Ethics of Medically Assisted Dying - PowerPoint Presentation

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Ethics of Medically Assisted Dying

Carter vs CanadaFebruary 6, 2015

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5th-1st century BCE:

Greek and Roman social tolerance towardinfanticide,euthanasia and suicide12th-15th century CE:

Christian majority view opposes euthanasia

(Thomas Aquinas)

History of Euthanasia

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17th-18th century:

Anglo-American common law traditions prohibit suicide and assisted suicide Europe, emerging North American statesRenaissance/Reformation writers challengeChurch opposition to Euthanasia

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Enlightenment thinkers promoted discussion of euthanasia

late 18th century sees religious revivalismreject suicide and euthanasia

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1870 Samuel Williams advocates morphine for end of life in addition to analgesia

1885 AMA opposes euthanasia1915 Dr. Harry Haiselden, allows debilitated infant to die

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1930’s: public support of euthanasia increases during Great Depression

1935 Voluntary Euthanasia Legislation Society founded in England

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1938 Natural Society for Legalization of Euthanasia

based on the right of the incurably diseased to have his life terminated gently1940’s Nazi’s use of involuntary “euthanasia”of mentally ill patients, handicapped children and atrocities of war close the discussion on euthanasia

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1942 Switzerland legalizes assisted suicide

1952 Groups petition UN to amend the Declaration of Human Rights to include euthanasia

1973 AHA adopts patients’ bill of rights

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1980 World Federation of Right to Die Societies forms incorporating dozens of global right to die organizations

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1988 Unitarian Universalist Association becomes first religious body to pass resolution in support of Aid in Dying

1990’s American polls show over 50% support for physician assisted death

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1990’s Dr. Jack Kevorkian assists many patients to die, much publicity, imprisoned

1994 Oregon Death With Dignity act passedFirst law in American history permitting physician assisted dying

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2001 Netherlands legalize euthanasia

2002 Belgium2008 Luxembourg

2008 Washington state and Montana

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2013 Vermont

2014 New MexicoAssisted suicide is also legal in Germany,Albania, Columbia and Japan

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What about Canada?

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1983 Law Reform Commission of Canadarecommends against legalizing or decriminalizing voluntary active euthanasia

1987 recommend ‘mercy killing’ be treated as second degree murder,not first. (No fixed or minimum jail sentence)

1982 Dying With Dignity founded

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1991 several private members’ bills and parliamentary bills to legalize euthanasia pass first to second reading

1992 Cases of Nancy B, (Quebec), nurse Scott Mataya, 2 Ontario physicians administering noxious substances

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1993 Sue Rodriguez loses her appeal for an assisted death in a 5-4 Supreme Court of Canada decision

She challenged the validity of the Criminal Code prohibition on assisted suicideWho owns my life?

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Sue later committed suicide with a physician’s assistance. The death was investigated, no criminal charges were laid

1995 Special Senate Select Committee on Euthanasia and Assisted Suicide report:Of Life and Death

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1990’s-2005 Several more cases of assisted death, several more Bills and Acts to address right to die issues

Bill C-407, Francine Lalonde2007 Canadian Medical Association maintains prohibiting assisted death

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2007 Ipsos-Reid survey: 76% of Canadians support right of Canadians with incurable diseases to have the right to die

2009 Quebec: Select Committee on Dying With Dignity begins consultation with citizens of Quebec

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2011 BC Civil Liberties Association files a case to challenge the laws that make it a criminal offense to assist seriously and incurably ill individuals to die with dignity

with certain safeguardsThe Carter Case: Kay Carter, Gloria Taylor, W. Shoichet

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2011 The Royal Society releases a report stating euthanasia should be legal

2012 BC Supreme Court rules the right to die with dignity is protected by the Charter of Rights and Freedom (Justice Lynn Smith)The federal government appealed

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2013 Quebec tables right-to-die legislation in National Assembly

2013 BC Court of Appeal overturns BC Supreme Court ruling in the Carter Case

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2014 Supreme Court of Canada agrees to hear the BCCLA appeal of the Carter Case

Bill 52 passed into law in Quebec, legalizing medically assisted dyingCMA majority vote supports assisted dying

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October 2014 Supreme Court of Canadahears the appeal

February 6, 2015Unanimous SC decision ruling in favour of decriminalizing assisted dying in cases of grievous and irremediable suffering

2014 DWD Ipsos Reid poll 84% of Canadians support assisted dying

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Gloria Taylor

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Euthanasia

SuicideMedically Assisted Dying

Terminology

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Euthanasia: Greek (eu) good (thanatos) death

sometimes defined as mercy killing, also the painless killing of someone with an incurable or painful disease, or in an irreversible coma

Words & Meaning-Hearts and Minds

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2 main classifications:voluntary

involuntary2 procedural classifications:passiveactive

Euthanasia

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Voluntary euthanasia- When a patient wishes to die, and consent is given for the intentional termination of life; acted on by the patient, or another individual.

Involuntary euthanasia-When time of death is chosen without consent of the patient who is incapable of the choice.

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Passive euthanasia-When life sustaining treatments are withheld (common, lacks clarity)

Active euthanasia-Lethal substances or forces are used to end the patient’s life (these actions may be performed by the individual or another)the above does not stipulate an assistant with medical training

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Is it euthanasia, if there is no intent to take life, when a physician increases a pain medication with the knowledge that this will likely hasten the proximate death of the patient?

A consideration

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Suicide

Is there one useful unqualified definition?The act of killing yourself because you do not wish to continue living

Canada decriminalized suicide: 1972

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The act or an instance of taking one’s life voluntarily and intentionally

(this looks closer, yet goes on to state: especially by a person of years of discretion and of sound mind)

Suicide

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David Hume: 1777 in Essays on Suicide and the Immortality of the Soul, put a modern perspective on suicide, and questioned religious attitudes toward suicide

Definitions and interpretations of suicide are often seen through a religious lens

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Identified suicide as a social and psychological phenomenon, altered by current societal thinking and values

Suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the “victim” himself, which he knows will produce this result

David Emi

David Emile Durkheim (1897)

le Durkheim 1897

(relevant today)

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another consideration

would a mother sheltering her child from trauma resulting in her own death, a prisoner who refuses to eat, an individual who shoots himself all be considered under the same definition of suicide?

Durkheim’s definition allows latitude for rational suicide

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Most of us in right to die organizations favour MAD. It is accurate, non-pejorative.

Suicide is the wording of the Criminal Code of Canada and therefore was impelled to be the language in use for the court case

Medically Assisted Dying vs Suicide

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The intentional hastening of death by a terminally ill patient with assistance from a doctor, relative or another person

The words chosen by intervenors for Carter were grievous and irremediable suffering. This terminology was maintained by the Justices in their ruling handed down February 6, 2015

MAD or Assisted Suicide

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Carter vs Canada

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Section 241(b) and s. 14 of the Criminal Code unjustifiably infringe s. 7 of the

Charter and are of no force or effect to the extent that they prohibit physician-assisted death for a competent adult person whoConclusion:

The appeal is allowed

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(1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.

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section 7

Everyone has the right to life, liberty, and security of the person, and the right not to be deprived thereof except in accordance with the principles of fundamental justice

Canadian Charter of Rights and Freedoms

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section 14

No person is entitled to consent to have death inflicted on him, and such consent does not affect the criminal responsibility of any person by whom death may be inflicted on the person by whom consent is given

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It is a crime in Canada to assist another person in ending her own life. As a result, people who are grievously and irremediably ill cannot seek a physician’s assistance in dying and may be condemned to a life of severe and intolerable suffering. A person facing this prospect has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.

Introduction to the Ruling

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In both cases the majority of the court agreed that the security of the individuals was deprived, and also section 15 regarding equality, but that the prohibition on physician assisted death was justified under section 1 of the

Charter in the case of RodriguezHow does

Carter

differ from

Rodriguez

?

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section 1The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits by laws as can be demonstrably justified in a free and democratic society

Canadian Charter of Rights and Freedoms

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section 241 Every one who

(a) counsels a person to commit suicide,or(b) aids or abets a person to commit suicide,whether suicide ensues or not, is guilty of an indictable offence (and liable...14 years)

Criminal Code of Canada

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Evidence on controlling risk of abuse with assisted suicide now exists

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Article 85 of the ruling the prohibition on assisted suicide is overbroad

the object is to protect the vulnerable, not everyone wishing MAD is vulnerable

different legal concept of s 7, particularly relating to overbreadth and gross disproportionality

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we do not agree that the existential formulation of the right to life requires an absolute prohibition on assistance in dying, or that individuals cannot “waive” their right to life. This would create a “duty to live”, rather than a “right to life”...

Article 63 of the ruling relating to s 7,(life)

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“is no longer seen to require that all human life be preserved at all costs”

in certain circumstances, an individual’s choice about the end of her life is entitled to respect

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The law allows people in this situation to request palliative sedation, refuse artificial nutrition and hydration, or request the removal of life sustaining medical equipment, but denies them the right to request a physician’s assistance in dying

article 66

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Alison Latimer Joe Arvay Sheila Tucker

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J.Smith ruled the prohibition on assisted dying interfered with “fundamentally important and personal medical decision making”

The SC Justices agreedArticle 65, s 7, liberty and security

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palliative care improves in jurisdictions with MAD

physicians improve their palliative care knowledge in legal jurisdictions What about palliative care?

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end of life care is an aspect of palliative care

quality of life for patients in palliation improves with the knowledge they may choose when to die

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Issues of access and quality control must be addressed

Interestingly, in Oregon, pain was low on the list of concerns of those who utilize assisted dying. Peace of mind, closure and autonomy were among priorities

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Secobarbital or Pentobarbital most commonly used

Agents may be administered intravenously,intramuscularly, orally or rectally.Sedating or anti-emetic agents may also be used

Methodology for assisted death

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The patient will feel relieved, sedate,then fatigued and fall asleep followed by a coma

Respiratory centres and heart function ceaseWhat happens?

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Yes, this procedure can be gentle and profound

What can go wrong?

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Parliament could invoke the Notwithstanding clause

(section 33 of the Charter which may override ss 7-15)Parliament could do nothing, leaving regulation as a provincial health care matter

What will legislation look like?

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Hopefully, and likely, we will have a federal law-changing section 241(b) of the Criminal Code

and varying provincial legislationallowing both direct physician assistance and physician presence if the patient self administers the lethal agent

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The CMA wants to be involved in crafting legislationas do the BCCLA and DWD Canada

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This was a democratic success informed by the good evidence of the presenting lawyers, ruled on with the wisdom, reason and compassion of the trial judge and upheld unanimously by the Supreme Court justices, brought forward by brave individuals representing the views of the majority of Canadians.

Ending on a High Note

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Ethical arguments: rights based

People have an explicit right to die, in the same way they have an explicit right to live,a separate right to die is not necessary, as our other rights imply it.

Pro euthanasia

Pro Euthanasia arguments

arguments

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Practical arguments:it is possible to regulate

spares resources (unpopular)it is already happening (utilitarian)

Pro (con’t)

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Philosophical arguments:euthanasia satisfies a criteria that moral rules must be universalisable

it happens anyway (consequentialist)

Pro (con’t)

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if no, some objections to it vanish,and if we decide death is not always a bad thing, then we can consider circumstances

when it may be a good thing.Is death a bad thing?

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intrinsic value of human life

religious reasons, life and death are the purview of God.(These form the the basis of most anti euthanasia arguments, if you don’t hold these statements to be true, they make poor arguments)

If death is a bad thing, why is it bad?

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most people don’t want to die

violates our autonomy in a drastic wayhowever, for people who are seeking control of their proximate death, these arguments don’t hold

If death bad...

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Ethical :life is sacred

devalues life(weakens society’s respect for life, some lives are worth less than others, “slippery slope”, euthanasia not in a person’s best interest)

Anti euthanasia arguments

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Practical:proper palliative care makes euthanasia unnecessary

no way to properly regulate euthanasiadiminishes care for the terminally illtoo much power given doctorsexposes vulnerable people to pressure

Anti (con’t)

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Historical:voluntary euthanasia leads to involuntary euthanasia

Anti (con’t)

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Religious:it is against the word and will of God

weakens respect for the sanctity of lifesuffering may have value

Anti (con’t)

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Your voice matters

Your vote countsThanks for having me, any questions?

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http://www.dyingwithdignity.ca/learn/history-of-right-to-die-in-canada.php

http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.dohttp://bccla.org/2015/02/the-death-with-dignity-decision-explained/

http://www.pch.gc.ca/eng/1356631760121/1356631904950

http://public.health.oregon.org/ProviderPartnerResources/DeathWithDignityAct/Documents/year15.pdf

http://durkheim.uchicago.edu/summaries/suicide.html

http://www.merriam-webster.com/dictinary/suicide

http://www.oxforddictionaries.com/definition/english/euthanasia

http://medicalnewstoday.com/articles/182951.php

http://euthanasiaprocon.org/view.timeline.php

JMedEthics 2007;33:591-597

JMedEthics 2005-? Steinbock,B. The case for physician assisted suicide: not (yet) proven

Citations

http://www.bbc.co.uk/ethics/euthanasia/infavour/infavour_1.shtml