College of Physicians and Surgeons of Alberta Re Consultation 028 Dear colleges, I would like to express concern about the upcoming modification of the Medical Assistance in Dying, Conscientious objection and Informed consent standards of care. Following the Supreme court of Canada Carter decision of 2015, legislation was enacted to permit the provision of death inducing treatment to those with a grave and irremediable condition in whom death was reasonably foreseen. Although arguably euthanasia or physician assisted suicide, this treatment was labeled with the euphemism “MAiD”. This “treatment” went beyond the previously accepted approaches of palliative care and cessation of active intervention. Although many perceived some level of discomfort, others perceived ethical tolerability of “MAiD” as it was reserved to those patients who would inevitably die, sparing a long and drawn-out illness and a potentially violent demise at their own hand. Euthanasia has of course been contemplated by physicians for millennia; even Hippocrates is said to have objected. In 2015, many already expressed concern about the “slippery slope” in Canadian law. As correctly predicted, over the past 9 years, “MAiD” has been expanded to include those patients who are not reasonably predicted to die and most recently those whose only illness is psychiatric. This has further been accompanied by mandates to refer, proposals to mandate participation in “MAiD”, proposals to prohibit belief-based care, loss of funding to institutions unwilling to participate in “MAiD” and likely rejection of medical school candidates too squeamish to participate. It is not unreasonable to predict that future court decisions may further expand eligibility and mandate physician participation to those providing advanced consent, consent by proxy (family members, guardians and curators), criminals and oppressors. Issues surround trust of practitioners if of significant importance to patients. The expansion of availability of “MAiD” creates a perception among vulnerable patients uninterested in death that a physician may propose or enact euthanasia. Especially among patients with complex conditions, potentially with serious ailments, potentially with anxious heirs, muddling along in a slow, inefficient overburdened heath care system, the thought that it might be easier to let one of those kind doctors kill them should not be discounted. Given the expansion of criteria for inclusion goes beyond the initial 2015 requirement of a grave, irremediable condition where death may be foreseen, and rather encompasses a large group of medical and social conditions, the term “Medical Assistance in Dying” should be reserved ONLY for those patients eligible to receive euthanizing treatment as per the original Carter 2015 decision. In all other more expansive cases where death is not reasonably predicted, the “MAiD” term should be retracted and correctly termed “Euthanasia care”. Similarly, the potential for future application of “MAiD” to prisoners should correctly be termed “Execution”, while the application to oppressors should correctly be termed “Murder”. This would apply to the CPSA standard of practice “Medical Assistance in Dying (MAID)” addressed in consultation 28. As professionals in the delivery of health care, many would argue that medical staff should not participate in “MAiD” and euthanasia. Many have argued against euthanasia based on secular arguments, devaluation of human life, slippery slope, palliative care can relieve pain and loss of trust that physicians will heal. Arguments against euthanasia are numerous and need not be repeated in this forum. A small, vocal minority of physicians do, however, continue to provide euthanasia as part of a gamut of medical services, presumably in a manner compatible with their moral and conscious beliefs, on the legitimate basis of wishing to alleviate suffering. Indeed, providing euthanasia, regardless of one’s beliefs surround this “treatment” does remain a legally recognized intervention in Canada. As a means of balancing the desire and ethical perspectives of those performing euthanasia with the conscientious objection for those who do not, the default expectation of a patient should be that the physician will heal rather than kill. In such manner, a patient will have full confidence that their physician will act to promote health and care while omitting “MAiD” and euthanasia from their scope of practice. Care provided by legitimate healers does include minimally controversial palliation and withdrawal of futile interventions at the end of life. Rather than creating a conscientious objection standard, the CPSA may choose to encompass the euthanasia performing practitioners into the “Medical Assistance in Dying” standard. A reasonable inclusive step to promote trust among patients would be the establishment of a registry of physicians who are willing and interested in performing “MAiD” and euthanasia services. This registry could be provided on the CPSA website (or in writing), potentially with quantitative data including the number of patients successfully treated with “MAiD” for each euthanasia performing practitioner. As the provision of “MAiD” and euthanasia is promoted as being free of stigma and bias, indeed it is a well-recognized and compassionate treatment in Canada, one would expect that practitioners in this field would welcome insightful statistics. As the legal landscape evolves, those serving as euthanasia providing practitioners may benefit from additional training and CPSA provided course curriculum. This step would serve patient safety, as euthanasia performing practitioners would be expected to navigate the complex issues of informed, free, unbiased consent in accordance with the “Informed Consent” standard as applied to “MAiD”. Similar to patients seeking a family physician, a patient seeking euthanasia services would be able to look up a euthanasia providing practitioner on the CPSA website, ideally in a local community, in order to undergo the treatment in a safe and expedited manner with full confidence that the practitioner is well trained, highly experienced and abreast of the legalities. Potentially in due time, euthanasia provision will be recognized as a distinct and exclusive act, carried out only by experts in the field. I do wish to clearly express that I have not and will not engage in the provision of euthanasia services. Thank you for providing a forum to discuss this important issue. Yours truly, Dr John McDermott, MD, FRCPC