1. David Campbell, PhD Ethicist, South East Community Care Access Centre Ethical Issues of Assisted Suicide October 1, 2015

2. 2 Feb. 6, 2015 Supreme Court strikes down Criminal Code prohibitions on assisted suicide and will no longer apply to “a competent adult person who (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. ‘Irremediable’, it should be added, does not require the patient to undertake treatments that are not acceptable to the individual.” PAS comes to Canada

3. 3 SC found Charter right to life doesn’t require absolute prohibition on assistance in dying (no “duty to live”) Forcing people to suffer impinges on security of the person PAS supported by autonomy and dignity Doctors not compelled to provide PAS Federal and provincial gov’ts have 1 yr to draft new legislation PAS in Canada

4. 4 Aug. 2014 Ipsos survey of 2,500 CNDs 84% support PAS 67% support PAS for “permanent and severe disability that significantly impacts quality of life and the ability to carry out basic activities of daily life” Over half responded that they had a family member or friend die after suffering Public Attitudes

5. 5 June/July 2015 CMA survey of 1,407 physicians 63% said they wouldn’t help pt die 8% said “unsure” 59% agreed with Supreme Court ruling 27% disagree, 13% didn’t want to comment 29% do not think they should have to refer PAS 42% favor referral 43% unsure if they would offer PAS to purely psychological suffering, 38% wouldn’t, 19% would Physician Attitudes

6. 6 Supreme Court ruling creates broad category for those requesting PAS “grievous and irremediable” medical condition, including disability extremely broad “enduring suffering that is intolerable” also very broad Does this include mental illness? Depression? Dementia? MS? Quadriplegia? Existential despair? Elderly tired of living? Fundamental Challenge

7. 7 Who does patient ask for PAS? Who delivers it? Who will determine capacity for consent? Will there be a “cooling off” period after a request for PAS? If so, how long? How many requests will a patient make for PAS? Does PAS have to happen in a hospital or can patient take lethal meds at home? What will be written on death certificate? Other Questions

8. 8 DNR or refusing aggressive medical treatment Refusing nutrition or hydration Palliative Care Terminal Sedation Withdrawing life support Involuntary euthanasia Murder Definitions: PAS is not…

9. 9 Is there such a thing as “rational suicide”? Does the ethical duty to relieve suffering include helping patients kill themselves? Is there an ethical distinction between withdrawing life support (passive euthanasia) and helping a patient end their life (active euthanasia)? Does the right to die imply a duty to kill? When the state legalizes a controversial activity, does it condone it? Fundamental Questions

10. 10 Overriding value in our culture and fundamental ethical principle within bioethics Nothing more personal and private than decision to end one’s life in manner of your choosing Especially important to the vulnerable and suffering as it might be the last decision they can make Medical professionals have duty to respect patient wishes Ethical Arguments for PAS: Autonomy

11. 11 Medical professionals have fundamental duty to relieve suffering (beneficence/non-maleficence) Pain and suffering cannot be always be controlled through pain meds Some have severe reactions to opioids (confusion, forgetfulness, nausea, constipation, etc.) Loss of control, dignity and inability to enjoy life (existential suffering) cannot be solved by palliative care Physicians can reduce harm by helping suffering patients die in safe, regulated manner Ethical Arguments for PAS: Compassion

12. 12 Justice the other main bioethics principle Able bodied have the ability to kill themselves Physically disabled cannot kill themselves without the aid of others, therefore not allowing PAS discriminates against the physically disabled Ethical Arguments for PAS: Justice

13. 13 Depressed and those tired of life might choose PAS Desperately ill might “give up” to early Danger of misdiagnosis Danger of coercion Ethical Arguments Against PAS: Harms to Patients

14. 14 PAS inconsistent with goals of medicine, against fundamental ethical principle of “do no harm” (turns doctors into killers) Physicians could suffer moral distress/residue PAS could harm public trust in physicians/medical system (e.g. palliative care) PAS could cause more patients/families choose futile EOL treatments (“death panel” fears) Ethical Arguments Against PAS: Harm to Physicians and Health Care System

15. 15 PAS weakens important social taboo against suicide PAS could lead to active euthanasia PAS could lead to involuntary euthanasia PAS could contribute to “culture of death” Elderly, severely ill, disabled, and depressed could feel pressured to kill themselves (duty to die) Ethical Arguments Against PAS: Harms to Society

16. 16 PAS could be option for forms of depression where treatment not an option Mental anguish can cause more suffering than physical pain therefore depressed have greater right to PAS than terminally ill (terminally ill can still enjoy some pleasures vs severely depressed) Depressed could be competent However, the depressed who can clearly judge their future without impairment would not meet criteria of being truly treatment-resistant Additional Quandaries: PAS and the Depressed

17. 17 Individuals diagnosed with dementia might want PAS when disease becomes severe and lose valued autonomy and become burden to loved ones Should we respect advanced directives asking for PAS when individual becomes demented? Whose quality of life matters more, the “former” person who had capacity or the “current” demented individual who might have some quality of life? More Questions: PAS and Dementia

18. 18 Good palliative care Terminal Sedation Refusing nutrition and hydration Refusing aggressive treatments Better mental health treatment, pastoral care etc. Alternatives to PAS?

19. 19 Need to draft legislation National legislation would allow for more consistency and promote and protect rights of all Canadians Need more public education and discussion Need to assure that opponents of PAS that law will respect their concerns and fears Need to ensure that palliative care is available for all What’s Next?

20. 20 Fundamental weakness of slippery slope arguments Opponents of PAS have legitimate fears which must be addressed and respected Odds are, few Canadians will actually choose PAS PAS must be monitored strictly Must respect ethical autonomy of physicians Final Thoughts

21. 21 If you have any questions on any ethics related issues, please feel free to contact me at: david.campbell@se.ccac-ont.ca david.campbell@se.ccac-ont.ca Thank You!