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06/01/2017

Euthanasia in Canada: Early Returns

Last week’s New England Journal of Medicine carried a report from physicians in Toronto about early results implementing “Medical Assistance in Dying,” or “MAiD,” the preferred euphemism for doctor-assisted suicide or euthanasia, in Canada.

“MAiD” became legally sanctioned throughout Canada in 2016.  It includes not only assisted suicide—where a doctor provides a patient with a drug prescription intended to be lethal if taken as directed—but also euthanasia, in which a doctor actively kills a patient, at the latter’s request (at least for now).  The recounts provisions in Canadian law intended to limit “MAiD” to people whose medical condition is deteriorating from a serious, incurable disorder, and to ensure that people who receive “MAiD” do so after freely requesting it, and affirming that request after 10 days to think it over.

To keep things “controlled,” the Toronto program is entirely hospital based, limited to lethal IV injection for which recipients are evaluated and ultimately killed by dedicated physicians who have freely agreed to participate.  The specific hospital ward where a patient is euthanized is rotated, so that no ward gets the title of the “MAiD ward,” but the medical team is set.

Some noteworthy points:

  • MAiD was assigned to the Department of Supportive Care. Other clinical departments demurred out of concerns like “conscientious objections of staff” and “obscuring their specialty’s role in protecting life.”
  • As reported elsewhere, patients receiving MAiD sought it because of loss of autonomy, as well as inability to enjoy life, not because of uncontrolled physical symptoms. These people “tended to be white and relatively affluent.”
  • From March 2016 to March 2017:

o   74 MAiD inquiries in the region served by the Toronto investigators.

o   29 went from request to formal assessment for eligibility, under the terms of the law, by the physicians.

o   19 actually received the injection (i.e., were killed by their doctors at their request).

  • In all cases, death occurred within minutes.

o   People who were not assessed or who were but were not injected did not progress because they died too quickly, changed their minds, or lost decision-making capacity.

o   Some patients refused symptom-controlling treatment—notably, opioids—in an attempt to stay clear-headed enough to be deemed to have a valid request for euthanasia.  That is, they requested compromise of their palliative care to keep the “MAiD” option live.

The authors believe that the MAiD decision process should be moved earlier in care—to the point at which end-of-life care and advance directives are discussed more generally—to prevent discussions or decisions about MAiD from being rushed at the very end of life.

They conclude,

“Just as advocacy from outside mainstream medicine brought palliative care ‘from the margin to the center,’ so has it brought MAiD into the mainstream of medicine.  It is now clear that MAiD education must be included in undergraduate medical education curricula…and in the training for a variety of specialties…[It remains to be seen] whether the legalization of MAiD…this ‘brave new world’ will ultimately be regarded as enlightened or dystopian.”

I cast a Huxleyan vote for “dystopian.”

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