MONTREAL — After 30 years in palliative care medicine, Dr. Bernard Lapointe is adamant that regardless of what the law says he will never euthanize a patient. He is among thousands of law-abiding Quebec doctors who are facing some of the most difficult days of their professional careers as the province hurtles toward Dec. 10 and the legalization of euthanasia.
Quebec’s controversial right-to-die legislation, Bill 52, makes it mandatory for physicians to either accommodate a patient’s request to die or to refer that patient to an obliging doctor in the same institution. With few exceptions, all Quebec health care institutions, including hospitals, hospices and palliative care facilities, are required to provide assisted-death services for patients who ask to die and qualify under government guidelines for assisted death.
“No institution has the right to conscientiously object,” said Lapointe, director of the Palliative Care Division of Montréal’s Jewish General Hospital. “Even faith-based hospitals with a religious attachment to them cannot ignore the law.
“The die is cast, the law is the law. No hospital is going to defy the law.”
Yet the medical staff at Universite de Montreal health centre have voted unanimously to reject doctor-assisted death and at least two of 29 hospices in the province have announced they will not participate: The West Island Palliative Care Residence in suburban Montreal and Maison Michel Sarrazin in Quebec City. Maison Auberge Lumiere in Sherbrooke will limit medical aid in dying to patients suffering from terminal cancer.
Most Quebec doctors oppose the legislation, Lapointe says.
“Doctors have the right to be conscientious objectors, and I for one will not do it,” he said. “There is not a tribunal in the country that can force me to do it.”
Quebec will become the first province in the country to allow physician-assisted death even though euthanasia and assisted suicide remain illegal under the Canadian Criminal Code. So, technically, doctors who help end a patient’s life can still be charged and face up to 14 years in jail. But Quebec lawmakers are skirting the federal law by insisting they are implementing medical aid in dying, which is a health care matter that falls outside the Criminal Code and is under provincial jurisdiction.
The bill does not specifically mention the word euthanasia or suicide. It uses euphemisms such as “end-of-life care.” The legislation allows terminally ill patients “who are of sound mind” and “in a state of unbearable physical and psychological pain” to request “palliative sedation.” Each request must be approved by an attending physician and approved by a hospital medical team.
Dr. Manuel Boyard, chair of the McGill University Health Centre, says you can read the language of the bill any way you want. What it offers, in his view, is “not assisted suicide, but euthanasia.”
“In Quebec, it is very clear that euthanasia is a medical act. It is not assisted suicide. It is much more likely that doctors will prescribe something for the patient to take home, rather than roll up their sleeves and inject the patient and wait by his bedside for him to die.”
Lawyer Michel Raciot, vice-president of Living with Dignity, disagrees. He argues that the fine print of the bill makes it clear that a physician “must administer medical aid in dying personally and take care of and stay with the patient until death ensues.”
Under the new law, physicians who refuse to provide such assistance must refer their patient to another physician who will accommodate the request to be killed. The law also allows patients to change their minds at the last minute and to withdraw any signed request for medical assistance in dying.
Quebec’s health minister, Gaetan Barrette, a doctor, insists that even medical institutions which disdain the law must comply with it. “Doctors do not own Quebec hospitals,” he has stated. He has threatened to deny hospital privileges to physicians who refuse to comply.
According to a recent poll, at least two-thirds of Quebec doctors have indicated they want no part of euthanasia.
Boyard believes proper palliative care would alleviate the need for euthanasia and Bill 52 is unnecessary.
“Palliative care in the right setting with the right resources and the right pain control is sufficient,” he said.
Perhaps in an attempt to appease critics, health minister Barrette has announced a five-year, $4.5 million plan to improve the quality of palliative care by allowing more people to die at home. But the man regarded as the father of Canadian palliative care is unimpressed.
“It is a tremendously important mistake to think you can improve palliative care by throwing money at it,” said Dr. Balfour Mount, a cancer surgeon who started the Royal Victoria Hospital’s Palliative Care Service, the first in North America, in 1975.
“I am fearful about the government’s new support for palliative care. Those of us who work in palliative care are skilled specialists. We have been trained to kill the suffering, not the person who is suffering.”
He calls Bill 52 “a phenomenally bad idea, a catastrophic idea,” but says the battle is lost and “any attempt to fight it is going to be useless.”
Last February, when the Supreme Court ruled that Canadians can’t be denied a blanket right to assisted suicide, the High Court gave the federal government until Feb. 6, 2016, to amend two sections of the Criminal Code to comply with its ruling. But because Bill 52 is so vague in its terminology, the Quebec government argues its bill qualifies as extended health care, which is not illegal.
Dr. Laurent Marcoux, head of the Quebec Medical Association, which represents 10,000 physicians and surgeons, spoke forcefully against Bill 52 in legislative hearings. But he says government guidelines will somewhat limit access to physician-assisted death.
“No patient will have easy access to death,” said Marcoux. “You just don’t get it into your head one morning and say, ‘I want to end it all, so give me the needle.’ It doesn’t work that way. The patient chooses, yes, but he is surrounded by a medical team and with the help of his family. The law frames that very well.”
The recently elected Trudeau government is expected to request a six-month delay to re-write the Criminal Code, but few believe the Liberals, who went from eight to 40 seats in Quebec in the last election, will take the political risk of prosecuting any Quebec physician who helps a patient die.
Section 16 of Quebec’s legislation paves the way for doctors to offer specialized services, much like abortion clinics, but which would permit doctors to administer end-of-life care at a patient’s home and presumably charge for the service. Some doctors suggest suicide clinics might be set up as a compromise.
“Those people with a degenerative disease, those who have gone to court asking for the right to die — their plight is important, and we have to listen to them,” said Lapointe. “In a pluralistic, secular society, I don’t see any way around it.”
Church leaders in Quebec are opposed to the new law but seem to be resigned to it. Quebec Cardinal Gerald Lacroix has said that whatever terminology you use, the notion that assisted suicide and euthanasia are medical solutions to pain and suffering is repugnant. He too believes there should be greater access to palliative care, and that doctors should be made more attentive to their patients’ psychological suffering.
“Now we will have to be ever more zealous and work with people who are dying so they do not have to request euthanasia,” Lacroix said.
“To cause death to a sick person is not to care for them. Lethal injection is not treatment.”
Hustak is a freelance writer in Montreal.