Undermined The Very Ethos

Cory Franklin writes:

If the Terminally Ill Adults (End of Life) Bill – to give it its full title – does pass, practical measures must be adopted to protect patients as much as possible. Kim Leadbeater, the MP who proposed the bill, has insisted that adequate safeguards can be put in place, although many of the details in the bill are yet to be made public.

This is hardly reassuring. Other countries’ experiences have shown that maintaining strict safeguards for physician-assisted dying always fails. It is a certainty that if assisted dying is legalised, patients who shouldn’t die will die. But two factors do seem to offer patients at least some measure of protection: the eligibility criteria for assisted suicide and the role of physicians in the process. We can see this in the contrasting experiences of two places that have legalised assisted dying: Canada and California.

The populations of Canada and California, at around 40million each, are comparable. The overall demographics, while not identical, are similar, and there are no significant differences in the leading causes of death, overall death rates or access to palliative-care services. Yet the difference in the numbers of assisted deaths between Canada and California is huge. Between 2016 and 2021, California recorded 3,344 assisted deaths, while Canada recorded 31,664.

In fact, in 2021 alone, there were 10,064 assisted deaths in Canada. That accounts for 3.3 per cent of all deaths nationwide. That same year in California, there were 486 deaths, which account for just 0.15 per cent of all deaths statewide.

The first reason for the disparity is clear. The standard a patient has to meet before he or she is eligible for assisted dying is much higher in California than it is in Canada. In California, a patient must have a terminal illness, with death reasonably expected within six months. In Canada, there is no requirement for the patient to have a terminal disease and death does not have to be imminent. Indeed, under Canadian legislation, a patient can be eligible by claiming to be enduring ‘unbearable suffering’ from a medical condition. There is also no requirement for medical practitioners to have tried any other options to relieve a patient’s suffering. In Canada, a patient’s seeming willingness to die matters more than what they’re diagnosed with and what treatment they’ve received.

Unsurprisingly, the looser Canadian criteria drastically expand the number of candidates for assisted suicide. They also raise legitimate concerns about the safety of the disabled, those with mental illness or depression, and patients with chronic but not terminal conditions.

Social factors matter here, too. Is assisted dying really an ‘autonomous choice’ if it’s made by those who are vulnerable, facing dire poverty, inadequate social services or failing healthcare systems? Data from Canada suggest not. A recent expert committee reviewing euthanasia deaths in Ontario, Canada’s largest province, found that a significant number of people who received euthanasia lived in the province’s poorest areas. People requesting euthanasia were also more likely to require disability support and be socially isolated. As one doctor on the expert committee put it: ‘To finally have a government report that recognises these cases of concern is extremely important. We’ve been gaslit for so many years when we raised fears about people [accessing assisted suicide] because they were poor, disabled or socially isolated.’

There is a second major reason for the disparity between Canada and California – namely, the role doctors play. California only allows physicians to prescribe medications for patients’ oral self-administration once the patient has resolved to die. Physicians are not allowed to administer lethal injections. This accounts for the low number of patient requests that are actually carried out in California – in fact, just 1.9 per cent of all requests in 2021 ended in death. Most patients either change their minds or die before they find it necessary to consume their lethal medications. There were no recorded instances of doctors administering lethal injections in the 486 assisted deaths in 2021. In Canada, however, doctors play a far more hands-on role, administering euthanasia via lethal injections. Of the 10,064 assisted deaths in Canada in 2021, 10,057 were by lethal injection.

The Canadian law allows doctors to euthanise patients with impunity. Prosecutions for improper practice are non-existent. Commenting on cases in the Ontario report, Trudo Lemmens, professor of health law and policy at the University of Toronto, said medical professional bodies and judicial authorities appeared to be ‘unwilling to curtail practices that appear ethically problematic… Either the law is too broad, or the professional guidance is not precise enough, or it is simply not seen as a priority to protect some of our most vulnerable citizens.’

There is no greater power than that over life and death. This is what assisted-dying legislation grants to doctors. It cannot help but muddy the relationship between patients and physicians. Will patients look their doctors in the eye and wonder what is in the back of their minds when they recommend assisted suicide?

A tenet of the medical profession that dates back to Hippocrates of Cos is that ‘I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan’. Any legislation involving assisted dying surely compromises this responsibility to patients. As Dr Sonu Gaind, professor of medicine at the University of Toronto, put it, ‘what we’re doing in many cases is the opposite of suicide prevention’.

And there’s the rub. Legalising assisted dying undermines the very ethos of the medical profession. Whatever happened to ‘first, do no harm’?