Addressing legal and ethical concerns of Medical Assistance in Dying

One of the biggest contemporary challenges facing health care delivery in BC and across Canada right now is the rapidly evolving implementation of Medical Assistance in Dying (MAiD). The history of this evolution is dramatic. In February 2015, the Supreme Court of Canada declared in Carter v. Canada that the absolute criminal prohibition of physician-assisted death is unconstitutional, and specified certain circumstances in which it must be lawful for a person to choose MAiD, giving the federal government one year to enact a legislative response within its jurisdiction. Thus, the Canadian Nurses Protective Society
explains:

On June 17 [2016] the federal government’s Bill C-14, An Act to amend the Criminal Code and to make related amendments to other Acts, (MAiD) became law in Canada. As a result, two forms of MAiD are exempt from criminal prosecution:

• • the administration of a substance to a person, at their request, to cause their death
  • the prescription or provision of a substance to a person, at their request, so that they may self-administer the substance to cause their own death.

Further, now the Canadian Bar Association is urging the federal government to expand its restrictive new law on assisted dying, “to extend the right to assisted dying to people suffering strictly from psychiatric illnesses and to mature minors and to allow people diagnosed with conditions that will eventually cause loss of competence to make advance requests for an assisted death while they’re still able to give informed consent.” While the Canadian Bar Association’s proposed expansion of the new law is not taking place at this point in time, the dialogue around MAiD is intensifying across Canada, and implementation of Bill C-14 has begun.

Addressing the Challenges
The rapidly changing legislative and societal landscape around MAiD means that all health care providers, including nurses, must be proactive in ensuring that the public is supported and protected. MAiD will only be a meaningful ‘choice’ if there are also robust supportive and palliative resources available to Canadians so that MAiD does not become a ‘default’. And health care providers ought to be provided with the resources they need so they can ethically and effectively participate in comprehensive end of life care, where MAiD is only one option. Such care must include the implementation of a durable palliative approach, where there is a ‘baseline’ of supportive care services provided to all who are suffering and/or dying as well as more specialized palliative care interventions for those whose symptoms are complex and/or intractable. As is articulated in a recent Joint Position Statement (p.8) by the Canadian Nurses Association, the Canadian Hospice Palliative Care Association and the Canadian Hospice Palliative Care Nurses Group (2015), the palliative approach to care:

uses palliative care principles (i.e., dignity, hope, comfort, quality of life, relief of suffering) with people facing chronic, life-limiting conditions at all stages, not just at the end of life. It reinforces personal autonomy, the right for persons to be actively involved in their own care and a greater sense of control for individuals and families. The palliative approach “does not link the provision of care too closely with prognosis”; rather, it focuses (more broadly) on “conversations with [people] about their needs and wishes”.

Indeed, at the Annual General Meeting of the Association of Registered Nurses of British Columbia (ARNBC) in June of 2016, nurses in BC passed resolutions to:

1. support equitable access to palliative care approaches in the context of Medical Assistance in Dying (MAiD) through provincial educational and policy initiatives in British Columbia; and
2. study the issues of MAiD in relation to people who struggle with mental health issues, mature minors, and those who have Advanced Directives in the context of nursing values and nursing practice.

Given the widespread inequities we have across Canada in access to resources for health and health care,8,9,10 action on these resolutions is crucial in British Columbia as well as across Canada.

UBC Nursing Leadership
The UBC School of Nursing has contributed—and is well-positioned to continue to contribute—to the important work laid out in the ARNBC resolutions. For example, four of the lead researchers working on articulating and implementing a palliative approach to care through a research/practice consortium known as iPanel are graduates of our UBC doctoral program in nursing–Dr. Barbara Pesut (a faculty member from UBC Okanagan), Dr. Sheryl Reimer-Kirkham and Dr. Rick Sawatzky (faculty members from Trinity Western University), and Dr. Kelli Stajduhar (a faculty member from the University of Victoria). Further, our UBC Nursing faculty member Dr. Sally Thorne is on the iPanel Advisory Board. And the authors of the two ARNBC resolutions noted above include myself (a UBC Nursing faculty member and graduate of our UBC doctoral program in Nursing) and Ms. Lynn Musto (a UBC School of Nursing doctoral candidate and a faculty member from Trinity Western University) as well as Dr. Reimer-Kirkham.

Members of our UBC School of Nursing faculty have programs of research that can continue to inform research and policy work related to MAiD. Our faculty has expertise in areas such as the care of older adults, end of life care and palliative support, health care ethics, and the support of populations who have been marginalized. For example, faculty members Dr. Jennifer Baumbusch (also a UBC PhD graduate), Dr. Jennifer Kryworuchko, and Dr. Alison Phinney have robust programs of research focusing on end of life care and the care of older adults. Together with the rich array of undergraduate and graduate students we are blessed with at the UBC School of Nursing, we can continue to work towards more accessible palliative approaches to care, more specialized palliative care interventions as needed, and a thoughtful and well-supported access to MAiD when necessary.

Contributed by Dr Patricia (Paddy) Rodney,
Associate Professor