Why I don’t support conscientious objection to MAID

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.

 

Advertisements

4 thoughts on “Why I don’t support conscientious objection to MAID

  1. Dear Dr. Barron,

    Thank you for your thoughtful post. It appears to me that you are a compassionate and caring physician who does not want to see patients suffer needlessly.

    I am a chronic pain consultant working in Edmonton. I also do palliative care call at one of your local hospices in the Edmonton area (in fact, I am on currently on call at the unit).

    While I appreciate your comments, I cannot support your conclusions. I am one of those physicians who feel strongly about conscientious objection. My strong objection to MAID is not only made on religious grounds but also on my professional integrity as a physician. I never imagined when I began medical school 30 years ago, that my profession would have MAID forced upon us. This was not something the majority of us asked for or wanted. I think this is one of the major problems. We are being asked to do participate in an activity that has nothing to do with our core values as a profession which is to heal and to provide compassion and hope.

    As a physician I cannot support any activity that suggests that taking a life is a therapeutic intervention. Furthermore, just because something is legal does not mean it is moral or ethical (we only have to think of the atrocities performed by some physicians during the Nazi reign in Germany)

    Conscientious objection protects the ethical and moral integrity of our profession. Without protection for conscientious objection we become pawns of the State or our regulatory professions to do as they see fit.

    As a physician who sees pain every day, whether it is chronic pain or pain at the end of life, there is so many options I can use to ease suffering. MAID is not one of them.

    I respect your right to disagree with me on this matter. Hopefully neither of our points of view will be imposed on us by the State or our regulatory bodies.

    Sincerely,

    Robert Hauptman
    Pain Consultant
    Assistant Clinical Professor U of A

    Like

    1. Dr. Hauptman, you are in a unique position when it comes to assessing end-of-life care in this country. First, you practice in Edmonton, which has an enviable national reputation for its comprehensive palliative care programs. Outside of urban centres in Canada, however, not all provinces have even designated hospice palliative care as a core service under their provincial health plans. The 2014 National Palliative Medicine Survey found that fewer than 200 physicians across Canada identified themselves as family physicians with a focused practice in palliative care or specialists/subspecialists in palliative medicine. Basically, patients in many rural or under-served areas don’t have a hope in hell of accessing the kind of pain management options you and your colleagues can provide in Edmonton. And secondly, I appreciate that many physicians working in palliative care also share your embrace of conscientious objection. Even those who don’t have any religious concerns seem to believe that not to embrace it may somehow mean an admission that the palliative care being provided isn’t adequate if patients decide they no longer want to suffer. I completely support your objection to personally participating in MAID (and being forced to do so is a non-starter anyway), but I’m alarmed that conscientious objectors also seem to be saying that they fully intend to refuse to refer a patient to somebody else.

      I’m merely a patient with ongoing cardiac issues, but I’ve also worked in the hospice palliative care field since 2000. As you know, Cicely Saunders’ work on the concept of “total pain” in the dying includes not just the physical pain you describe, but also the patient’s psychological, social, emotional, and spiritual pain – and that’s the kind of suffering that our pain meds can’t address.

      Urban docs like you are not the problem here, thank goodness, because I hope that most urban patients in Canada will have ready access to some other local physician who will help them if you refuse to do so. The deep concerns that have worried me since my earliest days in palliative care, however, is the appalling inequality of good palliative care services throughout most of our big country. Until we achieve that equality, and only then, should physicians be allowed to refuse to refer.

      I found Dr. Barron’s essay to be compelling and (from a patient who can clearly see the writing on the wall some day) reassuring to those of us who believe that our quality of life – and death – should not be at the mercy of conscientious objector gatekeepers to dictate.
      regards,
      C.

      Like

  2. Great post Dr. Barron! I’ve posted a similar blog post outlining a land where conscientious objection is much a real thing without limits.. Its a pretty scary place, it certainly doesn’t put patients first.

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s