Wednesday, April 13, 2016

Physician Assisted Dying public meeting held in Pincher Creek

John Barlow at Physician Assisted Dying public meeting in Pincher Creek
Josh Davis

On Thursday April 7 Foothills MP John Barlow hosted a public meeting facilitated by David Green regarding the issue of  Physician Assisted Dying at the Pincher Creek Community Hall, which over 30 people attended. It was one of a series of similar meetings held in Alberta and across Canada.  “Legislation on doctor assisted dying will happen. That is the Supreme Court’s directive to us as the House of Commons,” said Barlow. “I know some of you here tonight want to speak out against having doctor assisted dying at all. I understand that, I sympathize with that, but again I have to make clear that this is going to happen.” Barlow explained that the federal government has asked for two extensions on this issue already.

Legislation must be passed on physician assisted dying by June 6, 2016, in the wake of a Supreme Court ruling made in February of last year. The Supreme Court’s February 6 2015 ruling declared section 14 and 241(b) of the Criminal Code null and void. This opened the door to physician assisted death for any competent adult person who clearly consents to termination of their life, and has a grievous and irremediable medical condition that causes intolerable and enduring suffering, including disabilities. However, the 21 recommendations put together by the Special Joint Committee on Physician-Assisted Dying go two steps further by including recommendations specifically protecting assisted dying in cases of psychiatric issues, and suggesting that youth can be declared “mature minors” and be granted access to assisted death with no regard for the wishes of their parents.

The committee’s document states that the terms relating to medical assistance in dying do not require further statutory definition. The committee recommends a two stage legislative process, with the first stage applying to competent adult persons 18 years or older, to be followed by a second stage applying to competent mature minors, to be put in place no later than three years after the first stage has come into force. The committee also recommends that the Government of Canada immediately commit to facilitating a study on the moral, medical, and legal issues surrounding mature minors.

One issue of key importance to rural communities is that a request for medical assistance in dying can only be carried out if two physicians who are independent of one another have determined that the person meets the eligibility criteria for physician assisted dying. While this second opinion serves as a safeguard, it also poses a problem in small towns like Pincher Creek. Physicians in rural communities are often not independent of each other, forcing those seeking assisted death to travel to other communities, and speak to doctors who don’t know them.

“There’s many cases where patients in question will have days left to live, at most, and will be in no state to travel whatsoever,” said Pincher Creek Associate Clinic Physician Dr. Tobias Gelber, who was present at the meeting. “In a situation where there’s only one physician that’s going to be a huge problem for that patient to find access. Secondly, when there’s only one clinic in town, you’re not going to find independent physicians.”

Another key issue is the future of palliative care. “There’s a lot of concern from palliative care and health professionals that doctor assisted dying would be the end of palliative care. But what we have said is that we need to ensure that palliative care is not only protected, but that it’s better funded, and that there’s more awareness," said Barlow, who added that the issue is much broader than just dealing with those who would be in palliative care, due to the nature of the recommendations.

Barlow said he opposes the recommendation that Doctors must provide effective referrals. ”That is probably one of the biggest concerns with these recommendations. We had four or five physicians in Okotoks last night. All of them voiced some very strong concerns with this recommendation.” Barlow said he will try to remove this recommendation. “We must have protection in there for physicians on decisions of conscience.” He also stated they must be free from reprimand. “The issue with this is even if we were to remove it, and we will work very hard to remove this recommendation, is that the College of Physicians & Surgeons has this as their code of ethics. So even if we were to remove this, we must also lobby the College of Physicians and Surgeons to remove it from their code of ethics.”

Barlow explained that while this will be legislated federally, each province would come up with their own system to provide the service. “The model that’s being discussed with Alberta Health Services would be a navigator. So it’d be out of the hands of family physicians, which would answer a lot of our questions on the rural side. What would happen is if a patient was interested in doctor assisted dying, rather than going to their family physician, or their local doctor in their community, they would go online, or call a 1-800 number, and get this navigator. The navigator would be a team of medical doctors, mental health professionals, nurses, psychiatrists, and they would walk them through the process, give them options, and see if this is something they would really want to do. That seems to be a compromise that may work.”

Not everybody is in agreement on a navigator as the best solution. “As a palliative care professional, as much as other health professionals feel that’s a good idea, I don’t know if I agree with having it out of the hands of local providers,” said Associate Clinic doctor Kristine Woodley. “I think we, in rural communities, provide really good care to our community, and to take that out of their hands and into the hands of strangers, and people that aren’t familiar with them… I don’t know that that’s a good idea.” She said it would be different if it was just an option.

One recommendation states that that the government of Canada work with the provinces and territories and their medical regulatory bodies to ensure that the process to regulate medical assistance in dying does not include a prior review and approval process. This means following the extensions granted on this legislation, if anybody does want doctor assisted dying, they can currently apply to the Supreme Court to request permission. This makes sense, since the Supreme Court wants to make sure the legislation is done in a timely fashion.

One possible concern is that the legislation may be pushed forward before effective safeguards can be developed. The recommendation that mature minors be granted physician assisted death is particularly relevant here. “Mature minor” with relation to medical issues refers to the doctrine that unemancipated minors may possess the maturity to choose or reject health treatments. In Canada youth of 16 or 17 years of age are assumed to be mature minors. Following a 2009 ruling by the Supreme Court, children may make life and death decisions about their medical treatment. This decision annulled laws restricting capacity determinations to those aged 16 and older. This means that any youth 15 or younger may be permitted a hearing, though historically few judges grant this autonomy to youth under 13 years of age.

Psychiatric issues are raised several times in the Special Joint Committee’s document. This could allow those with depression or schizophrenia to seek out assisted suicide, provided they can find two doctors that believe the psychological pain their condition causes is irremediable, and cause intolerable and enduring suffering. The document also notes that “irremediable” does not require the patient to undertake treatments that are unacceptable to them. This means a depressed patient could choose assisted dying over medication as a treatment option, provided they can show that their emotional distress is intolerable to them.

Since there was a little bit of confusion, Dr Gelber explained differences between assisted suicide and euthanasia. "Physician assisted dying is a overarching term. Physician assisted suicide is one branch of that where a physician would write a a prescription of something, yet to be determined, where the patient could take it in their own environment to end their own life, as opposed to a physician actually committing the act, which is commonly referred to as euthanasia."

Another question raised by the crowd was whether or not somebody could seek assessments repeatedly. Unclear is what happens once a person has approached a doctor and has been found ineligible, specifically whether or not they will be able to continue seeking doctors in order to be found eligible for assisted death.

Barlow said that support drops from 82% in favour of assisted death to 35% when the stipulations of the recommendations are considered. In an interview following the presentation, he raised questions about the definitions. “What is irremediable? What is intolerable? I think those make it very grey, and very open to interpretation. And I think that's something that we have to be aware of." Barlow said that he would be very surprised if the legislation was actually passed by June 6, and that they may be asking for another extension. "This is not something that we should be rushing through parliament. This is something that we should be taking time with, and make sure that we do it right."
Related (more recent) story:
MP John Barlow on tabling of Doctor Assisted Dying legislation

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