As the frequency of medical aid in dying continues to rise in Quebec, the head of the independent body that monitors the practice in the province says he worries doctor-assisted deaths are no longer being seen as a last resort.
Quebeckers have stopped appreciating MAID as an exceptional procedure for people with incurable illnesses whose suffering is unbearable, Dr. Michel Bureau said in a recent interview.
“We’re now no longer dealing with an exceptional treatment, but a treatment that is very frequent,” said Bureau, head of Commission sur les soins de fin de vie, which reports to the legislature.
Quebec is on track to finish the year with seven per cent of all deaths recorded as doctor-assisted, Bureau said. “That’s more than anywhere else in the world: 4.5 times more than Switzerland, three times more than Belgium, more than the Netherlands. It’s two times more than Ontario.”
Earlier this month, Bureau’s commission sent a memo to doctors reminding them that only patients who have a serious and incurable disease, who are suffering and who have experienced irreversible decline in their condition can receive MAID. The memo reminded doctors that the procedure must be independently approved by two physicians, and that doctors shouldn’t “shop” for a favourable second opinion.
“We see, more and more, that the cases receiving medical aid in dying are approaching the limits of the law,” Bureau said. “It’s no longer just terminal cancer, there are all kinds of illnesses – and that’s very good, but it requires a lot of rigour from doctors to ensure they stay within the limits of the law.”
Bureau said he’s witnessed a slight increase in the number of cases that violate Quebec’s end-of-life legislation.
In the commission’s last annual report, which covered a period between spring 2021 and spring 2022, it said 15 out of 3,663 doctor-assisted deaths in Quebec didn’t respect the law. The problematic cases involved one instance in which MAID was administered to someone who had an expired provincial health insurance card. In six cases, patients were not admissible for the procedure; in three other cases, patients were unable to consent.
Those 15 cases were reported to Quebec’s college of physicians – College des medecins du Quebec. In an e-mail, the college said that none of the 15 cases were referred to its internal disciplinary tribunal. Spokeswoman Leslie Labranche said the self-regulatory organization doesn’t have data about whether other disciplinary measures may have been taken against doctors who allegedly violated MAID rules.
The college declined to comment on the commission’s memo.
Bureau said he worries doctors are being put in difficult situations by elderly patients who are ready to die but whose health problems aren’t serious enough for them to qualify for MAID.
“Medical aid in dying is not there to replace natural death,” he said.
Bureau said he hasn’t heard of a single case in Quebec in which MAID was recommended by a doctor instead of a patient.
According to Health Canada’s most recent annual report on MAID, published in July 2022, doctor-assisted deaths accounted for 3.3 per cent of deaths in Canada in 2021. In Quebec, which had the highest number of MAID deaths in the country, the number was 4.7 per cent of deaths that year, second only to B.C., where MAID accounted for 4.8 per cent of deaths.
Those numbers have continued to rise. In 2022, MAID represented 6.1 per cent of deaths in Quebec, according to the province’s statistics institute. And in B.C., MAID deaths accounted for 5.5 per cent of deaths in 2022, according to the province’s Health Department; as of June 30, MAID deaths represented 6.2. per cent of deaths in that province.
Bureau said he’s not sure why Quebec has a higher rate of MAID than other parts of Canada, adding that he believes the province’s framework for MAID is stricter than elsewhere in the country, and better monitored.
But even though there are tight rules around the procedure, MAID is deeply integrated into Quebec’s health-care system, allowing patients to receive a doctor-assisted death from a physician that is already caring for them.
“It’s very easy to go from palliative care to medical aid in dying,” he said.
Dr. Mona Gupta, a psychiatrist and bioethics researcher at Universite de Montreal, said in an interview Tuesday it’s difficult to make international comparisons, such as those between Quebec and European countries, due to the “very different historical, cultural, political and health-care contexts.”
Quebeckers tend to have secularized attitudes toward individual moral choices, including divorce and abortion, said Gupta, who has advised the federal government on MAID policy. She said there was a widespread civil society dialogue in Quebec about doctor-assisted death in the years leading up to the province’s 2014 MAID law – two years before it was legalized at the federal level.
“There was really a very high degree of civic engagement, I think, on the issue, which predates that of the rest of Canada,” she said.