‘Take my name off the list, I can’t do any more’: Some doctors backing out of assisted death

Published in the National Post on February 26, 2016. Click here to read the article on their site.

Some doctors who have helped the gravely ill end their lives are no longer willing to participate in assisted death because of emotional distress or fear of prosecution if their decisions are second-guessed, according to their colleagues.

In Ontario, one of the few provinces to track the information, 24 doctors have permanently been removed from a voluntary referral list of physicians willing to help people die. Another 30 have put their names on temporary hold.

While they do not have to give a reason, a small number have advised the province they now want “a reflection period to decide whether medical assistance in dying is a service they want to provide,” according to a health ministry spokesman.

The Canadian Medical Association says reports of doctors backing away from the act are not just anecdotal. “I can’t tell you how many, but I can tell you that it’s enough that it’s been noted at a systemic level,” said Dr. Jeff Blackmer, the CMA’s vice-president of medical professionalism.

For some doctors, the act is simply too distressing, he said.

“We’re seeing individuals, or groups of physicians who are participating and really feel like they’re alleviating pain, alleviating suffering,” Blackmer said.

“And then we’re seeing doctors who go through one experience and it’s just overwhelming, it’s too difficult, and those are the ones who say, ‘take my name off the list. I can’t do any more.’ ”

The act is performed out of care and compassion, Blackmer said. “But for most (doctors), it doesn’t make the psychological impact of that final, very definitive act, any less than it would be for anybody.”

However, eight months after legalized doctor-assisted suicide took effect in Canada, doctors who have carried out the act say the issue is far less about moral or psychological angst than it is about the legal ambiguities and uneasiness involved.

“I’m sure that there have been maybe a handful of physicians that have done this and decided they didn’t want to do it again — who, for moral reasons, on reflection said, ‘you know what? This isn’t something I’m comfortable with,’ ” said Dr. James Downar, a critical care and palliative care doctor with Toronto’s University Health Network.

However, Downar said the far bigger issues are the paperwork and bureaucracy involved, finding the medications and someone able to administer them, faith-based hospitals refusing to play any part in assisted-death requests, scrutiny and scorn from colleagues opposed to assisted dying and confusion over who, exactly, qualifies.

The federal law, which came into force last June, permits euthanasia and assisted suicide for those with a “grievous and irremediable” condition and “enduring suffering.” However, the procedure is limited to people whose death is “reasonably foreseeable.”

According to Downar, grievous and irremediable means serious, and incurable. That could apply to most chronic conditions, he said. In cases of advanced cancer, “many people may have a remote chance of a cure, or disease stability. If it’s one, two or five per cent, is that ‘curable?’ ”

The criteria that death must be “reasonably foreseeable” is similarly fraught with confusion, says Vancouver Island family physician Dr. Jonathan Reggler. “Those words will not appear in any medical textbook.”

Lawyers advising doctors are typically defining it as six months. “But, ask a doctor, ‘is your patient’s death from heart failure or chronic obstructive pulmonary disease reasonably foreseeable?’ Well, yes, maybe in a year or two. But they still see it as reasonably foreseeable.”

“That confusion causes great anxiety for physicians, and many just pull back,” said Reggler, chairman of Dying with Dignity Canada’s physician advisory council. They see it as too high a risk, he said. “If the doctor doesn’t carry out the medically assisted death according to the law, that doctor is at risk of being prosecuted for murder.”

Last fall, the commission overseeing Quebec’s euthanasia law, the first of its kind in Canada, reported 262 completed euthanasia deaths in the first nine months of the law. Of those, 21 cases were found to be non-compliant with the regulations.

In most of those cases — 18 — the two doctors who assessed the patient were considered not sufficiently independent. Of the remaining three, the commission ruled that two of the people were not at “end of life” while the third, according to the panel, didn’t have a serious and incurable condition.

Quebec’s college of physicians has reviewed the cases. According to a spokeswoman, the majority “are all in conformity with the law and guidelines.” However, some are still under study. “No doctor has yet faced the discipline committee,” she said.

“You have to imagine that if you’re one of those physicians, you might be pretty upset that a panel of people (the oversight commission) — none of whom have ever performed medical aid in dying and only two of whom are physicians — is second-guessing your medical judgment,” Downar said.

“Can you understand why people might be concerned and say, ‘maybe this isn’t for me,’ ” he said, adding that doctors need to be supported and assured “they aren’t going to be punished for acting in good faith.” 

He and others say the scarcity of doctors providing assisted deaths is putting serious pressure on the few who are.

In Ontario, as of Feb. 17, 137 doctors were on the province’s voluntary roster of willing providers.

Of those, 30 would only be willing to provide a second patient assessment, and not administer a lethal injection or prescribe a life-ending dose of drugs. 

Conservative senator Kelvin Ogilvie, co-chairman of a special parliamentary committee on assisted death, said early challenges were expected.

“When anything of this nature first comes into a society, you’re going to get a number of adjustments as you go along,” Ogilvie said. More tragic, he said, are reports of people starving themselves to meet criteria for assisted death, and others taking “matters into their own hands,” he said, referring to the case of a Montreal man charged with second-degree murder last week in the death of his 60-year-old wife. According to the CBC, the disabled woman had suffered from Alzheimer’s. Her family’s request for a medically assisted death had been refused.