Jesse Pewarchuk is a clinical assistant professor of medicine, University of British Columbia
Bill C-14, the proposed legislation on medically assisted dying, signals a new era for Canadian patients. The law would legalize this option for certain competent adults suffering from irremediable illness, but although it affirms fundamental Charter rights for some people, it is a flawed document that falls short of its promise for others.
It fails both patients and doctors because it denies people the opportunity to establish advance directives requesting medically assisted death. Advance directives, or living wills, are critical legal documents that every competent adult Canadian should have, irrespective of age. This document communicates a person's wishes in the event of lost capacity to make health-care decisions.
Patients often specify discontinuing life-prolonging therapy – "no cardiopulmonary resuscitation," "no feeding tubes," "no artificial life support" – if there is little or no quality of life expected. These issues are best addressed by patients when they are of sound mind, rather than by practitioners or family members who may be guessing at what the patient would want (and can be biased).
Bill C-14's biggest flaw is that it forces the hand of those who have a progressive disease that relentlessly and predictably results in lost mental capacity to consent. Alzheimer's patients can expect, with virtual certainty, to lose the capacity to make medical decisions over time.
Under Bill C-14, they would be faced with a difficult dilemma: They would have to request, and receive, a medically assisted death while still competent to make such a decision. This would mean having to end their life prematurely, to avoid the crippling final stages of the diseases. If they were to wait and request a medically assisted death later, they would likely be deemed to be incompetent. The challenge of dementia is that competency is typically lost before quality of life reaches a nadir where many would want to hasten death.
Worse, the wording of the proposed law introduces significant doubt as to whether an Alzheimer's patient who has yet to lose capacity (yet is certain to) would even be eligible, since death can take years, even from the point of entering long-term nursing care. "Foreseeable death" and "advanced state of decline in capability" are loaded, ambiguous clauses that seem to eliminate the Charter rights of dementia patients to be eligible, and to put any physician carrying out their wishes in considerable legal peril.
Canadians already routinely decline life-prolonging options, such as feeding tubes and artificial life support, and we allow those decisions to be made while fully competent, and to respect them fully even when the patient becomes incompetent.
Bill C-14 recognizes the right of competent adults to end their lives with medical assistance. But by excluding advance directives, and by including clauses about "foreseeable death" and "advanced state of decline in capability," it would create an environment where those with progressive terminal disease must choose to end their lives prematurely, or risk enduring the full natural course of the illness.
Amending the bill to eliminate dangerous wording and to carefully include advance directives will not only prevent disease-based discrimination, it will also enhance patient options and allow the most desirable outcome for those choosing medical assistance in dying: maximum quality of life, and a death on one's own terms, rather than those of the disease.