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The Scrupulous Monitoring Of Physician Assisted Dying

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The Special Joint Committee on Physician Assisted Dying is expected to report by February 26. The Committee must respect the Supreme Court of Canada's requirement that physician assisted dying (PAD) have stringent limits that are "scrupulously monitored and enforced".

Who should monitor the limits to be placed on PAD? Quebec has legislated; and both the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying and the Canadian Medical Association have proposed the creation of new administrative agencies to monitor the PAD limits. These agencies would ensure that only those people who qualify to receive a physician-assisted death will do so, that further investigation will occur when needed and that data will be properly collected and reported.

But these goals can be achieved effectively and efficiently by the existing death experts: coroners and medical examiners. In fact, deaths caused by the administration or ingestion of drugs already trigger the involvement of coroners and medical examiners in most Canadian jurisdictions. The best way to monitor the new practice of death is to engage these death experts more fully.

Coroners and medical examiners are central to monitoring PAD. As experts in accurate death reporting, they routinely engage in relevant oversight activities: they decide when a death requires further investigation, they report aggregate data concerning death and they make public matters of interest and concern regarding trends.

Indeed, because physician-assisted deaths will probably occur because of the administration or ingestion of drugs, these deaths will be reportable to coroners and medical examiners in all but possibly three jurisdictions (Quebec, Nova Scotia and Newfoundland). (All physician-assisted deaths should be explicitly mandatorily reportable to the provincial and territorial coroner and medical examiner offices.)

Using only coroners and medical examiner offices for physician-assisted dying oversight would avoid the problems of fragmentation of accountability and the confusion that comes from overlapping jurisdictions of multiple agencies.

Reporting a physician-assisted death only to the coroner or medical examiner's office is important for ethical reasons. Limiting the number of oversight offices would reduce the number of public offices that receive sensitive patient health information, and would permit family members to learn the truth about how their loved ones died. Coroners and medical examiners are dedicated to truth telling on medical certificates of death. Truth telling is an important value in itself, and is likely to increase public trust in the practice of physician assisted dying.

Arguments for new oversight agencies presuppose that such new government expenditures are justified. But will public money be well spent on 14 new agencies -- one for each province and territory, and for the nation? The experience of other jurisdictions suggest that PAD in Canada will involve only between 0.23 and 4.6 per cent of all deaths. Coroners and medical examiners could probably monitor these relatively few deaths with only modest budgetary increases. The money saved by not creating new monitoring agencies could be spent on palliative care service delivery -- as requested by many physicians.

We respectfully suggest that the Federal Government initiate and chair a meeting of all provincial and territorial chief coroners and medical examiners who, with the Forensic Pathology Section of the Canadian Association of Pathologists, might recommend how best to state cause and manner of death, and to agree upon a system to monitor the practice's limits. The provinces and territories could then opt in to the proposed recommendations, thus creating the national PAD monitoring system recommended by many.

Coroners and medical examiners have unique expertise in accurate death certification and death investigation. The systems in which they operate are already in place. Creating new systems from scratch, staffed by people without the relevant training or expertise in death reporting and investigation, would not only be expensive but would probably fail to achieve the objective of scrupulous monitoring.

Governments currently have a pressing problem: by June 6, they must decide how to assure Canadians that the new practice of assisted dying will be used only to relieve suffering according to law. An obvious solution is to fund adequately the coroner and medical examiner offices to monitor one more practice of death.

Juliet Guichon, Christopher Doig and Ian Mitchell are faculty members in the Cumming School of Medicine, University of Calgary, Pauline Alakija is a forensic pathologist and clinical professor at the University of Alberta medical school, Pascal Thibeault is a Master of Laws student at the University of Toronto..

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