Implementing Carter “The Big Issues” October 27, 2015

What did Carter resolve? What did Carter not fully resolve? What did Carter not address at all?

What did Carter resolve? The floor for any regulatory framework

Physician-assisted dying = Assisted suicide + Voluntary euthanasia

Criteria for access Cannot have depression as excluded condition Cannot limit to terminal illness Cannot exclude mental illness

Criteria for access Cannot define “adult” as specific age (e.g., age of majority) – any presumption of incapacity must be rebuttable Cannot have non-ambivalence as criterion

Consent “Informed” requires disclosure of: diagnosis prognosis feasible alternative options including palliative care aimed at reducing pain and avoiding loss of personal dignity risks of PAD

Consent Consent standards/processes can be higher than most other medical decision-making BUT Consent standards/processes cannot be higher than other end-of-life decision-making

Other settled matters System must reconcile right to life, liberty, security of person (patient access) and freedom of conscience (providers, institutions, and patients) Regulatory framework should include scrupulous monitoring and enforcement Regulation of PAD is shared F/P/T jurisdiction

What did Carter not fully resolve? Digging deeper

Who does what parts of regulatory framework? Federal government Provincial/territorial governments Health professional regulatory bodies

How to reconcile life, liberty, and security of the person & conscience Right to access Right to self-determination Duty to inform re: position on issue Duty to inform re: PAD among options Duty to refer/transfer care Duty to provide Individual/Institutional right to opt out/refuse

Faith-based and concept of medicine/palliative care-based objections Values-based and concept of medicine/palliative care-based requests and willingness to provide

What heightened scrutiny processes in relation to consent are justifiable? Commonly suggested – Two physicians confirming criteria met – Psychiatry consult – Waiting/cooling off period BUT None of these is required for other end-of-life decision-making

When does patient need to be competent/suffering? competent at time of request, experiencing intolerable suffering, and competent at time of provision of assistance competent at time of request and experiencing intolerable suffering but lost competence before assistance could be provided not yet experiencing the intolerable suffering but preparing advance directive while competent in anticipation of such suffering

Who can provide PAD? Medical practitioner “person under the direction of a medical practitioner” – Regulated health professional Registered nurse, nurse practitioner Pharmacist

How should monitoring and enforcement system be designed? Case review System oversight

What Carter didn’t address at all de novo

Physician presence at death Appeal processes where access denied Citizen, permanent resident, insured person Access in rural and remote areas (esp. North) Insurance – Life – Liability Death certificates Payment for PAD services Support, Consultation, and Education Network of Providers Public education

Bottom line The SCC settled a lot of issues – Stop trying to Bedford Carter Lots of work has already been done on the issues not fully settled (or addressed at all) by the SCC – Stop trying to reinvent the wheel We can meet the deadline – Get feds to the table – Start communicating and cooperating Stop duplicating efforts Stop trying to regulate that which lies outside jurisdiction