MAID doctors shouldn’t shoulder burden alone

I’m a family physician who provides MAID — medical assistance in dying.

Today in Canada, to be eligible for MAID, you must be in the advanced stages of a disease, illness or disability. It must be causing you enduring and irremediable suffering. you must have been offered help that you don’t find acceptable, and your natural death must be reasonably foreseeable.

The Senate is meeting this week to debate if MAID should be broadened to include people for whom death is not reasonably foreseeable (dnrf).

I’m fine with the idea of removing the limitation of dnrf.

but I disagree with the idea of MAID assessors and providers, doctors like me, being the sole judges of these complex and hard-to-call cases, as we are with more straightforward cases. In fact, given that a patient has years to live, I’d strongly favour a panel or a designated committee assuming the role of second assessor in these cases.

This takes more time, but that extra step will ease the burden on individual MAID doctors by letting us share it.

Over the years, I have assessed patients who did not meet eligibility criteria for MAID because of dnrf.

If I can’t help these people die with dignity, because disability, disease or insecurity of living has robbed them of dignity and purpose in life, who will secure this basic right of liberty and bodily autonomy under the Charter?

Let me illustrate my concern with two patient examples.

I assessed a 70-year-old man who had a long-standing mental disorder. I had no doubt of his capacity in his request for MAID. The second assessor and I went back and forth deliberating his request for almost a year. We arranged a geriatric psychiatric consultation and the consultants agreed that he was capable in making his request.

Finally, my colleague and I came to a consensus. We justified his request because of his history of a myocardial infarction, i.e., a heart attack.

but what mattered for me was visiting him in his oneroom highrise apartment in downtown Toronto. Seeing the hole in the wall as a result of his being beaten by the pimp of the hooker he had brought home told me more about how and with what risk he lived his life than any chart review. Not one of his outreach workers had ever been inside his home. He allowed me in, with some apprehension on my part, because I was there to help him die. I never doubted that he was deserving of his well-considered request, in spite of his delusions.

Should I have excluded him because of his mental illness?

He wasn’t making his request on the basis of mental illness as his sole reason, but was it not a major factor in how he was living out his life?

My second case involves a spry 94-year-old woman requesting MAID on the basis of “life-lived.” Hard as I tried, I could not find any illness, disease or disability aside from extreme old age that would justify her request.

Is old age a disease? A disability? Is old age a qualifier in itself? If so, and if requesting to die because “it’s time” is allowed, I believe Canadians with some hazard, are on the precipice of assigning a value to life itself.

She was bitterly disappointed when I declined her request. Nonetheless, I felt in her case, I was absolutely denying her Charter rights to liberty and autonomy of body. I know that once I have assessed a person, even if I deny their request, “they are mine.” Many of these patients remain on file, even today.

Nine months later, she called me with a newly diagnosed condition and she said, “Now am I in your ballpark?”

In that interval, she could have had a natural death. She could also have had a stroke and been left mute, or comatose or unable to consent in the moment that I was to provide her with an assisted death.

All these considerations weigh on any assessor. If, in the end, we have waited too long and the patient doesn’t have the capacity to consent in the moment, will my moral compass permit me to end that life? I am a part of their death and any moral conundrums that I hold, necessarily stay a part of me.

removing dnrf will assuredly increase the number of MAID requests.

And as I’ve learned in the past five years, deciding who should live and who should die comes with a corrosive burden shouldered by a very small group of doctors and nurses.

When MAID was legalized in Canada in 2016, I anticipated that family doctors would step in to service their patients. In the Netherlands, family doctors provide MAID in 75 per cent of cases.

In my own practice of 13 physicians, I am the sole point of referral for MAID. And community physicians referring their patients to me have shown no appetite for this work.

In 2019, Ontario alone already had an estimated shortfall of 700 providers. We face an onerous workload, risking bad judgments, burnout and attrition in providing MAID.

While I applaud the very public Senate hearings and court challenges, I plead the same right of hearing for all Canadians who have a well-considered request for assisted dying.

The cost of such a process, assigned to the courts, would be prohibitive. The burden of consideration in these circumstances needs to be shared, well beyond the world of assessors and providers. Canadians should not shy away from such a shared undertaking, establishing a new model that ensures oversight, rigorous qualifiers, and review within the framework of the Charter.

DECIDING WHO SHOULD LIVE AND WHO SHOULD DIE COMES WITH A CORROSIVE BURDEN.

IS OLD AGE A DISEASE? A DISABILITY? IS OLD AGE A QUALIFIER IN ITSELF? — JEAN MARMOREO