life and death

The Plague-Ground – It’s complicated. Life and death always is.

On Monday I wrote about A Bill to Kill You, otherwise called Bill C-7 which proposes big changes in the rules of Medical Assistance in Dying (MAiD).

Today, you can qualify for MAiD if you are in the advanced stage of a serious illness, disease or disability; if it is causing you enduring suffering; and if your “natural death is reasonably foreseeable”.

C-7’s changes include denying MAiD if you’re suffering solely from a mental illness; reducing the number of witnesses to your request from two to one;  removing the mandatory 10-day waiting period between your request and its execution; and doing away with the idea that your death must be reasonably foreseeable.

The Bill was meant to be voted on by Parliament three different times this year. Three times it was delayed, from March 11th to July 11th to today, December 18th. But last Friday, Ottawa asked for a further delay. One reason is, Canadians are waking up to the consequences of these changes and think they should be aired and not rushed.

Not just religious groups, some of whom view taking your own life as a mortal sin; and not just disability groups who fear Canadians with disabilities will become victims of death-on-demand.

One of the people saying: “Hold on. Let’s talk about this” is me. But I’m just an interested bystander.

Another is my wife, Jean Marmoreo. As a MAiD doctor, she’s in the thick of this; she lives it. She was one of the founding members of CAMAP, the Canadian Association of MAiD Assessors and Providers, and serves on the medical advisory committee of Dying With Dignity.

So I asked her what she thinks:

Foreseeable Death

“I think removing the ‘foreseeable death’ clause will open the doors to many more people with chronic illnesses, like Parkinson’s or Rheumatoid Arthritis, thinking about MAiD, almost as a treatment option. I don’t think doctors will say that helping you die is a treatment for your terrible illness. But I think patients will.”

“This means that a 35-year old woman living with Lupus may qualify for MAiD.” 

Mental Illness

“Not giving mental illness the same standing as physical illness stigmatizes a clinical condition that has the same right to be considered. I recently assessed a woman who met the criteria for treatment-resistant depression. I consulted with a psychiatrist who would assess her eligibility, the same way an oncologist would help me determine how reasonably foreseeable her death would be if she had cancer.”

“I relied on the psychiatrist to tell me that every form of treatment had been tried, without success. Today, it’s possible that she could have been eligible for MAiD. But after Bill C-7 is passed, she couldn’t. As it turns out, she was offered a new treatment and she was willing to still try carrying on.”

One Witness, Not Two

“Right now, neither of the two people who witness your request for MAiD can benefit in any way from your death or be involved with your direct care. But with just one independent witness needed to sign, there’s a greater chance of abuse or mistakes. Asking a single volunteer to be the sole gatekeeper in a legal step in the process is too casual and, at the same time, too burdensome.”

“Two doctors are required to assess a patient because, when it comes to deciding if someone is eligible to be put to death by one of them, two heads are not only better than one, that one doctor isn’t all alone. For much the same reasons, let’s keep those two witnesses.”

No More 10-Day Waiting Period

“The obvious danger here is that your last act will be impulsive. But I can tell you that every one of Canada’s 300 MAiD doctors is going to take a lot longer getting an expert opinion if the patient is pushing to die tomorrow.”

“In my four years of assessing and providing MAiD, I’ve never heard a specialist say: “‘I agree. He’s eligible for MAiD.’ What they’ll say is: ‘In 10 years, this patient with this rare neurodegenerative disease will be in a vegetative state.’ It’s up to me to conclude that he’s eligible for MAiD.”

“Under C-7, I’ll be a canvassing more specialists because, with the loosening of the criteria for MAiD, comes the risk of making a terrible mistake.”

“The Coroner’s on the Line”

“Every province has a different oversight and reporting system. In Ontario, all MAiD deaths are reported to the Coroner’s Office immediately after the patient’s death. I’ve had many calls with them where they ask: ‘How did you determine if this person’s death was foreseeable?’ and I’ve learned to have my answers, full and complete, at the ready. But with C-7, it’s certain there will be more questions and pushback simply because the criteria for MAiD are frankly byzantine.”

*    *    *    *    *
Ultimately, Jean believes that Canadians have done a stellar job in making MAiD possible, and thus relieving the intense suffering of people at the end of their lives. But also in decriminalizing a process that was deeply covert and unspoken.

She also believes that Bill C-7 is too much, too soon. Looking at the growing divisiveness around this Bill, it should make us pause and reflect, not push harder to ram it through unexamined. Ottawa should open both the door and the debate. This can only be done after we’ve come out the other end of the pandemic which, in her words “has shown us how poorly we really care for our oldest and frailest citizens.”

Last night, Ottawa was given its third extension for Parliament to vote on Bill C-7, until February 26th.

That’s not long enough.

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13 thoughts on “The Plague-Ground – It’s complicated. Life and death always is.”

  1. I’d like to see doctors removed from the process. I believe some other countries have done so. As a basic premise, I suggest that the state has no role to play in my decision to die whenever I wish. My body, my decision.

  2. Jean, I’m with you. As the wife of someone who opted for MAiD, I understand its benefit. But it’s not a frivolous action. There has to be careful scrutiny and examination, and certainly not by only one person. Please keep fighting for this right but under the appropriate conditions. (BTW, my sister, who’s a GP in the UK, was horrified at my husband’s choice. We had to try and make her see that we treat our pets at the end of their lives better than we treat our loved ones. I still don’t think she approved.)

  3. Re the comment on foreseeable death, I looked up who is eligible under Bill C-14 and one of the criteria is that you have to “have a grievous and irremediable medical condition”. To meet this particular criterion, you “must have a serious and incurable illness, disease or disability; be in an advanced state of decline in capability that cannot be reversed; and be enduring physical or psychological suffering from the illness, disease or disability that is intolerable to him or her and that cannot be relieved under conditions that he or she considers acceptable”.

    So removing the requirement that the person “be at a point where his or her natural death has become reasonably foreseeable, taking into account all of his or her medical circumstances” will obviously open the door a little bit but a 35-year old woman living with Lupus or anybody else with a chronic condition will still have to meet the other criteria. As I remarked in a previous post, this requirement was not in the Supreme Court ruling and in my view, should never have been added.

    I agree with all the other points.

  4. Thank you Jean for bringing to light . Regarded especially at this time of year, and when the sky darkness is longest. .And, yes in the depths of the pandemic Joy with knowledge breaking through for a new dawn shedding light on the need for better care of our most frail & disadvantaged, Hope in the advancements in palliative approach to care. With courage and presence with what we do not understand and looking forward with Hope to the shadows being pushed back for a new dawning and Peace.

  5. Jean, as I supporter of DWD I want to thank you for your perspective and for the invaluable care you provide to those who are suffering.

    1. Thanks, Adam, for this comment and your previous one. Indeed, the 35-year old with Lupus has to meet all the other criteria.
      My hope is that the pace and quality of debate on these issues will grow in the next few months. Cheers. Bob

    2. Ken — By “doctors removed from the process”, do you mean the decision-making process, or the actual process of ending someone’s life?
      All the best,
      Bob

  6. Jonathan Reggler

    Thank you for this interesting blog post.

    Like Dr Jean Marmoreo, I am a MAiD provider. I have carried out hundreds of MAiD assessments and well over 100 MAiD provisions. I was one of the six physicians who actually founded the Canadian Association of MAiD Assessors and Providers in October 2016. I remain on its Board. I am a Board member of Dying With Dignity Canada and am co-chair of the Clinicians Advisory Council, of which Dr Marmoreo is a member. I am a family physician.

    I am writing privately as an experienced MAiD provider and am responding both to this post and to your previous post on the subject of C-7 in order to correct some errors and to respond to Dr Marmoreo’s views on C-7.

    In your earlier post you stated that only one doctor will be required to find a person eligible for MAiD. This is simply incorrect: it will remain two. The text of C-7 can be found here, so your readers can check the veracity of this.
    https://parl.ca/DocumentViewer/en/43-2/bill/C-7/third-reading

    You asserted that C-7 would remove the obligation for doctors to present MAiD as an option. There has never been an obligation enshrined in the law for physicians to do this and C-7 does not speak to this at all. The Canadian Medical Association does not say that physicians must present MAiD as an option; it has no power in this regard. The duties of physicians in terms of practice standards are actually determined by the Colleges of Physicians and Surgeons of each province or territory. They vary in their requirements of physicians around the issue of onward referral if a patient has requested MAiD and the physician is a so-called conscientious objector; some like Ontario require “effective referral”, others like British Columbia require the less clear “effective transfer of care”. Most physicians – and the great majority of those who do not allow their own religious views to impact their duties towards patients – would now probably agree that best practice concerning any end-of-life discussion with a patient ought to include at least a question from the physician to determine if the patient is interested in learning about MAiD. For the record, I ask all of my over 75 year old patients whether they would wish me to include information about MAiD if in the future we were having an end-of-life-discussion. Over 85% have told me that they would.

    Now to “It’s complicated. Life and Death Always Is”. I will take it on trust that you have reported Dr Marmoreo’s comments accurately, so I will not preface everything with “Dr Marmoreo allegedly stated…”. I hope she had the opportunity to correct any inaccuracies in this regard.

    I do broadly agree with Dr Marmoreo’s comments on mental illness. C-7 specifically states that mental illness will not qualify a person for MAiD, however severe their suffering.

    Not all mental illness can be cured. Not all mental illness gets better of its own accord. To deem a person whose wish for MAiD is due solely to the intolerable suffering caused by a severe, intractable and incurable mental illness as somehow too vulnerable to allow them to make this choice is cruel, deeply stigmatizing, and unacceptably paternalistic. For a deeper analysis of this, your readers may wish to read the following article published in the Canadian Journal of Psychiatry.
    https://journals.sagepub.com/doi/full/10.1177/0706743718766055

    Dr Marmoreo said:
    “I think removing the ‘foreseeable death’ clause will open the doors to many more people with chronic illnesses, like Parkinson’s or Rheumatoid Arthritis, thinking about MAiD, almost as a treatment option. I don’t think doctors will say that helping you die is a treatment for your terrible illness. But I think patients will.”

    I agree that doctors won’t see MAiD as a “treatment option” for those who have intolerable suffering but do not have a reasonably foreseeable natural death. But eligible patients won’t either. Patients must have capacity to be eligible to choose MAiD; all of those whom I have found eligible have necessarily understood that they will die if they choose MAiD. No medical treatment has death as the intended outcome. Treatment is something you aim to survive in order to carry on living. If a patient does not understand this, they are not eligible, as they don’t have capacity. MAiD is not a treatment, it is a decision: that death is better than intolerable suffering almost without end.

    Dr Marmoreo states:
    “Right now, neither of the two people who witness your request for MAiD can benefit in any way from your death or be involved with your direct care. But with just one independent witness needed to sign, there’s a greater chance of abuse or mistakes. Asking a single volunteer to be the sole gatekeeper in a legal step in the process is too casual and, at the same time, too burdensome.”

    The two witnesses currently required do not carry out any useful safeguarding function at all. They are not gatekeepers. They do not question the patient about the way in which they have come to their conclusion that they wish to have MAiD. They do not assess whether or not coercion has taken place. That is the job of the two clinician assessors. The requirement that there should be two witnesses introduces a barrier that can be difficult to surmount. The person may live in a very remote area. They may be part of an ethnocultural community that is opposed to MAiD and they may have little contact with other people outside that community. They may not wish this very personal medical decision to be known by strangers. Reducing the requirement to a single witness at least reduces the height of the barrier. However, it would be better to remove the need for witnesses altogether.

    It is not clear to me from the blog post what Dr Marmoreo’s view is concerning the removal of the 10-day waiting period that the law currently requires. However, she seems to conflate it with what she calls a “loosening of the criteria for MAiD” and worries that this risks “terrible” mistakes.

    Removing the 10 day wait means that patients who are suffering intolerably and who have a reasonably foreseeable natural death will no longer have to wait in physical or psychological agony for no good reason. Those patients whose death is not reasonably foreseeable will have to wait 90 days if C-7 is passed.

    Apart from the removal of the requirement that the patient’s natural death must be reasonably foreseeable – because this requirement was quite predictably found to be unconstitutional by a court as it did not appear in the Supreme Court’s 2015 decision in Carter – none of the other criteria have been changed. The patient must have a serious and incurable illness; they must be in an advanced state of irreversible decline in capability; they must have intolerable suffering. No loosening of criteria there, and rightly so. What is being changed is that safeguards that have been found to be barriers to access to MAiD in a timely fashion and which serve little or no purpose (the 10 day wait, the requirement for two witnesses) will be removed or improved by C-7.

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