A significant minority of Canadian physicians — 29 per cent — say they would be willing to assist a gravely ill patient who wants to end their life.
But despite a Supreme Court of Canada ruling striking down the prohibition on assisted death, the majority of physicians, 63 per cent, still want no part of it. (The other eight per cent were undecided.)
Those numbers, from a poll of 1,403 doctors done by the Canadian Medical Association, serve as a backdrop as the association tries to fashion its position on the complex, emotionally charged issue of physician-assisted death.
Dr. Chris Simpson, president of the CMA, said the challenge is to create rules and regulations that ensure that patients have access to the end-of-life care they want, up to and including hastened death, while ensuring the autonomy of doctors and not forcing them to engage in care that clashes with their religious and moral beliefs.
"We've moved away from a yes-no dichotomy on this issue to a more nuanced discussion," he said.
In fact, delegates to the CMA's general council – which bills itself as the Parliament of Canadian medicine – spent half the day Tuesday debating how to best achieve that juste milieu, especially on the issue of conscientious objection.
Most of the discussion revolved around the question of whether physicians who oppose assisted death have a legal and professional obligation to refer patients to someone who is willing to provide the service.
"Referral is akin to participation in the process. It's not morally acceptable," said Dr. Diane Haak, president of the Christian Medical and Dental Society of Canada.
Dr. Jennifer Tong of Vancouver warned that "coercing physicians against their conscience" would damage patient-doctor relations and push some out of the profession.
But Dr. Trevor Theman, registrar of the College of Physicians and Surgeons of Alberta, took a different view, saying referral is a doctor's duty. "Patient rights trump our rights. Patient needs trump our needs," he said.
Dr. Chris Milburn of Sydney, N.S., also argued that personal beliefs have to be set aside in the service of patients. "We can't decide willy-nilly what not to provide. We don't judge our patients."
However, most doctors participating in the debate staked out a middle ground. "It doesn't need to be a referral. We need to provide information to patients in a timely manner," said Dr. Bill Cavers of Victoria.
In a straw poll, about 75 per cent of delegates agreed with that position, saying physicians should provide information to patients on all end-of-life options available to them but should not be obliged to refer.
Practically speaking, based on the experience in other jurisdictions, most assisted deaths will be carried out by family physicians. Interestingly, they seem most open to the idea.
In a smaller poll of 372 family doctors, 65 per cent said they would be willing to provide an assisted death if there are clear rules, such as those set out in the Supreme Court of Canada ruling.
On Feb. 6 of this year, the top court struck down two provisions in the Criminal Code of Canada, essentially saying that it is unconstitutional to deny gravely ill patients choice in how they die. But it also placed some fairly strict parameters on who can choose hastened death – only a competent adult with an irremediable condition that causes enduring, intolerable suffering – and said physicians could not be forced to participate.
The court also gave federal lawmakers one year to come up with new legislation, but the current government has stalled, so that deadline is unlikely to be met.
Dr. Simpson, head of the CMA, said: "We're lobbying for replacement legislation but preparing for the likelihood there won't be."
He said the worst-case scenario for patients would be an absence of federal legislation and a patchwork of provincial regulations.
Dr. Jeff Blackmer, vice-president of medical professionalism at the CMA, said the court's deadline – assisted death becomes legal in Canada on Feb. 6 – puts a lot of pressure on physicians. "I'm not sure we'll be able to help people on Feb. 7," he said.
It will be essential to provide training and information to physicians so they can have informed discussions with patients, and also so they have the technical skills to perform an assisted death if they so choose, Dr. Blackmer said.
But the biggest challenge, he said, will be providing equitable access to end-of-life care in a country as vast as Canada.