The Supreme Court of Canada decriminalized medical assistance in dying on February 6, 2015. The Court’s ruling has taken effect on June 6, 2016. The federal government’s proposed legislation is currently before the senate. There are many ethical issues relating to eligibility for and practice of medical assistance in dying raised by the Court’s ruling and the proposed legislation.
This article serves to provide a foundation for those discussions.
The decriminalization of medical assistance in dying is the result of the Court’s ruling in Carter v Canada. The Court declared the Criminal Code’s prohibition against providing assistance in dying (section 241 (b) and section 14) void with respect to physician-assisted death for a competent adult person, because it limits the rights to life, liberty and security of the person (section 7 of the Charter).
The proposed legislation, Bill C-14, provides a framework for access to medical assistance in dying. If passed, the legislation will introduce exemptions to the criminal code for medical practitioners, nurse practitioners and any other persons helping the practitioner in this process, such as social workers assessing voluntariness, pharmacists filling prescriptions and lawyers reviewing consent documents.
The term ‘medical assistance in dying’ refers to voluntary euthanasia, i.e. “the administration by a medical practitioner or nurse practitioner of a substance that will cause a person’s death at their request”; and assisted suicide, i.e. “the prescription or provision by a medical practitioner or nurse practitioner of medication that a person could self-administer to cause their own death.”
The Supreme Court’s ruling applies to competent adult persons who “ (1) “clearly consent to the termination of life; and (2) have a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable for the individual”.
According to Bill C-14, a person is eligible for medical assistance in dying if all of the following criteria are met:
• Minimum 18 years of age and competent to give voluntary consent to assistance in dying;
• Has a grievous and irremediable condition which is defined as an incurable illness, disease or disability, causing physical or psychological suffering;
• Is in an advanced state of irreversible decline, and the patient’s natural death must be within foreseeable future (no specific time prognosis required);
• Is eligible for publicly funded health care in Canada.
The proposed legislation limits access to medical assistance in dying to those who are terminally ill. This makes it more restrictive in regards to eligibility than the Court’s ruling. In addition to the Court’s exclusion of mature minors, the legislation also excludes patients with psychiatric disorders as the sole underlying medical, and patients wishing to make an advance request.
Further study is mandated in the legislation with a view to looking into the implications of extending eligibility to these patient groups.
The proposed legislation promotes two key principles: respect for patient autonomy, and the inherent and equal value of every life. Recognizing the need to protect vulnerable persons from being talked into medical assistance in dying, Bill C-14 introduces procedures to safeguard patients and practitioners:
• A request for medical assistance in dying must be made in writing and signed and dated by, or in the presence of, the patient and two independent witnesses.;
• A substitute signing the request on behalf of the patient must have capacity and must not be directly involved in the care providing of the patient;
• The patient’s eligibility must be assessed by two independent witnesses;
• The patient must be informed (at the time of the request and just prior to the procedure) that the request can be withdrawn at any time;
• Practitioners must inform the pharmacists when medication is prescribed for the purpose of medical assistance in dying.
The proposed legislation currently acknowledges issues around conscientious objection to participation by health care practitioners, but does not specifically address this. The legislation provides a framework for practice with a view to establishing a reasonable degree of consistency in the practice of medical assistance in dying across Canada. However, access to medical care varies greatly across Canada. This is also likely to be the case for medical assistance in dying. The regulation of the practice related to health care aspects and civil law implications is left for the provincial and territorial governments to address. Not all provinces and territories will choose to further regulate on this matter. Without federal legislation in place, physicians are currently relying on guidance from provincial colleges of physicians and surgeons.
This summary is based on the following material:
The Government of Canada (2016). Legislative background: Medical Assistance in Dying (Bill c-14).
Note: This publication provides a detailed description of the legislative background for Bill C-14, including details about definitions of terms, and considerations of international regimes of medical assistance in dying.
Other useful links:
Government of Canada. Department of Justice . Questions and Answers.
Government of Canada. Medical Assistance in Dying.
College of Registered Nurses of Nova Scotia. 2016. Update on medical assistance in dying. May 10, 2016.
Simons, Paula. 2016. Damning decision from Alberta Court of Appeal questions constitutionality of assisted dying- bill. Edmonton Journal. May 19, 2016.
Brydon, Joan. 2016. Alberta appeal court rules against federal approach to assisted dying. CBCNews, Politics. May 18, 2016.
Lund, Susan. 2016. Missed deadline on medical assistance in dying leaves doctors divided. CBCNews, Politics. June 6, 2016.
The Government of Canada (2016). Legislative background: Medical Assistance in Dying (Bill c-14). page 4-5
Op. Cit. page 7
Op. Cit. page 3
Op. Cit. page 9
Op. Cit. page 10
Watch our featured Fireside Chat video: Disability, Dignity, and Medical Aid in Dying by Catherine Frazee – Professor Emerita, School of Disability Studies, Ryerson University & Former Chief Commissioner, Ontario Human Rights Commission.
Save the Date of October 20, 2016 for our newly formatted version of our annual conference.
In light of increasing restrictions on travel within NSHA, we’re redesigning our annual conference. We are planning a free, three hour education “blitz” of presentations by various speakers on the topic of medical assistance in dying. These presentations will be broadcast to sites in each zone as well as streamed online on October 20th. They will be followed by facilitated workshops in each zone to facilitate networking and engagement with questions raised by the presenters as well as with specific cases. The workshops will occur toward the end of October and beginning of November; we’re still sorting out dates and locations.
Stay tuned for more information.
We have two new feature article summaries available for your reading pleaser.
The articles being summarized are:
Reframing Conscientious Care. Providing Abortion Care When Law and Conscience Collide
Let’s not Forget about Clinical Ethics Committees!
NSHEN provides summaries of recent articles of interest from the health ethics literature for those unable to access or too busy to read the entire article. If you would like a copy of the full article, please contact NSHEN at firstname.lastname@example.org
This database of cases was developed as a educational tool to support ongoing efforts to enrich your capacity to recognize, analyze and address ethics concerns related to patient/family-focused care, professional practice, and policy development. You are free to use the content of this resource for your teaching and learning needs; we ask only that you acknowledge the Nova Scotia Health Ethics Network (NSHEN) as the source.
Unless otherwise indicated, the cases presented in the database are fictional or have had significant details fictionalized to respect confidentiality and privacy concerns. Some have been adapted from previously published materials (details indicated following the case).
Each case in the database includes one or more questions as well as a list of relevant values and ethics issues to help get the discussion started. These are only suggestions and certainly not exhaustive- feel free to adapt the cases, discussion and analysis to suit your own learning needs. As you consider a case, keep in mind that often there is no single “right” answer, but some will be “more right” than others. Reflecting on this and trying to understand why it may be so is a big part of working through the analysis and developing potential solutions for each case.
Here is the link to the NSHEN Case Database.
You can also download this case database as a PDF document on the NSHEN website.
NSHEN is now on Twitter!
Give us a follow at:
On July 1, 2014, Canada’s anti-spam legislation (CASL) came into effect. This new legislation prevents NSHEN from sending emails that promote a programme or resource with a fee (such as our annual conference) without express consent from the recipient.
To ensure you are on NSHEN’s mailing list to receive periodic notice of our resources and events, please contact Krista at email@example.com or 902.494.4038 and indicate your request. You can, of course, unsubscribe at any time.
We hope you have found our communication helpful and informative and would like to continue providing these to you.