TORONTO - In the wake of the Supreme Court of Canada's historic ruling that struck down the ban on physician-assisted death, health professionals are grappling with a host of thorny ethical and practical issues raised by the decision.
Here are some of the questions being asked by and of key medical organizations and the answers they are so far able to provide:
Q: What do doctors now tell suffering patients who ask them for help to die?
A: The Canadian Medical Association (CMA) is advising its 80,000 members that the law prohibiting medically assisted death is in effect for a year, giving government time to revamp the legislation.
"So nothing changes over the next year while the details are being sorted out," said CMA president Dr. Chris Simpson.
Q: How many doctors would be involved in deciding whether a patient meets the criteria for physician-aided death?
A: Simpson said the 12-month period gives physician groups and legislators the opportunity to study how medically assisted death is performed in other jurisdictions where the act has been legalized, such as the Netherlands, Switzerland and a handful of U.S. states.
"In general, we want the process to be pretty extraordinarily robust and careful with a lot of steps," said Simpson, including safeguards to protect the vulnerable and to ensure the person seeking to end their life isn't being influenced or coerced by others, even subtly."
"So I would envision multiple steps with more than one doctor, maybe even a panel or some sort of a board that evaluates all of the complexities of this. Because ultimately, at the individual patient level ... it's not an emergency that needs to be done right away. There's time for a process to be thoughtful and ensure that only the people who truly should have medical aid in dying get it."
Q: What about a patient who is physically incapable of giving themselves a fatal drug dose — because of quadriplegia or advanced ALS, for instance?
A: Simpson calls this one of the "important nitty-gritty details" yet to be worked out. It's a question that needs to be explored by doctors groups, legislators and legal experts as a framework for how medical aid in dying will actually be delivered.
"A lot of doctors regard the prescribing of a lethal substance as the moral equivalent to actually administering a lethal substance," he said. And while hooking up an IV and giving a fatal dose could be done by any trained physician, "many doctors are saying there should be another class of clinicians who does only this."
"I'm not sure that really absolves anybody because the hard work is in the decision-making. The hard work is not in hooking up the IV."
Q: The Supreme Court ruling says Canadians who are enduring intolerable physical or mental suffering have the right to seek medical help to end their lives. But what constitutes mental suffering and where would the line be drawn?
A: Padraic Carr, president of the Canadian Psychiatric Association (CPA), said that's one area of the judgment, in particular, that needs further legal clarification.
"Every patient is different and it's unclear who would meet that legal test or what they define as intolerable, enduring suffering," he said of the nine justices' unanimous decision.
Carr said their ruling speaks to four points in which physician-assisted death may be considered: where a patient is competent; clearly consents; has what they define as a grievous and irremediable condition; and has enduring intolerable suffering.
"I think it would be very difficult for a patient who has a severe mental illness to meet these four criteria."
Q: People with clinical depression and certain other psychiatric disorders are often suicidal. How would doctors tease out whether a patient's desire to die is a result of their illness and might be alleviated with treatment?
A: Carr said the court ruled that a patient must be "competent" to obtain medically assisted death, a term which psychiatrists call the "capacity to make decisions."
Capacity means a patient must: be able to make a choice; have the ability to understand the relevant information around that choice; must appreciate their situation and the consequence of making the choice; and demonstrate that they can manipulate that information rationally, he said.
"So depression and other psychiatric illnesses, including psychotic disorders, can certainly influence your insight and judgment and they can also affect that ability to appreciate your situation and to manipulate that information rationally. So all of those would be included in any capacity assessment."
While the 4,700-member CPA has no official position on the court's ruling as yet, Carr said he can't imagine a scenario in which a patient would meet all those criteria and their situation be thought hopeless.
"It would be a rare instance in psychiatry where a condition would be considered irremediable. Even when someone is called clinically resistant, there are still other treatments that may work."
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A look at some jurisdictions where right-to-die laws are in place. (Information courtesy of The Canadian Press)
A right-to-die bill was adopted last year, the first legislation of its kind in Canada. The law, scheduled to go into effect in December, stipulates that patients would have to repeatedly ask a doctor to end their lives on the basis of unbearable physical or psychological suffering. They would have to be deemed mentally sound at the time of the requests. The law, however, is being challenged in court by two Quebec-based groups on the grounds that it undercuts sections of the Criminal Code that outlaw assisted suicide and euthanasia. The federal government has expressed its opposition to the legislation but is named as a defendant in the court challenge because it is responsible for the Criminal Code.
The results of a referendum made Oregon the first U.S. state to make it legal for a doctor to prescribe a life-ending drug to a terminally ill patient of sound mind who makes the request. However, doctors cannot administer the life-ending drugs and the patient must swallow them without help. Patients must state three times -- once in writing -- that they wish to die, and those statements must be made at least 15 days apart. They must also obtain a concurring opinion from a second doctor that they have less than six months to live and are of sound mind. The law took effect in late 1997, and through June, 2014, just over 800 people had used the law.
The state became the first in the U.S. to allow a person's right to die through legislation rather than through a court decision or a referendum result. Vermont's law, which took effect in May 2013, is closely modelled on the system in Oregon and uses the same safeguards. Patients must state three times, including once in writing -- that they wish to die. They must also obtain a concurring opinion from a second doctor that they have less than six months to live and are of sound mind.
In January 2014, a judge ruled that competent, terminally ill patients have the right to seek their doctors' help in getting prescription medication if they want to end their lives on their own terms. The state's attorney general is appealing the ruling, and a decision on whether it will be upheld is expected later this year.
A referendum saw the state enact right to die legislation in 2008. As in Oregon, patients with less than six months to live must administer the doctor-prescribed lethal medication on their own. According to a government report, 549 people applied for the right to die between 2009 and 2013. Of those, 525 actually took their own lives.
In 2009, the state's Supreme Court ruled that Montana's public policy supports mentally competent, terminally ill patients being able to choose aid in dying. Physicians are allowed to prescribe medication that patients must administer themselves. More detailed legislative bills have been introduced in the state but have not passed. The court ruling still stands today, but data about its usage is not available.
A law passed in 1942 forbade anyone from helping someone kill themselves for selfish reasons. As a result, people arguing that they are assisting with a suicide for unselfish motives are not considered to be committing a crime. Suicides can be assisted by people other than doctors and no medical condition needs to be established. Switzerland is the only country that allows foreigners to travel there for the purpose of ending their own lives.
In the Netherlands, euthanasia is legal under specific circumstances and for children over the age of 12 with parental consent. In Europe, patients don't have to prove that they have a terminal illness -- establishing unbearable suffering is usually sufficient. Dutch doctors are allowed to perform euthanasia if a patient whose unbearable suffering has no hope of improvement asks to die with a full understanding of the situation. A second doctor must agree with the decision to help the patient die.