The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) Derryck H. Smith, MD FRCP(C) Clinical Professor Emeritus Department of Psychiatry University of British Columbia Vancouver, British Columbia [email protected]BC College of Family Physicians 2014 Spring Family Medicine Conference Vancouver, British Columbia Four Seasons Hotel June 7, 2014 Faculty: Dr. Derryck H. Smith I have no financial or academic conflicts of interest to declare I am a Board Member and Chair of the Physician Advisory Council for Dying with Dignity I am not affiliated with any religious groups I have been involved in the Gloria Taylor case as an expert witness I have presented to the Liberal Senate Caucus on these issues.
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The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Derryck H. Smith, MD FRCP(C)Clinical Professor EmeritusDepartment of PsychiatryUniversity of British ColumbiaVancouver, British [email protected]
BC College of Family Physicians2014 Spring Family Medicine Conference
Vancouver, British ColumbiaFour Seasons Hotel
June 7, 2014
Faculty: Dr. Derryck H. Smith I have no financial or academic conflicts of interest
to declare I am a Board Member and Chair of the Physician
Advisory Council for Dying with Dignity I am not affiliated with any religious groups I have been involved in the Gloria Taylor case as an
expert witness I have presented to the Liberal Senate Caucus on
these issues.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
• No Commercial Support
Mitigation: The act of reducing the severity, seriousness orpainfulness of something.
• My goal is to mitigate the effects of a painful,meaningless death.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Why should we allow Medically-AssistedDying in Canada?
What are the common arguments againstMedically-Assisted Dying, and are they valid?
For:1. Individual autonomy2. Relief from pain and suffering3. An obligation to assist patients
Against:1. Intrinsic wrongness of killing( mostly religious based)2. Integrity of the profession3. Potential abuse of the vulnerable4. Would detract from Palliative care
There is no evidence to support 2,3 or 4 from jurisdictionswhere euthanasia in all its forms are legal.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
• The Principle ethical principle in medicine and inwestern civilization is individual autonomy.
• Competent patients who are in the terminal stages ofdying should be able to have control over when they dieand the interventions that are being used to keep themalive.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
The wise man lives as long as he should, not aslong as he can. He will always think in terms ofquality, not quantity. Dying early or late is ofnot relevance, dying well or ill is. A prolongedlife is not necessarily better, a prolonged deathis necessarily worse.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
• Non religious 89.5% Agree• Highly religious* 53.2% Opposed
* Attends church more than 2 – 3 times/month
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Source: Forum Research Inc. December 2011
Sample1,160 adults –December 13, 2011
67% favoredphysician assistedsuicide of terminallyill patients
“I don’t know how I want to go, but I do know that Iwant to be the one who decides.”
Wayne Sumner, Assisted Death: A Study in Ethics and Law
Polls routinely show that 60-80% of Canadianssupport the legalization of Physician-AssistedDying Support across all regions, genders, age groups,
languages, income, and party affiliation These numbers have remained steady since 1993 Highest support Quebec 79% , British Columbia 76%
Environics Institute, October 2013
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
CMA Poll of 2125 members – Physician Assisted Suicide
CMAJ , March 5, 2013 185(4) pp 357
Yes No Not Certain No ResponseIf euthanasiawas legal wouldyou participate
20% 42% 23% 15%
Participation inPhysicianAssisted Suicide
16% 44% 26% 15%
Should assistedsuicide be legal
24% 36%
59% had withheld life sustaining intervention following a request from apatient.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
CMA Policy 2007“Canadian physicians should not participate in euthanasiaor assisted suicide.”
CMAJ , March 5, 2013 185(4) pp 357
Timing and manner of death are arbitrary Withdrawal of Life Support Withholding of Life Support Artificial feeding and hydration
Causation is subjective Requests for assisted death are also related to terminal
illness Why should people have to wait for a fatal
complication? Potential for symptoms, trauma to family members
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Frequently in my experience the debate is reallyabout religious beliefs.
My view:In modern pluralistic society public policy shouldnot be driven by religious beliefs, but bymaximizing the autonomy of the individualcitizen.
Not physicalsymptoms◦ 2/5 in importance
Loss of control Dependence on
others
Ganzini. J Gen Intern Med 2007;23(2):154–7
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
• Death with Dignity Act passed 1993• 2013, 71 people “hastened their death”• 0.2% of all deaths• 87% were in a hospice (versus 45% in other deaths)• 97% died at home• Number one reason “wanting control over their final
days”
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
End of Life Decision-Making in Canada: The Report by the Royal Society of CanadaExpert PanelOn End of Life Decision-Making 2011 Page 62http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265521/
The Dutch ExperienceLegal Termination of Life introduced 2001
This 73-page report concludes there is no evidence of a “”slippery slope”.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Need to be vigilant Non-voluntary euthanasia
No law will stop people breaking the law Assisted death/LAWER in countries where it is illegal
5.6% of deaths in NZ are assisted suicide or euthanasia 1/3 of Australian surgeons have given medications with the
intention of causing death, often without a request
Denmark Italy SwedenDoctor-assistedDying
1.82% 0.1% 0.23%
LAWER 0.67% 0.06% 0.23%
Van der Heide et al. Lancet 2003;362:345-50.Mitchell and Owens. N Z Med J 2004;117:U934.Douglas et al. Med J Aust 2001;175:511-5.
2001• 20% of deaths involve withholding treatment• 20% use of opioids• 2.4% active euthanasia• 0.2% physician assisted death
• Public support for euthanasia - 90%• Doctors - 57% have performed euthanasia
- 10% would never perform euthanasiaThere is no evidence that the availability of euthanasiaundermines palliative care.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Oregon MDs who opposed Physician-AssistedDeath were 2x as likely to report a patientbecoming upset or leaving their practice as aresult of their position compared withphysicians who supported Assisted Suicide
13% of MDs became more supportive of PADwith time, compared with only 7% who wereless supportive
Ganzini et al. JAMA 2001;285:2363-9.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
What is “symptomcontrol”? Transient statistical
improvement? 97% of patients in
Oregon whoreceived AssistedDeath were enrolledin hospice care
Oregon Death With Dignity Act, 2012 Annual Report http://www.healthoregon.org/dwd.Meyers FJ et al. JPSM 2004;28:548-556.
Dying with Dignity – anexhaustive 175 pagereport on assisted dying
“unrealistic to believe thatpalliative care will beuniversally available in thenear future (p 59)
In Europe “the legalizationof euthanasia has boostedthe development ofpalliative care”
The committee visitedBelgium and Holland andwere reassured that therewas no evidence of abuseor a “slippery slope”
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
PC available to only 30% of Canadianpopulation
Carstairs, Raising the bar (2010)
Oregon – 0.2% Holland – 2.2%* Belgium – 3.8%*
◦ * lower than pre-legalizationlevels
Oregon Death with Dignity Act 2011 Annual ReportVan der Heide. N Engl J Med 2007;356:1957-65.
Bilson et al. N Engl J Med 2009;361;1119-21.
The Case For Legalizing Medically-AssistedDying in Canada2014 Spring Family Medicine ConferenceJune 7, 2014
Derryck H. Smith, MD FRCP (C)
Netherlands and Belgium Growth in PC and hospice services
Oregon Among highest rates of hospice referral, opioid
prescription and EOL communication Increased referral to hospice since legalization Increase in MD self-education about PC practices Clearer distinction between PC and PAD
Quill T. NEJM 2007;356:1911-3.Ganzini et al. JAMA 2001;285:2363-9.
1. The majority of Canadians (and many dyingphysicians) want to be able to decide when to endtheir lives – PAD is the most reasonable option.Only 20% of Canadian doctors are in favor.
2. There is no evidence thata) Vulnerable citizens are being killedb) PAD undermines PCc) There is no huge increase in PAD over time
In summary, there is “NO SLIPPERY SLOPE”.
3. Jurisdictions with PAD report general satisfactionfrom both physicians and patients.
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