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Submission 660 - Royal Society of Canada Expert Panel.Pdf Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2011.01939.xSubmission 660 End-of-Life Decision-Making in Canada: The Report by the Royal Society of Canada Expert Panel on End-of-Life Decision-Making UDO SCHÜKLENK, JOHANNES J. M. VAN DELDEN, JOCELYN DOWNIE, SHEILA A. M. MCLEAN, ROSS UPSHUR AND DANIEL WEINSTOCK TABLE OF CONTENTS INTRODUCTION 1. Introductory Remarks and Objectives 2. Terminology 3. Outline CHAPTER ONE: END-OF-LIFE CARE IN CANADA 1. Introduction 2. Canadian Experience at the End of Life a. Mortality and Life Expectancy Trends in Canada b. Location of Death c. Quality of and Access to Palliative Care 3. Expanding the Range of Palliative Care a. Dementia b. Chronic Kidney Disease c. Congestive Heart Failure d. Chronic Obstructive Pulmonary Disease e. Disability 4. Demographic Transition in Canada a. Aging b. Diversity c. First Nations 5. Advance Directives and Substitute Decision-Making 6. Sedation Practices 7. Paediatric End of Life Care 8. Attitudes of Canadians Toward Voluntary Euthanasia and Assisted Suicide a. General Public b. Health Care Professionals c. Patients 9. International Comparisons 10. Conclusions Address for correspondence: Prof. Udo Schüklenk, Department of Philosophy, Queen’s University, Kingston, Ontario K7l 2G3, Canada. E-mail: [email protected] Conflict of interest statement: No conflicts declared Re-use of this article is permitted in accordance with the Terms and Conditions set out at http://wileyonlinelibrary.com/onlineopen# OnlineOpen_Terms © 2011 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. Electronic copy available at: http://ssrn.com/abstract=1961111 2 Udo Schüklenk et al. Submission 660 CHAPTER TWO: THE LEGAL LANDSCAPE 1. Introduction 2. Withholding and Withdrawal of Potentially Life-sustaining Treatment a. Relatively Clear and Uncontroversial b. Less Clear and More Controversial c. Very Unclear and Very Controversial 3. Potentially Life-shortening Symptom Relief a. Somewhat Clear and Relatively Uncontroversial 4. Terminal Sedation a. Very Unclear and Potentially Very Controversial 5. Assisted Suicide a. Very Clear and Very Controversial 6. Voluntary Euthanasia a. Very Clear and Very Controversial 7. Conclusions CHAPTER THREE: THE ETHICS OF END-OF-LIFE CARE 1. Introduction 2. Core Values 3. Autonomy 4. Moral and Legal Rights 5. Autonomy and Assisted Death 6. Limits to the Right to Medically Assisted Death a. No Inference from the Right to Refuse Treatment to the Right to Assisted Death b. A Priori Arguments: Suicide is not Choice-worthy c. A Priori Arguments: Suicide Offends against Human Dignity 7. Arguments against the Legal Right to Assisted Death a. Medical Professionals b. Slippery Slopes and the Protection of the Vulnerable 8. Conclusions CHAPTER FOUR: INTERNATIONAL EXPERIENCE WITH LAWS ON ASSISTED DYING 1. Introduction 2. Mechanisms for Change to Law and/or Practice a. Judicial Decisions (Netherlands, Montana) b. Prosecutorial Charging Guidelines (Netherlands, United Kingdom) c. New or Revised Laws i. The Netherlands ii. Belgium iii. Luxemburg iv. Oregon v. Washington State d. Evolution of Practice Without Legal Change (Switzerland) 3. Elements of Regulated Permissive Regimes © 2011 Blackwell Publishing Ltd. Electronic copy available at: http://ssrn.com/abstract=1961111 End-of-Life Decision-Making in Canada Submission 660 3 4. Practical Experience a. Data on Voluntary Euthanasia and Assisted Suicide i. Netherlands ii. Belgium iii. Switzerland iv. Oregon v. Washington State b. Slippery Slopes? 5. Conclusions CHAPTER FIVE: PROPOSALS FOR REFORM 1. Introduction 2. Withholding and Withdrawal of Potentially Life-sustaining Treatment a. Valid Refusals by Competent Adults (or Legally Authorized Substitute Decision-makers) b. Mature Minors c. Unilateral Withholding and Withdrawal 3. Advance Directives 4. Palliative Care 5. Potentially Life-shortening Symptom Relief 6. Terminal Sedation 7. Assisted Suicide and Voluntary Euthanasia a. Legal Mechanisms i. Criminal Code Reform ii. Prosecutorial Charging Guidelines iii. Diversion Programs b. Core Elements i. Assisted Suicide and/or Voluntary Euthanasia ii. Features of the Person iii. Features of the Decision iv. Features of the Person’s Condition v. Features of the Request for Assistance vi. Features of the Provider vii. Oversight and Control © 2011 Blackwell Publishing Ltd. End-of-Life Decision-Making in Canada Submission 660 5 It is, therefore, an apt time to revisit the public policy even in the face of profound disagreements (about, for questions surrounding assisted death, in the light of example, the values of autonomy and life), it is possible – new evidence and arguments. In 1995, a majority of the and indeed necessary – for those involved in the conver- Special Senate Committee on Euthanasia and Assisted sation to listen carefully to all positions presented and to Suicide recommended continuing to treat euthanasia as work together to find a policy position consistent with the murder (albeit with a lesser penalty), and the assisted core features of Canada’s parliamentary democracy and suicide provision in the Criminal Code.7 Would a careful our Charter of Rights and Freedoms.8 The Panel hopes consideration of these issues in 2010 come to the same that, through this conversation, all stakeholders will find conclusions? common ground to respond better to the wishes and In order to address this question, and to both catalyze needs of Canadians at the end of their lives. and contribute to a process of public reflection on these critically important public policy issues, the Royal 2. Terminology9 Society of Canada established the Expert Panel on End of Life Decision-Making (RSC EOL Panel) with the follow- It is particularly important to define the terms employed ing objectives: in discussions about assisted death. Frequently people discuss these issues at cross-purposes, using the same 1. There is a large body of medical science evidence term to describe different practices or using different that, if summarized for the public, would be helpful terms to describe the same practice. This often leads to to their consideration of the issue. unnecessary and unproductive confusion and conflict. As 2. The public could also benefit from a presentation of there are, by necessity, no objectively true definitions of evidence about actual experience from the various the terms needed to discuss assisted death, the Panel jurisdictions that permit physician-assisted death. stipulates the following definitions for the purposes of 3. The public would also benefit greatly from having a this Report: careful, balanced review of various pros and cons of decriminalization of physician-assisted death from • ‘Withholding of potentially life-sustaining treatment’ is well-reasoned ethical and legal standpoints. the failure to start treatment that has the potential to 4. Many medical personnel would also benefit from sustain a person’s life. An example is not providing having all the issues laid out in a comprehensive and cardiopulmonary resuscitation to a person having a sensitive way. cardiac arrest. 5. The Panel should consider proposing policy recom- • ‘Withdrawal of potentially life-sustaining treatment’ is mendations for public consideration that are the stopping treatment that has the potential to sustain results of its review. a person’s life. An example is the removal of a venti- The members of the RSC EOL Panel were experts in the lator from a patient with a devastatingly severe head following areas relevant to the issues the Panel was tasked injury after a motorcycle accident with no prospect of to address: bioethics, clinical medicine, health law and improvement. policy, and philosophy. • ‘Advance directives’ are directions given by a compe- The members of the Panel met in person and con- tent individual concerning what and/or how and/or ducted business via e-mail and phone. Panel members by whom decisions should be made in the event that, brought their own expertise and experience to the project at some time in the future, the individual becomes and additional research was conducted as required. incompetent to make healthcare decisions. An Drafts were circulated and edited through a collaborative example is a woman who has signed a document that and iterative process. states that, should she fall into a persistent vegetative This document presents the unanimous Final Report state, she does not wish to receive artificial hydration of the RSC EOL Panel. The Panel trusts that it will serve or nutrition. Or, as another example, a man who as a marker for the beginning of a new conversation has signed a document that states that, when he is about end-of-life law, policy, and practice in Canada. The Panel notes that the conversation will require mutual 8 Canadian Charter of Rights and Freedoms,PartIoftheConstitution attention and respect and acknowledges the many impor- Act, 1982, being Schedule B to the Canada Act 1982 (U.K.), 1982, c.11. tant interests at stake and values in play. Passions run 9 These definitions are drawn (and sometimes modified) from Dying deep in discussions about end-of-life matters. However, Justice: A Case for Decriminalizing Euthanasia and Assisted Suicide in Canada.Toronto: University of Toronto Press, 2004 at 6–7 and Canada, 7 Canada, Special Senate Committee on Euthanasia and Assisted Special Senate Committee on Euthanasia and Assisted Suicide, Of Life Suicide, Of Life and Death – Final Report (Ottawa: Special Senate and Death – Final Report
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