Bill 84 has been passed into law in Ontario and outlines the legal issues surrounding medical aid in dying (MAID), which has been legal in Canada since last year. The patient’s death must be “reasonably foreseeable” and their suffering “grievous and irremediable” to qualify for the service. Groups such as those with advance directives, mental illness, and minors are left out, and whether they should be allowed access to this service in the future is an issue for another time. One of the most contentious aspects of Bill 84 is the requirement for the treating physician in Ontario to provide a referral for a patient who has requested MAID to a physician who provides it.
I’m a surgeon and I do not provide MAID as it is not within my skill set, but I absolutely support patients who qualify having access. Multiple surveys have been quoted in the press using statistics of the % of physicians willing to provide MAID as a surrogate marker for the % of physicians who support their patients having access to this service. The two are not the same. You don’t have to spend a lot of time in my job on the wards of a small community hospital to see suffering, often profound suffering, in the dying. Discomfort that medical science hasn’t been able to relieve, certainly not completely, and a lot of the time and especially near the end of life, not even close, even with access to the best of palliative care. The struggle of breathlessness with incurable but maximally treated lung or heart disease, the unrelenting pain of a locally recurrent rectal cancer, or the ongoing nausea of an untreatable malignant bowel obstruction. A lot of patients whose death is “reasonably foreseeable” on the ward (and an even higher number at home) simply cannot even get out of bed, much less find their own way to the very small number of physicians who are providing MAID in Ontario. This group of patients are sick, suffering, and vulnerable. While the group of patients requesting MAID, to be eligible by definition must be of sound mind, in a lot of cases they are not going to be physically even able to self refer. While allowing both conscientious objection and effective referral for MAID would be great in theory, the reality is that in some situations, the two are going to be mutually exclusive. You simply can’t have both and not expect that in an unknown number of people who would have wanted MAID, you are going to prolong suffering. Whether or not you are able to access a legal health service in Ontario should not depend on which institution you are admitted to, who your doctor happens to be, and even less on what that physician’s religious beliefs are.
These doctors who object to doing these referrals are not being asked to provide MAID, to be clear. They are being asked to provide an effective referral for a patient who has requested it. It will be the case sometimes that patients referred may not qualify for MAID. “Let’s set up a hotline! And a website!” people say. That way patients requesting MAID can do what is called “self referral”. Meaning they can just call the doctor who provides MAID themselves. Doctors who find the idea of being involved, even very peripherally, in MAID, would be off the hook, their consciences clear. Well that would be great, if it weren’t so obviously unreasonable in the reality of these very ill patients day to day lives. The sad fact is that many of these patients can’t pick up a phone, or go to a website, usually by virtue of the very illness which is causing them to want to be referred for a medically assisted death in the first place. In remote and rural communities, allowing conscientious objection could mean the difference between weeks or months or suffering, or the patient being able to access a legal medical service. Another big issue of course, is that the physician involved with the patient may be the only one with access to information about whether or not the patient qualifies for MAID, thus creating a catch-22 for the doctor trying to assess for suitability in the first place.
Life is a condition with a 100 % mortality rate- cure sometimes, treat often, comfort always, in the words of Hippocrates. There are other instances, such as abortion, where physicians’ personal or religious beliefs come up against the expectations of patients, their families, government, or society generally. In requiring physicians to honour patients’ reasonable requests for access to legal health services, the government has got it correct to err on the side of legislating for patient access. I can’t even imagine how much distress a patient has to be in to even broach this subject with their physician. I imagine the bar is pretty high, given our propensity to treat aggressively into the last embers of life. Raging against the dying of the light is ok, if that’s what the patient wants. When what the patient wants if to be referred for MAID, it’s our duty as physicians to provide it. The government of Ontario has got this one right.