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  • I have a bunch of patients who are waiting for it, right?

  • They've been approved

  • They've not been approved.

  • They're waiting and hoping to be approved.

  • These two doctors have conflicting viewpoints

  • on euthanasia in their country.

  • I think Canada's approach to assisted dying has been successful.

  • I am very concerned about medical assistance

  • in dying laws in Canada.

  • Euthanasia became legal in Canada in 2016.

  • They call itmedical assistance in dyingor MAID for short.

  • Since then, the number of assisted deaths in Canada

  • has risen to over 10,000 people in 2021.

  • That's more people by raw number than any other country

  • where assisted dying is legal.

  • In 2021, eligibility for MAID expanded to include people

  • who are not nearing the end of their lives.

  • And starting next year...

  • that will include people suffering solely

  • from serious mental conditions, too.

  • Our participants are here to engage in a new kind of debate.

  • Yeah, that's where you and I would disagree.

  • I know.

  • Where instead of fighting over unvetted talking points...

  • we ask each expert to pick three facts

  • that their opponent would have to concede are true.

  • Dr. Maher, do you agree that these facts are true?

  • I do.

  • Dr. Green, do you agree that these facts are true?

  • Yes, I do.

  • They'll present their facts and they'll each get a chance

  • to respond with a footnote.

  • And after the fact exchange...

  • we'll also have four additional rounds

  • to further clarify their positions.

  • This is a fact-checked debate about euthanasia...

  • in Canada.

  • Here we go.

  • In Canada

  • assisted dying is a rights-based issue...

  • resulting from constitutional court challenges.

  • The legalization of assisted dying did not come about due to

  • voter initiated ballots, as happened in some US states...

  • or because the government thought it was a good idea.

  • Both of which can change with shifting political winds.

  • Importantly, these court cases were brought and won

  • by people with both terminal

  • and non-terminal illnesses.

  • It is true that court cases...

  • gave people who didn't have terminal illness...

  • the right to have assisted deaths.

  • But one of the plaintiffs in that key case...

  • Jean Truchon, who had cerebral palsy...

  • when he was considering getting assisted death

  • what he said was that it was the loneliness...

  • that was brought on by the pandemic...

  • that was leading him to make that choice.

  • So I'm really concerned about what that means

  • for people in Canada...

  • who will make choices to die.

  • Not for medical reasons alone, or maybe not even primarily

  • because of medical reasons

  • but because of social reasons: poverty...

  • isolation, loneliness.

  • That worries me a great deal.

  • Jean Truchon ultimately led his challenge

  • to the new law for assisted dying...

  • because he was about to lose function in his remaining limb.

  • That was his initial incentive.

  • Ultimately, this comes down to a question of rights.

  • And who, if anyone, controls our lives.

  • My name is Dr. Stefanie Green

  • and I'm a provider of assisted dying in British Columbia, Canada.

  • I've always been taught about the importance

  • of patient-centered care.

  • And I have found it to be profoundly meaningful

  • to be involved at this time in their life...

  • and to provide and facilitate their final wishes.

  • There are 15 countries that allow

  • some form of medically assisted dying...

  • Including ten US states and Washington, DC...

  • that allow people with a six month prognosis...

  • to self-administer a prescribed drug.

  • Canada is one of eight countries

  • that allows assisted dying for people

  • without a terminal diagnosis.

  • Next year, it will join most of these countries

  • in extending eligibility to people

  • whose only condition is a mental illness.

  • In these countries, cases involving

  • primarily psychiatric conditions are rare.

  • In Belgium and the Netherlands...

  • they made up about 1% of all cases.

  • Canada's assisted dying laws

  • lack the safeguards that other countries have.

  • There is no requirement

  • that all reasonable treatments

  • at least have been tried by the patient.

  • The doctors are able to initiate the conversation.

  • There is no review process.

  • There's nobody looking to see

  • whether people in Canada licensed to do this...

  • have in fact followed the law and followed the rules.

  • Canada rejected paternalism in medicine quite a few decades ago.

  • The Supreme Court decision states that a patient...

  • is not required to undertake medical treatments...

  • that are unacceptable to the individual.

  • We have long accepted that patients can refuse medical treatment.

  • Even if the result of that refusal is death.

  • There's actually a very rigorous process in place

  • for this assisted dying model.

  • There's a number of eligibility criteria, but once they are met

  • there are on top of that, a number of procedural safeguards.

  • Of course, we're in complete agreement

  • that paternalism is not a good thing

  • and every Canadian is free to make their own choices.

  • But when we're talking about assisted death

  • we're talking about choices made at a point in time

  • when a person is profoundly vulnerable.

  • My name is John Maher.

  • I'm a psychiatrist with a community mental health team

  • in Ontario, Canada.

  • My goal is to help my patients

  • live their lives the way they want...

  • and to do all we can to ensure that mental illness...

  • and all that follows from that doesn't keep them

  • from living full, rich lives.

  • There was an initial concern

  • that people would request assisted dying...

  • because they couldn't access palliative care.

  • But the data has put that fear to rest.

  • Over 80% of the people who receive MAID in Canada...

  • are receiving palliative or hospice care at the time of their death.

  • For those few who are not...

  • 88% of them have access to such care.

  • Compare that to the wider Canadian population

  • and all causes of death

  • when statistics suggest

  • that only a minority of people are receiving

  • palliative care before they die.

  • The data that you're referencing...

  • comes from the forms that are filled out by the MAID providers...

  • and it tells us nothing,

  • nothing at all, about the quality of the palliative care.

  • We also know from the data you're citing that 21% of people who...

  • who received MAID had palliative care for less than two weeks.

  • While it's true, we don't have an objective marker...

  • for the quality of palliative care received.

  • What we do know from lots of data...

  • is that since MAID was legalized in Canada...

  • we have a significant increase

  • in the funding for research for palliative care and an increase

  • in the number of people receiving and dying with palliative care at home.

  • The vast majority of people who access MAID in Canada

  • are patients with a cancer diagnosis.

  • The next most common underlying

  • illness are end-stage organ failures.

  • So end-stage heart disease

  • end-stage lung disease, end-stage liver disease...

  • and neurologic conditions, they're around the 10% to 15% range.

  • The wait times for MAID in Canada

  • are shorter than the wait times

  • to get a lot of specialized services.

  • That might be pain clinics, psychiatric care...

  • long-term care homes, veterans' benefits...

  • supportive housing, community-based care.

  • That's not right.

  • My job as a MAID provider

  • requires me by law to ensure

  • that my patients have been offered the resources and services

  • that could potentially reduce their suffering.

  • I agree we need to reduce wait times

  • but at some point when potentially helpful resources...

  • are not reasonably available

  • we can no longer hold individuals hostage to society's failings.

  • It seems to me that the greatest failing

  • we're talking about here is a society

  • that's willing to help its citizens die...

  • rather than provide the services...

  • that we know help, that we know work...

  • that we know reduce suffering.

  • Killing people while they're on wait lists...

  • is profoundly immoral.

  • National polls consistently show

  • that the Canadian public supports assisted dying.

  • This includes people who self-identify

  • as religious and people with disabilities.

  • These polls were conducted before our law changed

  • to allow assisted dying,

  • in the first five years of legalized practice...

  • and in every year since the amendment that extended eligibility

  • outside the end of life context.

  • Two polls that asked Canadians

  • about their views on MAID for mental illness

  • came back with very different results.

  • One poll showed over 60% of Canadians in favor.

  • Another poll, one in particular looking at MAID for mental illness

  • showed that only 31% of Canadians support it.

  • I don't think Canadians have a full understanding...

  • of what is happening.

  • But those organizations that are focused on what's happening...

  • and drawing attention to it

  • namely the 137 disability organizations in Canada...

  • the national indigenous organizations...

  • the mental health organizations, the United Nations...

  • everyone who is looking at this and understanding

  • what is going on is gravely concerned...

  • about the discriminatory impact of this legislation.

  • Canadians have been talking about and debating

  • assisted dying since the 90s.

  • There are multiple reports, multiple committees...

  • multiple news stories, multiple court cases...

  • to suggest that Canadians are unaware of what the issue is

  • is not exactly fair to the Canadian public.

  • There is no consensus

  • among Canadian psychiatrists

  • on when any particular psychiatric illness is incurable.

  • And under the law that comes into effect in 2024 in Canada

  • a psychiatric illness must be incurable

  • and a person must be in a state of irreversible decline.

  • But we can't say who that is.

  • Consensus in health care is rarely required.

  • There is no consensus amongst doctors...

  • about whether they can accurately predict

  • a prognosis of six months.

  • Yet it's an eligibility requirement for assisted dying

  • in several countries, including the United States.

  • However, in Canada, for MAID to proceed...

  • two independent clinicians must be of the opinion...

  • that the patient's condition is incurable.

  • When someone has a terminal illness...

  • say cancer, we have a pretty good idea...

  • of how long they might live.

  • May not be precise, but we have a good idea.

  • In mental illness, we have no idea.

  • People get better after five years, after ten years.

  • These are very, very different conditions...

  • very different circumstances.

  • Now, we'll move on to the additional rounds.

  • Questions.

  • Personal experiences.

  • Debunk.

  • Uncertainties.

  • Stefanie, can you ask John a question

  • that helps clarify his position?

  • John, do you believe every person

  • with a mental health disorder can be treated successfully?

  • Because if not and they have capacity...

  • should they not be allowed to access the same legal health care

  • available to everyone else?

  • We both know the majority of people living with mental illness...

  • have full capacity.

  • They can make their own treatment decisions.

  • To answer your question, can we treat everyone?

  • I don't think that's the right question.

  • The question is, can we reduce suffering?

  • Can we help people cope with suffering?

  • There are certainly going to be people

  • whose illness will not get better, their physical illness.

  • But can we mitigate their experience of their symptoms?

  • Can we bring support...

  • care, compassion, and love to them in a way

  • that makes their life for them worthwhile?

  • I'm not talking about denying anyone...

  • the option of choosing MAID.

  • To be frank, everyone can already choose suicide.

  • What we're working to do is to ensure

  • that every person is treated with respect, dignity...

  • provided with care and support...

  • that we know can help reduce suffering.

  • Okay, John, would you like to ask Stefanie a question?

  • Only one in three Canadians

  • have access to mental health care who need it.

  • Only one in five children.

  • We know from disability organizations across the country...

  • that disability supports are completely inadequate...

  • to live a meaningful life.

  • People are suffering...

  • in ways that we can do something about.

  • I'm asking you...

  • would you support providing MAID to someone...

  • while they're waiting for treatment or care...

  • that could help them?

  • But it's down the road a bit.

  • I would happily stand with you

  • and call for our government to do better than what it's doing.

  • I think it's a separate issue.

  • There can come a time, on a case-by-case basis...

  • Every situation is individual, every situation is unique

  • and every case needs to be assessed in a unique way.

  • There may be a time when a certain treatment

  • is available, too far away,

  • much too expensive, inaccessible to the patient.

  • In this case, we have to seriously consider

  • not holding them hostage to society's failing

  • and to consider offering MAID if it's truly what they need.

  • A tough situation.

  • I grant you that.

  • John, can you tell us something from your personal experience

  • that has strengthened your conviction on this issue?

  • As a psychiatrist...

  • who works with a community mental health team...

  • supporting people with the most serious mental illnesses...

  • We are becoming overwhelmed...

  • by what MAID has introduced...

  • into our clinical worlds.

  • I have patients who are already saying...

  • “I'm going to stop treatment.”

  • “I'm not going to keep trying.”

  • “I can die.”

  • Our efforts to help them stick with the very challenging

  • and sometimes long-term treatment required to heal and recover

  • is being undermined.

  • We're not just doing suicide prevention anymore.

  • We're doing MAID prevention.

  • I'm going to tell you about a gentleman I'll call Ray

  • who was 62 years old with metastatic lung cancer.

  • And Ray had been asking for MAID for quite some time.

  • And as he and I worked through the rigorous eligibility criteria...

  • at some point, I was able to sit in front of him

  • and tell him he was eligible for this care.

  • And when I sat there and did that, I saw in him...

  • a physical transformation, which I've learned actually happens...

  • almost every time.

  • I saw his shoulders relax.

  • I think I saw him smile for the first time since I'd met him...

  • and it was immediately followed by an expression of gratitude

  • for the mere possibility.

  • He decided to proceed with MAID

  • and we held it not long after, in the rooftop garden

  • of the facility in which he was living.

  • And as is required by law

  • I was seeking his final consent

  • before I administered the medication.

  • He was surrounded by his friends...

  • and as he gave me that consent

  • he reached out and grabbed my hand.

  • He looked at me and he said,

  • “I know this is going to sound odd, Dr. Green

  • but I think you saved my life.”

  • And it reminds me all the time...

  • that for the people who actually need and want this care

  • it is tremendously important.

  • Stefanie, what is one piece of specific misinformation...

  • that you've heard about MAID that you'd like to correct?

  • Recently, a number of eye catching headlines

  • have appeared in the news about Canadians requesting

  • assisted dying due to the threat of homelessness...

  • or the fact that they're living in poverty.

  • And while it's true that anyone can ask

  • for an assessment of eligibility for MAID...

  • and those unacceptable social inequities

  • might be contributing towards suffering.

  • The law is actually perfectly clear and Canadians cannot access

  • MAID based on those factors alone.

  • John, would you like to clarify a piece of misinformation?

  • Some MAID providers have argued that MAID...

  • for non-terminal conditions...

  • is not suicide.

  • For decades, suicide has been defined

  • as taking steps to arrange your own death.

  • Some have said that what makes MAID different than suicide...

  • is that it's well thought out.

  • It's not impulsive.

  • But in fact, in one US survey of over 1.4 million Americans

  • 80% of people reported

  • that they thoughtfully planned their suicide...

  • Which means that we have to consider

  • where it fits into all of our suicide prevention efforts...

  • and whether it undermines those very directly.

  • And now for a round called Uncertainties.

  • John, what is something we don't know

  • about this issue that we need more research on?

  • Canada currently collects data...

  • on the illnesses

  • the physical illnesses that lead to requests for MAID.

  • What we don't have is data...

  • that considers the socioeconomic reasons people might request it.

  • And how significant an impact...

  • that might have on the request

  • and perhaps whether it drives it completely.

  • We don't know whether poverty, homelessness...

  • being on a waitlist for treatment...

  • being refused disability benefits...

  • we don't know why...

  • people are choosing MAID and we should.

  • On this point, John, I think we're almost in agreement.

  • Canada has recently expanded the type of data it's...

  • gathering on patients who request and receive MAID.

  • And I'd be curious to see if it mirrors what we know

  • from international jurisdictions.

  • Everywhere where this data is collected elsewhere...

  • we know that it is the socially advantaged...

  • who are accessing assisted dying

  • not the socially disadvantaged.

  • So I'll be curious to see if that plays out

  • in the Canadian context, which is what I expect to be frank.

  • That said, I think we do have a good idea

  • of how people describe their own suffering...

  • and therefore why they're requesting MAID.

  • Primarily, it's for people who can no longer do the things

  • that bring meaning to their lives...

  • who no longer are able

  • to do what we call the activities of daily living...

  • who've lost a sense of dignity or independence.

  • And I think if we could find research

  • that would help us better understand...

  • what leads to that type of suffering...

  • potentially there's a way we can learn to treat it.

  • I'm concerned about this law...

  • having, I'll acknowledge, the unintended...

  • but profoundly disturbing consequence...

  • of having people feel like they're a burden

  • and that they should choose death over life.

  • That they should no longer demand

  • of their government, of their fellow citizens...

  • that care and support be provided.

  • Having spent time

  • with many suffering individuals, I can tell you...

  • that Canadians are extremely grateful for this option.

  • In a testament to the quality of care being provided...

  • not a single person has been charged with misappropriate action.

  • I think Canada's approach to assisted dying

  • is more than adequate.

  • It is solid.

  • It is good, and for some, it may be a model...

  • for considering care in their own region.

I have a bunch of patients who are waiting for it, right?

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A fact-checked debate about euthanasia

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    林宜悉 發佈於 2023 年 07 月 27 日
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