Carter versus Canada: effects on us and our profession

Dear Colleagues,

The recent Supreme Court of Canada (SCC) ruling on Carter versus Canada¹ and the upcoming changes in Quebec regarding physician-assisted dying² are important examples of the dynamic nature of society’s contract with our profession. In a unanimous decision, the SCC struck down the Criminal Code’s absolute prohibition on providing assisted dying. Whereas the Quebec law is restricted to patients with terminal illness,² the effect of the SCC’s decision is broader: [Patients] must be competent adults who clearly consent to the termination of life, and have a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual.¹

The court also recognized the diversity of views among the medical profession regarding assisted dying. Physicians should not feel obligated to fulfil requests for medical aid in dying and should not be discriminated against should they feel morally opposed to this.^1,3

What effect will this decision have on our patients and their families, on us as family doctors, and on the relationships that we have nurtured over time as we accompany our patients in this last phase of their lives? How do we prepare current and future family physicians to provide excellent palliative care and, also, to be competent in all aspects of assisted dying (counseling, enabling patients to make informed decisions, assessing the capacity and the voluntary nature of the request, meeting documentation requirements, understanding the technical aspects, connecting with patients’ circles of support, and so on).

In addition to considering the effects on our educational standards, your College has done the following.

• Representatives from our ethics and palliative care committees have produced a Guide for Reflection on Ethical Issues Concerning Assisted Suicide and Voluntary Euthanasia that will be released in the fall of 2015. This reflective document aims to assist physicians in understanding the changes in the law, the terminology, and the effects of legal changes on physicians.

• We are providing input on the Canadian Medical Association’s Principles-based Approach to Assisted Dying in Canada,³ to be further discussed at the Canadian Medical Association general council meeting. We support the foundational principles that underpin medical aid in dying—respect for patient autonomy, equity, respect for physician values, consent and capacity, clarity, dignity of life, protection of vulnerable persons, accountability, solidarity—and are providing input on recommendations for potential regulatory frameworks.

• We are joining forces with other members of the Canadian Medical Forum in advocating for federal legislation to avoid a tapestry of differing provincial and territorial regulations so that Canadians who, after due process, decide to proceed in this direction, have access to the same regulatory framework anywhere in Canada.

We are trying to better understand and appreciate your perspective as members on this through the work of our committees and through your feedback on our most recent ePanel Survey, conducted in May 2015.⁴ A total of 58% of the 663 ePanel members responded; of these, 53% supported the SCC decision. When asked what follow-up would be most meaningful to them, the following were ranked most highly: suggested actions for patient requests for assistance in helping them die (77%); summaries of the legislation and implications for family physicians (75%); guidance on ethical approaches and considerations for physician-assisted suicide and euthanasia (68%); and education and continuing professional development on what this means for the profession and our practice (65%). There is work under way to address most of these priorities, and more specific guidelines will be considered as concrete legislation on this important issue emerges. We are always looking to collect more of our members’ opinions as part of these polls—please consider joining the ePanel to lend your voice to future surveys (www.cfpc.ca/CFPC_ePanel).

Most palliative care in Canada is provided by teams that include family physicians (both those providing comprehensive care and those with enhanced skills in this domain). Considerable work has been done reviewing these core and enhanced skills competencies. It is essential that together we—providers, policy makers, system planners—minimize the barriers and provide superb care to those nearing the end of life’s journey.

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