A principles-based approach to assisted dying.

1. End-of-life care in Canada:
A principles-based approach to assisted dying
Dr. Jeff Blackmer
Vice-President, Medical Professionalism

2. CMA activities on
end-of-life care
What’s new since we last met in Ottawa

3. Activities on end-of-life care
• The CMA revised its policy on assisted dying based on feedback
from 2014 General Council
• We developed and released a comprehensive report on palliative
care designed to be a national call to action to improve access to
quality palliative care
• We undertook further extensive consultation with our members
and with key stakeholders on a principles-based approach to
assisted dying

4. CMA intervention in
Carter v. Canada
October 15, 2014

5. CMA appeared as an intervener - a friend of the court –
in Carter v. Canada to present key considerations:
→ CMA supports members on both sides of the issue
→ The profession, like the public, is divided
→ There are important practical considerations to be considered
→ End of life discussions need to be supported and become a part
of routine medical practice
→ Canada needs a national palliative care and end of life strategy

6. February 6 2015:
 Held: The appeal should be allowed.
Section 241 b and s. 14 of the Criminal Code
unjustifiably infringe s. 7 of the Canadian
Charter of Rights and Freedoms.

7. CMA principles-based approach
to assisted dying

8. Principles-based approach to assisted dying
Ten principles:
1. Respect for autonomy 6. Dignity of life
2. Equity 7. Protection of patients
3. Respect for physician values 8. Accountability
4. Consent and capacity 9. Solidarity
5. Clarity 10. Mutual respect

9. Principles-based approach to assisted dying
Recommendations:
1. Patient qualifications for access to medical aid in dying
2. Process map for decision-making in medical aid in dying
3. Role of the physician
4. Responsibilities of the consulting physician
5. Moral opposition to medical aid in dying

10. Consultation process
 June – July 2015
 Online survey (1407 responses)
 Online dialogue (595 participants)
 Stakeholder consultation
 Individual member consultation

11. CMA member consultation
Key online survey results

12. Following the Supreme Court of Canada decision regarding
medical aid in dying, would you consider providing medical
aid in dying if it was requested by a patient?

13. If Yes: Would you provide medical aid in dying to someone
whose suffering was purely psychological?

14. If Yes: Would you provide medical aid in dying to someone
not suffering from a terminal illness?

15. If a physician refuses to provide medical aid in dying, what
should they be required to do?

16. What do you believe the role of the CMA should be in
relation to medical aid in dying?
%

17. Would you consider providing medical aid in dying if it was
requested by a patient? 2014 v. 2015
20144 20154

18. CFPC ePanel: Do you agree with the recent Supreme Court of
Canada decision that struck down sections of the Criminal Code
that prohibit physicians from helping patients die?

19. CFPC ePanel: Would you help a competent, consenting
dying patient end her/his life if requested?

20. CMA stakeholder and member
consultation
Key strategic questions and
responses

21. 1. What should be the processes followed after the patient requests medical
aid in dying?
2. The Supreme Court of Canada has laid out broad terms which patients
will qualify for assistance in dying. Should there be other clinical
specifications or requirements?
3. Some physicians will choose not to participate in assisted dying for
reasons of conscience. What specific mechanisms can physicians
employ to ensure this access?
Key strategic questions

22. • There was wide agreement that the first response should be to assess patient
needs and provide alternative treatment options
• There was wide agreement there should be procedural safeguards to assess
and respond to requests and that it requires expertise and training
• There was disagreement on the appropriate timeline with some suggesting it
should be shorter and others suggesting it should be longer
Process to respond to request

23. Questions to consider:
1. Does the proposed timeline require revision?
2. Should the process include a palliative care or a psychiatric consultation
as a requirement? And/or should the consulting physician be a palliative
care physician?
3. Should we further clarify the roles and next steps if there is a
disagreement in the assessment of the patient?
Process to respond to request

24. Clinical specifications and requirements
• There was wide agreement that the eligibility criteria defined in Carter are
problematic, i.e., what does “grievous and irremediable” mean clinically?
• There was disagreement on the appropriate scope of eligibility with some
suggesting narrow criteria and others suggesting broad criteria should be
adopted
• There were some suggestions that the waiting (“cooling off”) period should be
proportionate to the patient’s expected prognosis, i.e., a standard waiting
period is not appropriate for all requests

25. Questions to consider:
1. What would be an appropriate scope of eligibility, i.e., narrower vs broader
criteria?
2. Should the prognosis, e.g., a terminal illness vs chronic pain, be taken
into account in determining the process?
Clinical specifications and requirements

26. 1. The vast majority expressed the view that physician conscience rights
must be integrally protected
→ There was disagreement on what that means with conceptions of
conscience as opposition, procedural non-participation, non-interference,
and participation
Conscientious objection

27. 2. There was agreement that the exercise of conscientious objection must be
protected in a way that balances patients’ ability to access assisted dying
→Options were discussed to support differences in conscience, in the form of
the duty to refer, duty to provide information, no duty
Conscientious objection

28. Options to consider:
1. Duty to refer directly to a non-objecting physician
2. Duty to refer to an independent third party
3. Duty to provide complete information on all options and advise on how to
access directly a separate central information, counseling, and referral
service
4. Patient self-referral to a separate central information, counseling, and
referral service
Conscientious objection

29. 1. Duty to refer directly to a non-objecting physician
PROS
→ It is the most direct way to facilitate patient access
CONS
→ It does not respect conceptions of conscience for which a duty to refer is
morally unacceptable
→ Referral implies forced participation procedurally that may be connected to,
and would be complicit in, a morally unacceptable act
Conscientious objection

30. 2. Duty to refer to an independent third party
PROS
→ It facilitates access to a designated third party who would act as an
information, counseling and referral service
→ It is consistent with Quebec legislation
CONS
→ It does not respect conceptions of conscience for which a duty to refer is
morally unacceptable
→ Referral implies forced participation procedurally that may be connected to,
and would be complicit in, a morally unacceptable act
Conscientious objection

31. 3. Duty to provide complete information on all options and advise on
how to access a separate central information, counseling, and referral
service
PROS
→It provides the patient with complete information and facilitates access to a
service
→It is the most widely morally acceptable option that takes account of, and
respects, differences in conscience, while facilitating access to a service
CONS
→It presupposes that there will be a central information service
Conscientious objection

32. 4. Patient self-referral to a separate central information, counseling,
and referral service
PROS
→It does not compel physicians opposed to assisted dying to participate in
any way
CONS
→It presupposes that there will be a central information service
→It does not facilitate patient access in any way
Conscientious objection

33. Next Steps
• GC Delegate discussion and feedback
• Use of framework to help shape legislation
and regulations at the federal and provincial
levels

34. End-of-life care in Canada:
A principles-based approach to assisted dying
Dr. Jeff Blackmer
Vice-President, Medical Professionalism