson disease. CMAJ [Internet]. 2019 Sep 9 [cited 2020 Feb 29]; 191(36): E989-E1004. Available from: https://www. cmaj.ca/content/191/36/E989.long 
59. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363:733-742. 
60. Open letter Dr. Balfour Mount [Internet]. 2019 Dec [cited 2020 Feb 29]. Available from: https:// www.cspcp.ca/wp-content/uploads/2019/12/ Letter-from-Dr.-Balfour-Mount.pdf 
61. Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018 Oct; 53(4):511-520. 
62. Nursing and Assisted Dying – Experiences from a Canadian Context [Internet]. Presented at: Voluntary Assisted Dying Implementation Conference; 2019 May 8-10; Melbourne, Australia [cited 2020 Feb 29]. Available from: https://www2.health.vic.gov.au/ Api/downloadmedia/%7B28620FDD-3485- 4292-98DC-52C08722D0E6%7D 
63. OHIP Payments for Medical Assistance in Dying [Internet]. 2018 Nov [cited 2020 Feb 29]. Available from: https://content.oma.org//wpcontent/uploads/MAID_Billing-Guide-final18Oct2018.pdf 
64. Dignity in Care [Internet]. 2016 [cited 2020 Feb 29]. Available from: https://dignityincare.ca/en/ 
65. Huyer D. Office of Chief Coroner of Ontario Oversight: Lessons from Ontario Medical Assistance in Dying [Internet]. May 2019 [cited 2020 Feb 29]. Available from: https://www2.health.vic.gov.au/Api/ downloadmedia/%7B59E8A8AB-B84C-4047- 8B9E-E263E0500E50%7D 
66. DWDC, CAMAP issue joint statement on forced transfers for assisted dying [Internet]. 2018 Jan 8 [cited 2020 Feb 29]. Available from: https://www.dyingwithdignity.ca/forced_transfers_statement 
67. Jones AM, Cousins B. Standoff between B.C. and hospice refusing to offer assisted dying [Internet]. January 20, 2020 [cited 2020 Feb 29]. Available from: https://www.ctvnews.ca/health/ standoff-between-b-c-and-hospice-refusing-tooffer-assisted-dying-1.4773755
68. Medical Assistance in Dying [Internet]. College of Physicians and Surgeon of Ontario. 2016 [cited 2020 Feb 29]. Available from: https:// www.cpso.on.ca/Physicians/Policies-Guidance/ Policies/Medical-Assistance-in-Dying#Policy 
69. Ontario Superior Court of Justice Divisional Court. The Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579 (CanLII) [Internet]. 2018 Jan 31 [cited 2020 Feb 29]. Available from: https://www.canlii.org/en/on/onscdc/doc/ 2018/2018onsc579/2018onsc579.pdf 
70. The Canadian Association of MAiD Assessors and Providers. Key Messages: End of Life Care and Medical Assistance in Dying [Internet]. 2020 Feb [cited 2020 Feb 29]. Available from: https://camapcanada.ca/wp-content/uploads/2020/02/FINAL-Key-Messages-EOLCare-and-MAiD.pdf 
71. Williams JR. Law catching up with ethics. CMAJ [Internet]. 2020 Feb 3 [cited 2020 Feb 29]; 192(5): E123. Available from: https://www. cmaj.ca/content/192/5/E123 
72. Downar J, Close E, Sibbald R. Do physicians require consent to withhold CPR that they determine to be nonbeneficial? CMAJ  [Internet]. 2019 Nov 25 [cited 2020 Feb 29]; 191(47): E1289-E1290. Available from: https:// www.cmaj.ca/content/191/47/E1289 
73. Ontario Superior Court of Justice Wawrzyniak v. Livingstone, 2019 ONSC 4900 (CanLII) [Internet). 2019 Aug 20 [cited 2020 Feb 29]. Available from: https://www.canlii.org/en/on/onsc/ doc/2019/2019onsc4900/2019onsc4900.html 
74. Kamal AH, Bull JH, Wolf SP, Swetz KM, Shanafelt TD, Ast K, et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. J Pain Symptom Manage. 2016 Apr; 51 (4): 690-696. 
75. Reddy S,  Yennu S,  Tanco KC,  Anderson AE, Guzman D, Williams JL, et al. Frequency of burn-out among palliative care physicians participating in continuing medical education. Journal of Clinical Oncology 2019; 37:31_suppl, 77. 
76. Wesley Smith. My Life, My Death, My Choice [Internet]. 2010 Aug 5 [cited 2020 Feb 29]. Available from: https://www.discovery. org/a/15141/

Categories: Discussion

Margaret Dore: New Jersey Motion for Reconsideration, on assisted suicide law.

Mon, 2020-04-27 03:38
This article was published by Choice is an Illusion on April 24, 2020.

Previous articles:
  1. New Jersey euthanasia act must be set-aside (Link).
  2. New Jersey appellate court lifts restraining order that stopped assisted suicide (Link).
  3. Court order temporarily stops assisted suicide in New Jersey (Link).
Margaret DoreTo view Dore's brief as submitted, click here.

I. RELIEF REQUESTED

Margaret Dore moves for reconsideration of the Court’s order dated April 1, 2020, which upheld the constitutionality of the Medical Aid in Dying for the Terminally Ill Act.[1]

II. THE ACT MUST BE SET ASIDE

The Court did not reach the Act’s violation of the object in title rule, which is dispositive to set the Act aside. The Court should reach this issue now to overturn the Act.

The Court’s order states that Dore asked the Court to declare the Act unconstitutional “on grounds not asserted by plaintiffs.”[2] The plaintiffs, did, however, ask the Court to rule on the issue, stating:
Ms. Dore’s brief should be considered by the Court since if the law is unconstitutional under the single object rule, it should be the Court’s responsibility to raise that issue sua sponte even if not raised by Ms. Dore or the Plaintiffs.[3]The Legislature understood that it was enacting a strictly voluntary law limited to assisted suicide for dying patients.[4] The prior judge expressed a similar view. See, for example, the transcript from the hearing on August 14, 2019 (“This case is not about euthanasia”).[5]

This case, however, is about euthanasia. The Act is also not limited to dying people. Patient voluntariness is allowed, but not required. These are material facts not disclosed by the Act’s title and related findings. The Act is unconstitutional and must be set aside.

III. WHAT THE ACT DOES
A. The Act Allows Physician-Assisted Suicide, Which It Terms Medical Aid in DyingDictionary definitions of “assisted suicide,” include “suicide committed by someone with assistance from another person especially: physician-assisted suicide.”[6] Dictionary definitions of physician-assisted suicide include the following:
[S]uicide by a patient facilitated by means (such as a drug prescription) or by information (such as an indication of a lethal dosage) provided by a physician aware of the patient's intent.[7]Here, the Act allows this same practice, which it terms medical aid in dying. The Act, “Findings, Declarations Relative to Medical Aid in Dying for the Terminally Ill,” states:
[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[8]The Act also specifically describes physician involvement to write the prescription for the lethal dose.[9] The bottom line, the Act allows physician-assisted suicide as traditionally defined, which it terms medical aid in dying.
B. The Act Legalizes Assisted Suicide as a “Right”Again, the Act states:
[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[10]If for the purpose of argument, this provision is limited to allowing voluntary assisted suicide (because it says that the patient may chose to self-administer the lethal medication), the Act will nonetheless also allow euthanasia due to assisted suicide being described as a “right.” This is true due to: (1) The New Mexico Supreme Court Decision, Morris v. Brandenburg, 376 P.3d 836 (2016); and (2) the Americans with Disability Act, both of which are discussed below.
1. Morris v. BrandenburgThe 5-0 decision states in part:
[W]e agree with the legitimate concern that recognizing a right to physician aid in dying will lead to voluntary or involuntary euthanasia because if it is a right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication. (Emphasis added).[11] 2. The Americans With Disabilities Act (ADA)The ADA is “a federal civil rights law that prohibits discrimination against individuals with disabilities in every day activities, including medical services.”[12] “Medical care providers are required to make their services available in an accessible manner.”[13]This includes:
Reasonable modifications to policies, practices, and procedures to make healthcare services fully available to individuals with disabilities, unless the modifications would fundamentally alter the nature of the services (i.e., alter the essential nature of the services). (Emphasis added).[14]Here, the Act legalized “medical aid in dying” as part of New Jersey healthcare.[15] If for the purpose of argument, the Act does in fact require self-administration, the ADA will require a reasonable accommodation for individuals unable to self-administer. This will mean administration by another person. The Act will thereby require euthanasia as traditionally defined.

IV. HOW THE ACT WORKS

The Act has an application process to obtain the lethal dose.[16] Once the lethal dose is issued by the pharmacy, there is no oversight.[17] No witness, not even a doctor, is required to present at the death.[18]

V. “ELIGIBLE” PERSONS MAY HAVE YEARS TO LIVE

The Act applies to “terminally ill” individuals. The Act states:
“Terminally ill” means that the patient is in the terminal stage of an irreversibly fatal illness, disease, or condition with a prognosis, based upon reasonable medical certainty, of a life expectancy of six months or less.[19]Such persons may, in fact, have years or decades to live. This is true due to actual mistakes (the test results got switched), and because predicting life expectancy is not an exact science.[20] Also, sometimes doctors are wrong, as in way wrong.

Consider John Norton, diagnosed with ALS at age 18.[21] He was told that he would get progressively worse (be paralyzed) and die in three to five years.[22] Instead, the disease progression stopped on its own.[23] In a 2012 affidavit, at age 74, he states:
If assisted suicide or euthanasia had been available to me in the 1950's, I would have missed the bulk of my life and my life yet to come.[24]VI. ELDER ABUSE
A. Elder Abuse Is a Problem in New Jersey; Perpetrators Are Often Family MembersElder abuse is a problem in New Jersey and throughout the United States.[25] Nationwide, prominent cases include actor Mickey Rooney and New York philanthropist, Brooke Astor.[26]

Perpetrators are often family members.[27] They typically start out with small crimes, such as stealing jewelry and blank checks, before moving on to larger items or to coercing victims to change their wills or to liquidate their assets.[28] Amy Mix, of the AARP Legal Counsel of the Elderly, states:
[Perpetrators] are family members, lots are friends, often people who befriend a senior through church .... We had a senior victim who had given her life savings away to some scammer who told her that she’d won the lottery and would have to pay the taxes ahead of time.... The scammer found the victim using information in her husband’s obituary.[29] B. Elder Abuse Is Rarely Reported, Victims Don’t Want to Report Their Children as AbusersThe vast majority of elder abuse cases are not reported to the authorities. Reasons include:
[F]ear of retaliation, lack of physical and/or cognitive ability to report, or because they don’t want to get the abuser (90% of whom are family members) in trouble. (Emphasis added).[30] C. Elder Abuse Is Sometimes FatalIn some cases, elder abuse is fatal. More notorious cases include California’s “black widow” murders, in which two women took out life insurance policies on homeless men.[31] Their first victim was 73 year old Paul Vados, whose death was staged to look like a hit and run accident.[32] The women collected $589,124.93.[33]

Consider also, People v. Stuart in which an adult child killed her mother with a pillow, so as to inherit. The Court observed:
Financial considerations [are] an all too common motivation for killing someone.[34]VII. PENALTIES PROVIDE A DETERRENT; NOT THE ACT

While elder abuse is a largely uncontrolled problem, there are penalties for doing it and when perpetrators are caught, they can be punished. The California black widows and the adult child who killed her mother with a pillow, discussed above, served prison time. With a risk of punishment, there is a deterrent to protect other potential victims from harm.

This is in contrast to the Act, in which purported protections are illusory, which renders potential victims sitting ducks to their adult children and other predators, without recourse. See below.

VIII. THE ACT IS STACKED AGAINST THE INDIVIDUAL
A. “Even If a Patient Struggled, Who Would Know?”The Act has no oversight over administration of the lethal dose.[35] In addition, the drugs used are water and alcohol soluble, such that they can be injected into a sleeping or restrained person without consent.[36] Alex Schadenberg, Executive Director for the Euthanasia Prevention Coalition, puts it this way:
With assisted suicide laws in Washington and Oregon [and with the Act], perpetrators can . . . take a “legal” route, by getting an elder to sign a lethal dose request. Once the prescription is filled, there is no supervision over administration. Even if a patient struggled, “who would know?” (Emphasis added).[37] B. Someone Else Is Allowed to Communicate on the Patient’s BehalfThe Act uses the word, “capable,” which is specially defined to allow other people to communicate on the patient’s behalf, as long as they are “familiar with the patient’s manner of communicating.” The Act states:
“Capable” means having the capacity to make health care decisions and to communicate them to a health care provider, including communication through persons familiar with the patient’s manner of communicating if those persons are available. (Emphasis added).[38]Being familiar with a patient’s manner of communicating is a very minimal standard. Consider, for example, a doctor’s assistant who is familiar with a patient’s “manner of communicating” in Spanish, but she herself does not understand Spanish. That, however, would be good enough for her to communicate on the patient’s behalf during the lethal dose request process. The patient would not necessarily be in control of his or her fate.
C. Purported Protections Are IllusoryThe Act says that the attending physician is to ensure that all “appropriate” steps are carried out in “accordance” with the Act as necessary. The Act states:
The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] . . . including such actions as are necessary to: . . . (6) recommend that the patient participate in a consultation concerning concurrent or additional treatment opportunities . . . [and] (8) inform the patient of the patient’s opportunity to rescind the request . . . . (Emphasis added).[39]The Act does not define "appropriate" or “accordance.”[40] Dictionary definitions of appropriate include "suitable or proper” in the circumstances.[41] Dictionary definitions of accordance include “in the spirit of,” meaning “in thought or intention.”[42]

With these definitions, the attending physician’s view of what is "suitable or proper" is enough for compliance with patient protections. The physician's "thought or intention" is similarly sufficient. The purported protections are neutralized to whatever an attending physician happens to feel is appropriate and/or had a thought or intention to do. The “protections” are unenforceable.
D. Deaths in Accordance With the Act Are “Natural” as a Matter of Law  1. Action taken in accordance with the Act is not suicide or homicideThe Act states:
Any action taken in accordance with the provisions of [the Act] shall not constitute patient abuse or neglect, suicide, assisted suicide, mercy killing, euthanasia, or homicide under any law of this State. (Emphasis added).[43]  2. The Act requires deaths to be reported as “natural”In New Jersey, death certificates have five categories for reporting the manner of death, four of which are substantive: (1) natural; (2) accident; (3) suicide; and (4) homicide.[44] The fifth category is “undetermined.”[45]

As noted in the preceding section, a death occurring in accordance with the Act does not constitute suicide or homicide under any law of the State. The death is also not an accident due its having been an intended event. This leaves “natural.” Deaths occurring pursuant to the Act are natural as a matter of law.
E. Dr. Shipman and the Call for Death Certificate ReformPer a 2005 article in the UK’s Guardian newspaper, there was a public inquiry regarding Dr. Harold Shipman, which determined that he had “killed at least 250 of his patients over 23 years.”[46] The inquiry also found:
that by issuing death certificates stating natural causes, the serial killer [Shipman] was able to evade investigation by coroners. (Emphasis added). [47]Per a subsequent article in 2015, proposed reforms included having a medical examiner review death certificates, so as to improve patient safety.[48] The New Jersey Act has instead moved in the opposite direction to require that deaths be reported as natural. Doctors and other perpetrators have been enabled to kill under mandatory legal cover.
F. The Act Renders New Jersey Residents Sitting Ducks to Their Heirs and Other PredatorsNew Jersey’s slayer statute prevents a killer from inheriting from his or her victim. The statute states:
[A]n individual who is responsible for the intentional killing of the decedent forfeits [his or her inheritance].”[49]The rational is that a criminal should not be allowed to benefit from his or her crime.[50]

Under the Act, however, a person who intentionally kills another person is allowed to inherit. This is due to the deaths being certified as natural. With the passage of the Act, New Jersey residents with money, meaning the middle class and above, have been rendered sitting ducks to their heirs and other predators.

IX. OTHER CONSIDERATIONS
A. My Clients Suffered Trauma in Oregon and Washington StateI have had two cases where my clients suffered trauma due to legal assisted suicide. In the first case, one side of my client’s family wanted her father to take the lethal dose, while the other side did not. The father spent the last months of his life caught in the middle and torn over whether he should kill himself. My client was severely traumatized. The father did not take the lethal dose and died a natural death.

In the other case, my client’s father died via the lethal dose at a suicide party. It’s not clear, however, that administration of the lethal dose was voluntary. A man who was present told my client that his father had refused to take the lethal dose when it was delivered, stating: "You're not killing me. I'm going to bed." The man also said that my client’s father took the lethal dose the next night when he (the father) was already intoxicated on alcohol. The man who told this to my client subsequently changed his story.

My client, although he was not present, was traumatized over the incident, and also by the sudden loss of his father.
B. In Oregon, Other Suicides Have Increased with Legalization of Physician-Assisted SuicideGovernment reports from Oregon show a positive correlation between the legalization of physician-assisted suicide and an increase in other (conventional) suicides. This correlation is consistent with a suicide contagion in which legalizing physician-assisted suicide encouraged other suicides.[51]
C. The Felony for Undue Influence Is IllusoryThe Act has a felony for “undue influence,” which is not defined and has no elements of proof. The Act merely states:
A person who . . . exerts undue influence on a patient to request medication pursuant to [the Act] or to destroy a rescission of a request is guilty of a crime of the third degree. (Emphasis added).[52]The Act also specifically allows conduct normally used to prove undue influence. For example, the Act allows an infirm person with a terminal disease to request the lethal dose. Physical weakness is a factor generally used to PROVE undue influence.[53]

How do you prove that undue influence occurred when the Act does not define it, and the Act also allows conduct generally used to prove it? You can’t. The felony for undue influence is illusory and unenforceable.

X. THE ACT VIOLATES THE OBJECT IN TITLE RULE

As noted supra, the New Jersey Constitution governs permissible legislative conduct when enacting legislation. To that end, the Constitution sets forth the object in title rule, as follows:
To avoid improper influences which may result from intermixing in one and the same act such things as have no proper relation to each other, every law shall embrace but one object, and that [object] shall be expressed in the title. (Emphasis added).[54]The rule is designed to protect against the misleading of the people. State v Guida, 119 N.J.L. 464, 465-466 (1938), states:
The sole requirement is that [the title] ‘shall express its object in a general way so as to be intelligible to the ordinary reader’; and it is the settled rule that a statute will not be judicially declared inoperative and unenforceable on this ground unless the deficiency plainly exists. (Emphasis added).In the case at bar, the deficiency plainly exists. The Legislature, the Attorney General and the prior court were all mislead by the Act’s deceptive title, implying that the Act is limited to voluntary assisted suicide, when the Act also allows non-voluntary euthanasia. This Court has also been mislead. The Act must be set aside.

Respectfully submitted this 18th day of April 2020

Margaret Dore Esq., MBA, appearing pro se
Law Office of Margaret K. Dore, PS
1001 4th Avenue, Suite 4400
Seattle, WA 98154
206 697 1217

Footnotes:

[1] The Act is attached in the brief's appendix, at pages A-1 to A-15.
[2] The Order, page 35, attached in the brief's appendix, at page A-20.
[3] Letter from E. David Smith, Esq., to Judge Lougy, dated March 20, 2020, in the brief's appendix at page A-23.
[4] See for example, the Order on Emergent Motion, Superior Court of New Jersey Appellate Division, August 27, 2019 (“the process is entirely voluntary on the part of all participants, including patients...”). Attached in the brief's appendix at page A-63.
[5] Transcript attached in the brief's appendix at page A-62.
[6] Merriam-Webster, attached in the brief's appendix at page A-27; https://www.merriam-webster.com/dictionary/assisted%20suicide?utm_campaign=sd&utm_medium=serp&utm_source=jsonld
[7] Merriam-Webster, attached in the brief's appendix at page A-28.
[8] The Act, Section C.26:16-2, attached in the brief's appendix at page A-1.
[9] The Act, Section C.26:16-6, states:
The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] before writing a prescription for medication that a qualified terminally ill patient may choose to self-administer pursuant to [the Act]. (Attached in the brief's appendix at page A-4).[10] The Act, page 1, attached in the brief's appendix at page A-1
[11] Morris v. Brandenburg, 376 P.3d 836, 848 (2016).
[12] U.S. Department of Justice, Civil Rights Division, and the U.S. Department of Health and Human Services, Office for Civil Rights, “Americans with Disabilities Act: Access to Medical Care for Individuals with Mobility Disabilities,” July 2010, available at https://www.ada.gov/medcare_mobility_ta/medcare_ta.htm
[13] Id.
[14] Id.
[15] The Act, Findings, attached in the brief's appendix at page A-1.
[16] See the Act, attached in the brief's appendix at pp. A-3 to A-7.
[17] See the Act in its entirety, in the brief's appendix at pp. A-1 to A-15.
[18] Id.
[19] The Act, C.26:16-3, attached in the brief's appendix at page A-3.
[20] Cf. Jessica Firger, "12 Million Americans Misdiagnosed Each Year," CBS NEWS, April 17, 2014, attached in the brief's appendix at page A-29; and Nina Shapiro, "Terminal Uncertainty — Washington's New 'Death with Dignity' Law Allows Doctors to Help People Commit Suicide — Once They've Determined That the Patient Has Only Six Months to Live. But What If They're Wrong?,” The Seattle Weekly, 01/14/09, attached in the brief's appendix at pages A-30 to A-33.
[21] Affidavit of John Norton, attached in the brief's appendix at pages A-34 to A-36.
[22] Id., ¶ 1.
[23] Id., ¶ 4.
[24] Id., ¶ 5.
[25] See e.g., Dansky Katz Ringold York, Attorneys at Law, Marlton New Jersey, “How to Spot and Prevent Elder Financial Abuse,” April 27, 2016, at https://njlegalhelp.com/how-to-spot-and-prevent-elder-financial-abuse; and Beth Fitzgerald, “New Jersey Considers Law to Prevent ‘Granny Snatching,’” New Jersey Spotlight, MAY 21, 2012, http://www.njspotlight.com/stories/12/0520/2037/
[26] Tom Cohen, “Mickey Rooney tells [U.S.] Senate panel he was a victim of elder abuse,” CNN, March 2, 2011; Carole Fleck, “Brooke Astor’s Grandson Tells Senate Panel of Financial Abuse,” AARP Bulletin Today, 02/05/2015 (“The grandson of socialite Brooke Astor, who blew the whistle on his father for plundering millions from his grandmother’s estate, told the Senate panel Wednesday that his grandmother’s greatest legacy may be the national attention focused on elder financial abuse.”), and Matthew Talbot, “Issues of Prosecuting Elder Abuse: The Casey Kasem Case,” Talbot Law Group, PC, January 4, 2016, available at
https://www.linkedin.com/pulse/issues-prosecuting-elder-abuse-casey-kasem-case-matthew-talbot
[27] Id., MetLife Mature Market Institute, “Broken Trust: Elders, Familyand Finances, A Study on Elder Abuse Prevention,” March 2009, at  http://www.metlife.com/assets/cao/mmi/publications/studies/mmi-broken-trust.pdf
[28] Id.
[29] Kathryn Alfisi, “Breaking the Silence on Elder Abuse,” Washington Lawyer, February 2015.
[30] “Adult Protective Services: Facts and Fiction,” Division of Aging Services, NJ Department of Human Services, available at
http://www.nj.gov/humanservices/dmahs/home/Adult_Protective_Services_Training.pdf
[31] See People v. Rutterschmidt, 55 Cal.4th 650 (2012). See also  https://en.wikipedia.org/wiki/Black_Widow_Murders
[32] Rutterschmidt, at 652-3.
[33] Id. at 652.
[34] 67 Cal.Rptr.3d 129, 143 (2007), available at
https://www.leagle.com/decision/200719667calrptr3d1291182
[35] See the Act in its entirety, attached in the brief's appendix at A-1 to A-15.
[36] The drugs used include Secobarbital, Pentobarbital and Phenobarbital, which are water and/or alcohol soluble. See excerpt from Oregon’s and Washington’s annual reports, attached hereto at A-41 & A-42 (listing these drugs). See also http://www.drugs.com/pr/seconal-sodium.htmlhttp://www.drugs.com/pro/nembutal.html and
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2977013
[37] Alex Schadenberg, Letter to the Editor, “Elder abuse a growing problem,” The Advocate, Official Publication of the Idaho State Bar, October 2010, page 14.
[38] The Act, C.26:16-3, attached in the brief's appendix at page A-2.
[39] Attached in the brief's appendix at page A-4.
[40] See the Act in its entirety, attached in the brief's appendix at pages A-1 through A-15.
[41] Attached in the brief's appendix at page A-43.
[42] Attached in the brief's appendix at pages 44 and A-45.
[43] The Act, C.26:16-17.a.(2), attached in the brief's appendix at page A-9.
[44] Andrew L. Falzon, MD, and Sindy M. Paul, MPH, “Death Investigation and Certification in New Jersey,” MD Advisor, a journal for the New Jersey medical community, 2016. (Attached in the brief's appendix at page A-46).
[45] Id.
[46] David Batty, “Q & A: Harold Shipman,” The Guardian, 08/25/05, at https://www.theguardian.com/society/2005/aug/25/health.shipman. (Attached in the brief's appendix at pages A-47 to A-49).
[47] Id., attached in the brief's appendix at page A-49.
[48] Press Association, “Death Certificate Reform Delays ‘Incomprehensible,”
The Guardian, January 21, 2015, attached in the brief's appendix at pages A-50 to A-51.
[49] NJ Rev Stat § 3B:7-1.1, attached in the brief's appendix at pages A-52 and A-53.
[50] Cf. Ilene S. Cooper and Jaclene D'Agostino, "Forfeiture and New York's 'Slayer Rule', NYSBA Journal, March/April 2015, attached in the brief's appendix at page A-54.
[51] For a more information, see Margaret Dore, “In Oregon, Other Suicides Have Increased with Legalization of Assisted Suicide,” August 18, 2017, attached in the brief's appendix at pages A-55 to A-57. See also the Declaration of Williard Johnston, MD, attached in the brief's appendix at pages A-58 to A-60.
[52] Attached in the brief's appendix at page A-10.
[53] Cf. Neugebauer v. Neugebauer, 804 N.W.2d 450, ¶17 (2011)(“physical . . . weakness is always material upon the question of undue influence”).
Categories: Discussion

The Covid-19 crisis has led to more cultural loneliness. Have you called your mom today?

Fri, 2020-04-24 20:40
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

I have published several articles about the epidemic of loneliness and isolation and how it effects the physical and psychological health of people. Loneliness and isolation also leads to requests for assisted death.
A British study found that 22% of seniors, over the age of 65 will talk to only three or fewer people per week. A September 7, 2019 article in studyfinds.org reported:
According to the survey of 1,896 seniors over 65 in the United Kingdom, more than one in five (22%) will have a conversation with no more than just three people over the span of an entire week! That translates to nearly 2.6 million elderly folks who don’t enjoy regular human contact on a daily basis. Perhaps most alarming though is researchers say an alarming 225,000 individuals will go a week without talking to anyone face-to-face.We can reduce the scourge of suicide and the cultural abandonment associated with assisted death, by caring for and being with others at their time of need. It is essential that people who feel that their life lacks value or purpose, or feel that no one cares, is offered purpose, support and genuine hope from their significant community.

The Covid-19 crisis and social distancing has led to more loneliness and social isolation.

One answer is to call your friends and family. A call to your family and friends can make a difference. Some families are communicating by video over the internet. This is an excellent way to communicate with others.

Your call may be the only call that your mother receives today.
Categories: Discussion

Dutch Supreme Court approves euthanasia for dementia.

Tue, 2020-04-21 21:27
This article was published by National Review online on April 21, 2020.
Wesley SmithBy Wesley J Smith
More than 20 years ago, the Dutch Supreme Court approved the assisted suicide of a woman in despair because her children had died. So we shouldn’t be surprised that it has now explicitly approved the forced euthanasia of patients with dementia if they asked to be killed before becoming incompetent. From Reuters:The Dutch Supreme Court on Tuesday ruled that doctors could legally carry out euthanasia on people with advanced dementia who had earlier put their wishes in writing even if they could no longer confirm them because of their illness.

The ruling is a landmark in Dutch euthanasia legislation which up to now had required patients to confirm euthanasia requests. This had not been considered possible for mentally incapacitated patients like advanced dementia sufferers.

“A doctor can carry out an (earlier) written request for euthanasia from people with advanced dementia,” the Supreme Court said in a summary of its decision.What the Reuters story failed to mention — and apparently the Supreme Court found to be irrelevant — is that the case in question involved a woman who fought against being killed. Nor does the story mention that the doctor had drugged the woman before starting to euthanize her, and that the doctor instructed the family to hold the struggling woman down so that she could administer the lethal injection. Moreover, the patient had also stated in her instructions that she wanted to decide “when” the time for death had come — which she never did. The termination “choice” was made by the doctor and/or family in violation of the patient’s advance directive.
But why would the Dutch Supreme Court let inconvenient facts get in the way of furthering the Netherlands’ ever-expanding national killing policy that already permits infanticide, joint geriatric euthanasia of married couples, termination of the mentally ill, conjoining euthanasia with organ harvesting, and the lethal injections of people with disabilities?
Categories: Discussion

MAiD (euthanasia) deaths increase in Ontario during Covid-19 crisis.

Tue, 2020-04-21 19:29
Sign the Petition: Stop euthanasia Bill C-7 (Link)

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Ontario Office of the Chief Coroner released new data for MAiD (euthanasia and assisted suicide deaths) indicating that from June 17, 2016 until March 31, 2020, in Ontario there have been 4888 reported assisted deaths with 199 reported assisted deaths in March 2020 alone.
 
In Ontario there were 1789 reported assisted deaths in 2019, 1499 in 2018, 841 in 2017 and 189 in 2016. The new data indicates that there were 570 reported assisted deaths in the first three months of the year with 199 in March alone. The euthanasia rate is sadly increasing.

According to the data there was a significant increase in reported assisted deaths in the second half of 2019 with 1015 up from 774 reported assisted deaths in the first half of the year in Ontario. The 570 reported assisted deaths in the first three months of 2020 indicates an increasing trend in assisted deaths.
Sign the Petition: Stop euthanasia Bill C-7 (Link)Parliament is currently debating Bill C-7, a bill to expand euthanasia in Canada. Bill C-7 amends the euthanasia law by eliminating the "terminal illness" requirement, allowing advanced requests for euthanasia, eliminating the 10 day waiting "reflection" period and it falsely claims to prohibit euthanasia for mental illness.

If Bill C-7 passes without amendments, it will give Canada the most extreme euthanasia law in the world and result in a greater increase in deaths by lethal injection.
A recent CBC Radio show by Duncan McCue, Stephanie Green, president of the Canadian Association of MAiD Assessors and Providers explained how MAiD can be done on a patient with Covid-19. Green stated:
"I have provided for MAID on the same day that I've met someone on certain occasions," "It's not common … MAID is a process that requires rigorous procedure and safeguarding and is meant to be that way."Green then explained that "MAID applications can be expedited if two assessing physicians agree a patient is at "imminent risk" of losing their capacity or life, they can forgo the typical 10 day reflection period required by law. Green then stated:
"If they're about to die, or we think they're going to die within 10 days, we actually can go ahead and waive that reflection period and move quicker,"I recently reported on an article written by Globe and Mail reporter Kelly Grant stating that the Ottawa and Hamilton regions temporarily stopped providing euthanasia "MAiD services" during the Covid-19 pandemic. Grant wrote:
The Champlain Regional MAID Network, which serves Ottawa and the surrounding area, issued a notice on Wednesday that it was shutting down the service in hospitals and homes to prevent the transmission of COVID-19 and to conserve health-care resources.  Hamilton Health Sciences, a hospital network with 10 sites, has also stopped providing assisted dying within its walls.It is possible that the MAiD (euthanasia) data will indicate a slowing trend in April 2020, but the current trend indicates a continuing increase in the number of lethal injection deaths in Ontario.

Do you have a personal euthanasia story? Sharing your story may help us prevent other euthanasia deaths. Contact the Euthanasia Prevention Coalition  at: 1-877-439-3348 or info@epcc.ca.
Categories: Discussion

Canadians oppose euthanasia for mental illness and child euthanasia. Canada must reject Bill C-7.

Mon, 2020-04-20 19:44
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Petition: Reject euthanasia Bill C-7 (Link)

Canada's federal government is debating the expansion of euthanasia with Bill C-7. 

Bill C-7 amends the euthanasia law by eliminating the "terminal illness" requirement, allowing advanced requests for euthanasia, eliminating the 10 day waiting "reflection" period and it falsely claims to prohibit euthanasia for mental illness.

Bill C-7, a bill to amend Canada's euthanasia (MAiD) law, if passed without amendments, will make Canada's euthanasia law the most permissive in the world.

On February 24, Canada's federal government introduced Bill C-7, an act to amend the Criminal Code (medical assistance in dying). Bill C-7 is the federal government's response to the Quebec Court decision that struck down the section of Canada's euthanasia law that requiring that "natural death be reasonably foreseeable" to qualify for death by euthanasia (lethal injection).
 
Bill C-7, seems to have been directed by the results of the online survey that was conducted in January 2020. On January 14, I urged EPC supporters to participate in the Canadian Department of Justice Medical Assistance in Dying consultation questionnaire. In my article I stated:
The language of the consultation questionnaire is not great, nonetheless, the questionnaire allows you to leave further comments.
On January 15 I published a Guide to answering the Questionnaire. The guide had more than 19,000 page views.

The assessment of the public consultation on Medical Assistance in Dying provides greater clarity concerning Bill C-7.

According to the the consultation that I called a sham, Canadians want the euthanasia law expanded but they don't want euthanasia for mental illness or child euthanasia. The assessment of the public consultation states:
Theme 4 - Concerns with expanding eligibility for MAID

Comments under this theme included concerns with expanding eligibility for MAID to those who suffer from mental illness and mature minors.

A majority of those who provided comments were not in favour of extending MAID to people who suffer from mental illness. They expressed concerns that people with mental health issues, such as depression, may feel that MAID is their only option, when effective therapies could lead to full recovery. Rather than extending the option to terminate lives, many respondents felt that the focus should be on increasing preventative measures, supports, resources, and intensive treatment for people with mental health issues, as well as increasing resources for people with physical disabilities. Some noted that people with mental illness, and those with physical and intellectual disabilities, are especially vulnerable to manipulation and abuse, or may feel like a burden on family, friends or the healthcare system, and suggested different and specific qualifying criteria for these groups.

In contrast, others felt that people suffering from mental illness should be eligible for MAID in certain circumstances (e.g., chronic, severe, disabling, treatment-resistant disorders). Some noted that mental health conditions can result in suffering that is as painful as physical disorders and not respond to treatment, resulting in people making dangerous suicide attempts rather than ending their life in a safe way.

Most respondents did not support MAID being extended to minors due to their state of development and the risk that they would make an irreversible decision and die before their time. Others were in support of extending MAID to minors in cases of terminal and incurable diseases, with proper safeguards in place.Theme 4 explains why Bill C-7 did not extend euthanasia to children and why the government claims that the bill prevents euthanasia for mental illness. Sadly, Bill C-7 does not prevent euthanasia for mental illness.

I reported, in September 2019, that the Quebec court expanded Canada's euthanasia law by eliminating the requirement that only terminally ill people could be killed by lethal injection.

By eliminating the "terminal illness" requirement, the court decision also expanded euthanasia to people with psychological conditions alone. Canada's euthanasia law states that a person qualifies for euthanasia if:

the illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

Before the Quebec court decision, a person didn't qualify for euthanasia based on psychological reasons alone since the law required that a person's "natural death be reasonably foreseeable." Since the Quebec court struck down this requirement, the law now permits euthanasia for psychological reasons.

Bill C-7 pretends to prevent euthanasia for "mental illness". Section (2.‍1) of Bill C-7 states:
For the purposes of paragraph (2)‍(a), a mental illness is not considered to be an illness, disease or disability. This statement does not prevent euthanasia for mental illness or psychological reasons since the law specifically permits it. To prevent euthanasia for "mental illness" the bill would need to properly define "mental illness."

It is typical of the Canada's federal government to falsely claim to do something, based on the wishes of Canadians.

The government has previously stated that it plans to have an official five-year review of the euthanasia law starting in June 2020.

The federal government needs to reject Bill C-7 and conduct a proper review of the law, as promised, starting in June 2020.

Petition: Reject euthanasia Bill C-7 (Link).
Categories: Discussion

Eugenics Must Not Be Allowed To Sneak In With Coronavirus

Mon, 2020-04-20 17:19
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Gordon MacDonaldDr Gordon MacDonald, who is the CEO of the Care Not Killing Alliance in the UK has written an insightful article that was published in the Huffington Post on April 19, 2020.

MacDonald writes about how eugenics, must not be allowed to sneak into the healthcare system through our response to the Covid-19 crisis. MacDonald first thanks healthcare providers for their incredible response to the Coronavirus but then he turns to warning the British healthcare system about the dark history of eugenics. MacDonald writes:Doctors will face difficult decisions over the coming weeks and months as the capacity of the healthcare system is pushed beyond its limits. But we must resist these siren voices, because we can’t allow a return to the eugenics movement and its dark past. MacDonad explains the history of eugenics:The eugenics movement started in Britain during the late 19th Century, arising in the context of social Darwinism and the theory of the survival of the fittest. It quickly spread to other Western countries. It led to abuses such as the sterilisation of people with mental illness or learning difficulties in the USA during the 1920s. The movement reached its awful peak in Nazi Germany during the late 1930s with the euthanising of disabled people and those who had learning disabilities.

The underlying philosophy was of racial and genetic superiority and anyone who did not fit this model, or that was considered to be less than perfect, had “a life not worthy to be lived”. This dangerous philosophy ultimately resulted in the slaughter of six million Jews and five million other people in the horrors of the Holocaust.

Following the war, eugenics was discredited because of these atrocities. MacDonald then comments on the resurgence of the eugenics movement. He writes: However, in recent years, a new eugenics movement has begun to appear with the opportunity provided by scientific advancement to alter the genetic make-up of human beings and to “breed out” disability and genetic conditions. The re-emergence of the idea that some lives are not worth living is being applied to vulnerable people who are deemed to have become a burden on society.

Worryingly this view has been given oxygen by former BBC Today presenter John Humphys, writing in the Daily Mail: “I know I’m among the vulnerable group for coronavirus, but just don’t believe all lives are equal.”

Similarly, Max Hastings, speaking on BBC World at One, stated that the elderly are “becoming a dead weight on the NHS”. Such thinking and sentiments are troubling.MacDonald continues by commenting on actions by doctors during the Covid-19 crisis: Already stories are beginning to emerge of GPs contacting their patients with existing health conditions to ask whether they would want a Do Not Resuscitate (DNR) order to be included in their notes.

This might simply reflect a desire to ensure that if one of their patients with another serious medical condition also develops Covid-19, or gets admitted to hospital for another reason, there is no lack of clarity over the patient’s wishes. But whatever the reason, we must be cautious when extending clinical judgements to the subjective measure of quality of life.

We have already heard reports of DNR notices being placed on groups of vulnerable patients, such as those in care homes, in a carte blanche manner and without any consultation with the patients involved or their wider families. This has now been forbidden by the health secretary, and care homes have been instructed to rip up existing agreements. But concerns remain about whether vulnerable people will receive life saving treatment should they be admitted to hospital with Covid-19, and whether they will even be admitted in the first place.

Although such examples do not constitute euthanasia or assisting suicide because doctors are not actively hastening the end of patients’ lives, there is a danger that the same eugenicist thinking can feature. He then states that disability rights leaders such as Baroness Jane Campbell or Baroness Tanni Grey Thompson have expressed concerns that disabled people are increasingly being seen as “expendable”. MacDonald concludes his article by restating:While we live through these unprecedented times, inevitably, very difficult decisions have to be taken about who to treat in a context of grossly overstretched healthcare resources. But we must be aware of the danger of changing medicine in a way which would be detrimental to the most vulnerable in society.

In responding to the Covid-19 virus, we must ensure no back door is left open to the dangerous philosophy of eugenics.Thank you Dr MacDonald
Categories: Discussion

Say No to Assisted Suicide by Telehealth

Fri, 2020-04-17 18:41
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition
*Sign the petition: Healthcare regulations must not permit assisted suicide approvals by telehealth (Link).

I received an email from an assisted suicide lobby group explaining how assisted suicide can be done during the Covid-19 crisis. The text of the email was based on  interviews with leading death lobby activists.

The email indicates that assisted suicide by tele-health/tele-medicine is being implemented in States that have legalized assisted suicide.

The death lobby activists answered questions by promoting access to assisted suicide approval by tele-health.

On March 20 I reported that the assisted suicide lobby was using the Covid-19 crisis to promote approving assisted suicide by telehealth.

This is not a new idea. In 2019 the New Mexico assisted suicide bill included a telehealth provision and the recent bill to expand assisted suicide in Hawaii included a telehealth provision.

On March 26 I reported that the association of death doctors stated that during the Covid-19 crisis "aid-in-dying" needed to be approved by telehealth. On the same day an assisted suicide lobby group thanked Congressional leaders for expanding access to telehealth during the Coronavirus crisis.

I understand the need to expand telehealth services during the Covid-19 crisis but assisted suicide is not medical treatment.

Approving assisted suicide by telehealth means that a person with difficult health issues who feels like a burden on others, or is experiencing depression or existential distress, could be assessed, approved and prescribed a lethal drug cocktail for assisted suicide by telehealth without being examined by the physician.

Considering the problem of medical misdiagnosis, is it reasonable to give physicians the right to prescribe a lethal drug cocktail without examining the patient first?

In April 2013, Pietro D’Amico, a 62-year-old magistrate from Calabria Italy, died by assisted suicide at a Swiss assisted suicide clinic. His autopsy found that he had a misdiagnosis.

It is unlikely that the US Department of Health and Human Services (HHS) realized that the assisted suicide lobby would take advantage of the Covid-19 crisis to begin approvals for assisted suicide by telehealth.

I urge you to contact Alex M Azar II, the HHS Secretary at: Secretary@HHS.gov or call his office at: 202-690-7000

Tell Secretary Azar that assisted suicide is not medical treatment and regulations must not permit assisted suicide approvals by telehealth.

*Sign the petition: Healthcare regulations must not permit assisted suicide approvals by telehealth (Link).
Categories: Discussion

Euthanasia and Covid-19. Euthanasia is not an essential service.

Wed, 2020-04-15 18:07
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Kevin YuillKevin Yuill, the author of the book Assisted Suicide: The Liberal, Humanist Case Against Legalisation, and Theo Boer, a member of a Regional Euthanasia Review Committee in the Netherland (2005 - 14) teamed up to write the article: What Covid-19 has revealed about euthanasia, that was published by Spiked on April 14.

The authors begin the article by commenting on Covid-19 and healthcare.There has not been, in living memory, more focus on healthcare, the vital role of doctors, the sacrifices made by nurses, and the wonderful efforts of everyone involved in the sector. Amid the coronavirus crisis, daily heroism, the scale of human loss, and the awful scenes in hospitals underline what is important – and what is not.Theo BoerThey authors comment on euthanasia and Covid-19 in the Netherlands:It will surprise some that in the Netherlands, the only dedicated clinic providing euthanasia and assisted suicide has closed. Euthanasia Expertise Centre (formerly known as End of Life Clinic) has suspended all euthanasia procedures. The clinic’s website says that existing procedures have been put on hold and new patients are no longer admitted. The centre – which in 2019 alone ended the lives of 898 patients suffering from cancers, psychiatric problems, early on-set dementia, and accumulated age-related complaints – is willing to make an exception only for those expected to die soon and those who may soon lose their capacity for decision-making.They comment on euthanasia and Covid-19 in Belgium:Similarly, in Belgium, Jacqueline Herremans, a member of the federal commission reviewing euthanasia, has noted that there are few resources and even fewer doctors available for euthanasia at the moment: ‘The most important thing right now is that we fight the coronavirus.’They then comment on euthanasia and Covid-19 in Canada:In Canada, authorities are also shutting down services. For a process that requires two different medical assessments and witnesses, the lives involved are not worth the risk. According to the Globe and Mail, two places in Ontario, where euthanasia and assisted suicide have been legal since 2016, have stopped providing medical assistance in dying (MAID) because of the coronavirus pandemic (one has since resumed for existing patients and those whose deaths are imminent).In Ontario, only two regions are known to decided that euthanasia is not an essential service. 
The authors point out that the Netherlands euthanasia clinic state that euthanasia is not a priority during the Covid-19 crisis. The statement from the euthanasia clinic follows an opposite statement last year where Steven Pleiter, the director of the clinic said:‘If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person’The authors point out that palliative care professionals and institutions have not shut-down during the Covid-19 pandemic.
So what has the Covid-19 pandemic taught us about euthanasia? The authors state:What the Covid-19 crisis has demonstrated is that the need for euthanasia and assisted suicide is abstract rather than practical. In the Netherlands in the 1980s, assisted dying started out as the ultimate solution to impending horrible deaths. In present times, with a high level of care for the dying available in most countries with good healthcare, assisted dying is not about actual deaths, but about deaths that people fear. The reality is that most people die peaceful deaths. But many fear loss of control and find the prospect of others caring for them terrifying. Covid-19 brings the reality of death, the necessity of caring for others and being cared for by others, into our living rooms, making the preciousness of all lives and the tragedy of all deaths real. We see the humanity of the elderly and frail; no longer are they burdens to be dispatched from this world, but victims of horrifying disease that all are invested in fighting.The authors conclude by stating:"Perhaps, though, we can remember this time when we made huge sacrifices to preserve every life, no matter how frail and vulnerable. We can remember this time when euthanasia no longer seemed necessary."Thank you Kevin and Theo. Euthanasia is not an essential service and it is not healthcare.
Categories: Discussion

Pressured to die by assisted death.

Tue, 2020-04-14 19:56
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Candice LewisCandice Lewis recently died a natural death. What was the controversy concerning Lewis?

In August 2016, Candice Lewis, who was 25, while receiving treatment at the hospitical, was pressured by a doctor to "request" an assisted death.

No one questions that Candice was very sick at the time, but as Candice's mother told CBC news, the doctor pressured her to request a physician-assisted death. The article stated:
"His words were 'assisted suicide death was legal in Canada,'" she told CBC. "I was shocked, and said, 'Well, I'm not really interested,' and he told me I was being selfish."Kevin Dunn interviewed Candice and her mother Sheila for the Fatal Flaws film. During the interview Sheila said:Not once die she say to them, "I want to end my life." The doctor cam in the next day after he told me about assisted suicide, stuck his face down in Candice's and said, "Do you know how sick you are?" When I got his eye contact we went out in the hallway and I told him, "Don't you ever pull something like that again."
How many cases, similar to Candice Lewis have occurred in Canada and either died by lethal injection or were so shocked by the experience of being pressured that they have not spoken about it?

I have received emails and calls about people being pressured to die by MAiD. Recently I received this email from a care-giver stating:Several weeks ago, in the space of a two week time period, I was made aware of four instances in which nursing staff at ... Hospitals seemed to be initiating discussion of MAiD with family/friends, and, in the last instance, a patient, without any apparent prior reference to MAiD on the part of the patient.During my Vancouver Island speaking tour, a man told the group how his mother, who required dialysis, was urged by healthcare "professionals" to ask for MAiD (euthanasia). He said that if he had not spoken to his mother, she may have died by euthanasia.

At the next talk a woman came up afterwards and shared with that her father, who had significant health issues, was urged by healthcare "professionals" on several occasions to consider MAiD (euthanasia).

It appears that many doctors and nurses are urging patients to ask for MAiD.

This type of pressure, at the most vulnerable time in a person's life, will lead some people, who would never have otherwise considered death by lethal injection, an option. In fact, it is likely that many people have died by euthanasia after being urged by a doctor or a nurse to do so.

If you have a story or a concern, please share it. Knowledge and awareness will help others to resist euthanasia when they are pressured.

I urge you to be involved in the lives of those who you know and care for. When someone is pressured by a doctor or nurse to ask for an assisted death, you can make a difference in their lives by saying - no, I care for you, I will not abandon you. Euthanasia is not the answer.
Categories: Discussion

Covid-19 triage guidelines and nursing home deaths.

Tue, 2020-04-14 18:37
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition


Nursing home residents, with Covid-19, may be experiencing discrimination when being denied beneficial life-saving treatments. It appears that some nursing homes are not transferring residents to the hospital, even when the treatment capacity is available. Some of these decisions should be considered elder abuse.

The disability movement is also concerned that people with disabilities are being denied medical treatment.

I understand that there are times when the person is nearing death and it is not reasonable to transfer the person to the hospital. I also understand that there are times when the hospital lacks the treatment capacity to accept the elderly person. I am concerned that treatable elderly people are not receiving treatment, even when there is treatment capacity.


I was interviewed by OneNewsNow about an article that I wrote concerning the Covid-19 triage guidelines developed by Dr James Downar, the former chair of the Physicians Advisory Council for Dying with Dignity, a euthanasia lobby group. OneNewsNow reported:
Alex Schadenberg of the Euthanasia Prevention Coalition tells OneNewsNow one of the problems is that if a hospital ICU is near capacity, then certain people would not receive medical treatment.

"Basically if a hospital, due to the COVID-19 crisis, [if] the ICU is full, then anybody who … has a medical condition [and] is less likely to recover, or they're over a certain age, they would simply not be given medical treatment," Schadenberg explains. But hospitals with a less populated ICU would treat them, and hospitals who are full could transfer patients to facilities that have beds available.I continued by commenting about my concerns about the growing deaths of elderly people in nursing homes. I stated:
So Schadenberg is mainly concerned about elderly people in Ontario nursing homes

"What we've seen based on these triage protocols is that the decision is not to transfer these people to a hospital, even if they have a significant condition, that is treatable," he reports. "So what you're finding is somebody who's living in a nursing home … if they come down with COVID-19 … they're basically only cared [for] in that nursing home, which is very limiting." He says that means they are more likely to die.Chris Aung-Thwin reported for the National Post that Theresa Tam, Canada's chief public health officer stated:
the spread of the virus in care homes has been at the root of half of the more than 700 deaths across the country.
Covid-19 nursing home deaths is a national problem. Adrian Humphries reported for the National Post that: 
In Quebec, a police investigation is underway after 31 residents at a care home in Dorval died under what Quebec Premier Francois Legault alleged was “gross negligence.” Pinecrest Nursing Home in Bobcaygeon, Ont., saw 29 COVID-19 linked deaths in its 65-bed home. In Toronto, 22 residents with COVID-19 died at Seven Oaks. Eighteen residents at Lynn Valley Care Centre in North Vancouver died with COVID-19; 10 at Almonte Country Haven in Ottawa.And on and on and on, in communities large and small.Some would suggest that the large number Covid-19 deaths in nursings homes is due to the age or other health conditions of those who died. I am convinced that there are other factors.

Some treatment protocols dictate that residents in a nursing home will not be transferred to the hospital, even when the hospital has the treatment capacity to care for them, leaving them far more likely to die.
 
Many residents or their families have stated, in a health care directive, that they would not want treatment or that they would not want to be sent to the hospital for treatment and that they would only want "comfort care" measures.

Order the Life-Protecting Power of Attorney for Personal Care from Euthanasia Prevention Coalition to protect your life (Link).

It is likely that some of the nursing home residents who died by Covid-19 may have survived with treatment. This is a form of discrimination, agism and elder abuse.

Elderly people need patient advocates. If your parent needs beneficial life-saving treatment that could enable recovery, then you need to demand equal treatment.

These are life and death decisions.
Categories: Discussion

Popular articles opposing euthanasia and assisted suicide.

Fri, 2020-04-10 06:00
1. Sick Kids Hospital Toronto will euthanize children with or without parental consent - Oct 10, 2018.

2. Paediatric Palliative Care Symposium and child euthanasia - February 26, 2018.

3. Declaration of Hope – Jan 1, 2016.

4. Fatal Flaws film will change the way you view assisted death - June 8, 2018.

5. Guide to answering the Canadian MAID consultation questionnaire - Jan 15, 2020.

6. Margaret Dore: Assisted Suicide: A Recipe for Elder Abuse and the Illusion of Personal Choice - Feb 17, 2011.

7. Kitty Holman: 5 reasons why people devalue the elderly – May 25, 2010.

8. Healthy 24-year-old Belgian woman who was approved for euthanasia, will live. Nov 12, 2015.

9. Kate Kelly: Mild stroke led to mother’s forced death by dehydration – Sept 27, 2011.

10.  The Euthanasia Deception documentary. - Sept 30, 2016.

11. Healthy 24 year old Belgian woman was scheduled for euthanasia - June 24, 2015.

12. Legalizing euthanasia saves money. Jan 23, 2017.

13. Boycott Me Before You - "disability death porn" - May 26, 2016.

14. Depressed Belgian woman dies by Euthanasia – Feb 6, 2013.

15. Dr's Annette Hanson & Ronald Pies: 12 Myths about Assisted Suicide and Medical Aid in Dying. July 9, 2018.

16. Physically healthy 23-year-old Belgian woman is being considered for euthanasia - October 14, 2019.

17.  Euthanasia is out-of-control in the Netherlands – Sept 25, 2012.

18. Belgian twins euthanized out of fear of blindness. – Jan 14, 2013.

19. Netherlands euthanasia review committee: euthanasia done on a woman with dementia was done in "good faith" -  Jan 28, 2017.

20. Mother upset after doctor urged her to approve assisted death for her daughter with disabilities - July 26, 2017.

21. Assisted suicide law prompts insurance company to deny coverage to terminally ill woman - Oct 20, 2016.

22. Woman who died by euthanasia, may only have had a bladder infection - Nov 14, 2016.

23. Judge upheld decision. Assisted suicide is prohibited in California. May 31, 2018.

24. New Mexico assisted suicide bill is the most extreme bill - Dec 21, 2018.

25. Woman with Anorexia Nervosa dies by euthanasia in Belgium – Feb 10, 2013.

26. 29-year-old healthy Dutch woman died by assisted death for psychiatric reasons. Jan 15, 2018. 

Become a member of the Euthanasia Prevention Coalition ($25) membership.

More important articles:
Categories: Discussion

Decision Making Protocols during the Covid-19 Pandemic

Thu, 2020-04-09 17:44
Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition


The Canadian Medical Association (CMA) approved a Framework for Ethical Decision Making During the Coronavirus Pandemic that is based on the protocol by Ezekiel J Emanuel et al  that was published in the NEJM on March 23, 2020 titled: Fair Allocation of Scarce Medical Resources in the Time of Covid-19

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of resources are limited then decisions are made which are often unjust and lack equality.
I am concerned that many Covid-19 deaths in Canada are related to decisions not to provide treatment for elderly people, even when capacity for treating these people existed. The high rates of death at nursing homes is not only based on the age of those who died, but also the decision not to transfer these patients to a hospital capable of treatment. This is why a doctor at one nursing home lamented that all they could do was provide comfort care.

The triage guidelines developed by the disability rights community seem to represent the fairest and most equitable response to providing treatment during a pandemic. (Link to the guidelines).

This article will provide some insight into the NEJM protocol by Emanuel et al that has been approved by the CMA.
The protocol states that the demand for medical resources may be greater than the supply of resources. I will not comment on the projections only on the proposed allocation of scarce medical resources. Emanuel et al is based on utilitarian principles.

Emanuel et al outline their protocol based on four fundamental values that they defined as: 
  1. maximizing the benefits produced by scarce resources,
  2. treating people equally, 
  3. promoting and rewarding instrumental value, and 
  4. giving priority to the worst off.
    They define each of the fundamental values in this manner:
    1. Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.
    2. Treating people equally could be attempted by random selection, such as a lottery, or by a first-come, first-served allocation. 
    3. Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past. 
    4. Giving priority to the worst off could be understood as giving priority either to the sickest or to younger people who will have lived the shortest lives if they die untreated. 
    Emanuel et al state that none of the fundamental values should be assessed alone but in relation to the other fundamental values.

    They then examine who would receive health resources in a Covid-19 pandemic. They state that the four fundamental values would be examined based on six specific recommendations for allocating medical resources in the Covid-19 pandemic, which are:
    1. maximize benefits;
    2. prioritize health workers; 
    3. do not allocate on a first-come, first-served basis; 
    4. be responsive to evidence; 
    5. recognize research participation; and 
    6. apply the same principles to all Covid-19 and non–Covid-19 patients
      Emanuel explains how his six recommendations would work.
      Recommendation one focuses on priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. ...There are many reasonable ways of balancing saving more lives against saving more years of life, whatever balance between lives and life-years is chosen must be applied consistently.
      A controversial proposal is the withdrawing ventilator support from someone who is currently receiving ventilator treatment. Emanuel states:
      Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.This is simply wrong. There are many people with disabilities, including Not Dead Yet President Diane Coleman, who require oxygen assistance to live. In Withdrawing ventilator treatment is a treatment decisions and should require consent. Decisions to approve or withdraw treatment should be defined as treatment decisions and should require consent.

      Recommendation two focuses on the care of front-line health care workers. Healthcare workers are needed to ensure a successful pandemic response, therefore their health is a priority. I agree with recommendation two.

      Recommendation three states that when making decision for who should receive care among people with a similar prognosis that those decisions should be based on a lottery and not a first come first served basis. 
      I personally don't agree with this point considering that our culture is used to a first come first served basis. Who will decide the parameters of the "lottery" and how is it to be fairly determined? I think that a lottery system will give the healthcare bureaucrat to more control of the system.

      Recommendation four suggests that the approach should be based on scientific evidence, which may change over time. Therefore it is suggested that a vaccine, which are preventative, should be given to the elderly and other vulnerable patients first, to reduce the loss of life.

      The protocol then states that ICU beds and ventilators, which involve curative treatments, should be allocated to those most likely to survive first. But the protocol goes further and suggests not only those who are most likely to survive but those who are most likely to survive the most number of years.

      This proposal denies treatment to older persons and people with disabilities in a discriminatory manner.

      As I stated in a previous article:
      People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment. In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care. A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment. A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.Recommendation five states that people who are willing to participate in medical trials for Covid-19 research should receive priority.

      Recommendation six states that if medical resources become scarce that all medical decision should be made based on the decision making protocol. For instance it states that if there is a scarcity of ventilators and a healthcare worker needs a ventilator for a different condition, that priority should be given.

      The pandemic decision making protocols developed by the disability community represent a fair and equitable response to the possible scarcity of resources. (Link to the protocol). I am concerned that the quality of life ethic, mixed with a utilitarian and discriminatory ethic towards people with disabilities will only lead to ingraining decisions that will result in the deaths of vulnerable persons.

      These utilitarian guidelines, such as the one designed by Emanuel et al, ingrains negative and discriminatory attitudes to vulnerable populations.

      Medical decisions should be made based on Justice and equality (non-maleficence) and not the elimination of the weak.
      More information on this topic:
      1. Pandemic Palliative care protocol. Selecting people to die (Link).
      2. As the threat of triage grows. Disability rights advocacy is needed more than ever (Link).
      3. Euthanasia doctor developed Covid-19 triage guidelines (Link).
      Categories: Discussion

      As the Threat of Triage Grows, Disability Rights Advocacy Is Needed More Than Ever

      Tue, 2020-04-07 19:23
      This article was published by Not Dead Yet on April 6, 2020
      Diane Coleman, Not Dead Yet.On Friday, April 3rd, six leading disability rights attorneys and their respective organizations issued a statement entitled Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing. The statement, which helps to interpret the federal bulletin issued a week earlier, was joined by over 90 organizations, including NDY.

      One of the most critical parts of the statement focuses on the following language in the federal bulletin:“[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities. Decisions by covered entities concerning whether an individual is a candidate for treatment should be based on an individualized assessment of the patient based on the best available objective medical evidence.”The disability advocates’ statement explained this, in part, as follows:
      • All persons should be eligible for, and qualified to receive, lifesaving care regardless of the presence of an underlying disability or co-morbid conditions, unless it is clear that the person will not survive in the immediate term or the treatment is contra-indicated.
      • Treatment allocation decisions may not be made based on misguided assumptions that people with disabilities experience a lower quality of life . . . .
      • Every patient must be treated as an individual, not a diagnosis. This means that the mere fact that a patient may have a diagnosis of, for example, intellectual disability, autism, cystic fibrosis, diabetes, spina bifida, spinal muscular atrophy, or schizophrenia cannot be a basis (in part or whole) for denying care or making that person a lower priority to receive treatment.
      • Generalized assumptions must be avoided and doctors must instead focus on the most current and best available objective medical evidence available to determine an individual patient’s ability to respond to treatment. . . .
      • . . . [V]alue judgments about the fact that a patient may require extensive support in activities of daily living, uses augmentative or alternative communication, uses a wheelchair, or experiences a psychiatric disability are irrelevant to decisions about whether such individuals should receive life-sustaining treatment.
      • Protocols which equate survival with “health” or the absence of chronically debilitating symptoms, risk importing quality life criteria on the triage process.
      Clearly, a carefully conducted individual assessment will protect many people with disabilities from being assigned a lower priority to receive treatment. Of course, as disability advocates know from decades of experience, individualized assessment, planning and services are easy words to say but much harder to get in practice. Our community must continue to press for this. It will save lives.

      An equal or greater concern is that people whose “individual assessment” suggests they may have a lower likelihood of survival from COVID-19, or (under some triage approaches) a shorter predicted life expectancy for other reasons, would be given lower priority for treatment that could benefit them in terms of potential for survival.

      One such “model” policy that is receiving a lot of attention is from the University of Pittsburgh. It calls for prioritizing individuals based on a combination of two primary factors. First, the “Sequential Organ Failure Assessment (SOFA) score (or an alternate, validated, objective measure of probability of survival to hospital discharge) is used to determine patients’ prognoses for hospital survival.” The second factor is “the presence of conditions in such an advanced state that life expectancy is very limited” {less than 1 year or less than 5 years), which is used to characterize patients’ longer-term prognosis. This does not inspire confidence in the policy’s objectivity. It provides for the kind of blatant discrimination that worries many of us (see, e.g., Alice Wong’s moving article in Vox.com).

      As the potential for implementing triage policies increases, advocacy will be needed more than ever. For more information, one excellent resource is the DREDF COVID-19 page.
      Categories: Discussion

      Candice Lewis has died a natural death RIP. Candice made a difference in the world.

      Tue, 2020-04-07 17:23
      Alex Schadenberg
      Executive Director, Euthanasia Prevention Coalition

      Yesterday, Candice Lewis died a natural death. Candice made a difference in the world.
      We first learned about Candice and her mom Sheila in July 2017 when CBC Newfoundland published an article concerning the complaint by Sheila about Candice being pressured to ask for Medical Aid in Dying (MAiD) while she was receiving medical treatment in August 2016. (Link)

      An in-depth article was written by Stephen Roberts, for the Northern Pen concerning the complaint letter that Sheila, sent to the hospital. It stated:
      Elson wrote that Heroux had taken her out into the hallway by Lewis’s hospital room to discuss physician-assisted death and advise her the option was legal in Canada.  She alleges the doctor said he supported physician-assisted death for Lewis. “This left me dumbfounded and I told him it was something I did not want to consider,” she said.
      She contends the doctor suggested she was being selfish and that she told him that she didn’t believe Lewis was able to fully comprehend what was being suggested. She says Lewis could hear the conversation from her room and it was causing emotional distress for them both.  “I am still very concerned about this, it is always on my mind. I am emotionally exhausted. I see that it has been also very stressful for Candice and one of my main reasons for writing this letter is that I don’t want any other family to have to go through this,” Elson wrote.We learned more in August 2017 when Roberts wrote a follow up article for the Northern Pen indicating that Candice's health had improved (Link).

      Candice and KevinKevin Dunn then visited Candice and Sheila for the filming of the Fatal Flaws film. After returning from Newfoundland we published this article and film clip.

      Yesterday Kevin published a tribute to Candice on his blog (Link).

      Since that time, Kevin and I have continued communicating with Candice and Sheila. They have made a difference in the lives of so many.
      How many cases, similar to Candice Lewis have occurred in Canada and either died by lethal injection or were so shocked by the experience of being pressured that they have not spoken about it? Thank you Candice for sharing your story.
      My deepest condolences go to Sheila and the family. Sheila loved and cared for her daughter Candice. Sheila told me that her heart is broken. 
      Candice lived her life and will be remembered for how she helped to change the world.

      Categories: Discussion

      Pandemic palliative care protocol. Selecting people to die and abusing the purpose of palliative care.

      Mon, 2020-04-06 18:31
      Alex Schadenberg
      Executive Director, Euthanasia Prevention Coalition

      There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 
      Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of certain resources are limited then decisions are made which are often unjust and lack equality.

      People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment.

      In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care.

      A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment.

      A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is truly futile. In this circumstance the person is not deemed futile but the treatment is medically assessed as futile.

      People with disabilities are genuinely fear that they will not be considered "worthy" for treatment, even when the benefit of the treatment is recovery. Further to that, some people with disabilities already require ventilator support to live. Should these people be denied ventilator support or have it withdrawn against their needs and wishes simply because another person requires a ventilator?
      Pandemic palliative care: beyond ventilators and saving lives.

      The CMAJ (March 31) published a protocol on the care of Covid-19 patients who are being withheld or withdrawn from treatment titled: Pandemic palliative care: beyond ventilators and saving lives. The authors of the protocol include Dr James Downar, the former chair of the Dying with Dignity Physician Advisory Committee and Dr Sandy Buchman, President of the Canadian Medical Association.
      Read: Euthanasia doctor developed Ontario Covid-19 triage guidelines (Link).

      The authors are asking for a response to the protocol. This is my assessment.

      The protocol claims to be based on fairness and equality, but actually institutionalizes the inequality and injustice that lead to people with disabilities and other vulnerable groups being selected for death based on negative and discriminatory attitudes.

      The protocol states:Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill. Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity.This statement tells us not to have blanket statements in our healthcare directive requiring comfort measures only. Certain medical conditions may lead to recovery with treatment, but with the above wording, no treatment will be provided.
      This statement is also unethical. To withdraw a ventilator requires consent from the patient or the power of attorney. Decisions to withdraw treatment require consent in the same manner as decisions to provide treatment. 
      People with disabilities who require a ventilator fear that decisions will be made to extubate them because their health condition is not clinically improving. People with disabilities may not "clinically improve" not because they are treatment resistant but because of the nature of the disability. It is discrimination to deny treatment based on disability.
      The protocol states that when a person is denied treatment that they must be provided palliative care. The authors state that they are not abandoning the patient when they provide palliative care and yet the triage system has already abandoned the patient.

      The protocol leads to an abuse of the ethical use of palliative sedation.

      Palliative sedation or terminal sedation is properly used for a patient who has symptoms that cannot be effectively alleviated in any other way. For instance, a person who is living with Neuropathic pain may only be effectively relieved of the pain through sedation. The authors of this protocol are proposing the use of sedation as a means of causing death, instead of (MAiD) euthanasia which is legal in Canada. The protocol states:In our opinion, palliative sedation is preferable to medical assistance in dying (MAiD) for patients with severe respiratory failure caused by SARS-CoV-2, given the 10-day reflection period, number of witnesses and assessors required, and the current requirement for full capacity to determine eligibility for MAiD. When analyzing euthanasia data from the Netherlands and Belgium you will notice a significant number of "assisted deaths without explicit request" that occur on a yearly basis. This protocol is endorsing the same procedures that are done in the Netherlands and Belgium to circumvent the euthanasia law. Downar is well aware that he is advocating for intentional acts to cause death. In 2014 Downar participated in the study: Characteristics of Belgian "life ending acts without explicit request."

      The protocol changes the ideology of palliative care. The concept of palliative care is to provide pain and symptom relief when a person is dying, to palliate the symptoms but never to hasten death. The protocol is suggesting that palliative care can replace active treatment, even when treatment may lead to recovery. So palliative care becomes a way of providing a comfortable death for people who have been medically abandoned.
      The protocol claims that it will lead to greater equity. The protocol acknowledges that people who live with mental illness or other conditions face substantial challenges to receiving healthcare and they conclude that: "Palliative care thus becomes the compassionate option to counterbalance this inequality."

      Palliative care is better than "sending them home to die" and to not palliate symptoms is to abandon the patient again. Nonetheless, this protocol institutionalizes the inequality and injustice. The protocol states that you must be kept comfortable as we abandon you. But it doesn't stop there, the protocol advocates for the abuse of the use of "palliative sedation" meaning, we will not only palliative your symptoms, but in certain circumstances we will end your life without your explicit consent.
      Categories: Discussion