‘Nothing about this felt OK’: The troubling debate over a ‘good’ death for all

As a doctor, killing patients has long been taboo. Ferrukh Faruqui examines the ethics of extending eligibility for euthanasia — MAiD — to those who are not dying

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Ferrukh Faruqui is an Ottawa physician and freelance writer who’s fascinated by the ethical quandaries that confront modern society. In this essay, she examines how expanding eligibility for medical assistance in dying (MAid) to those with non-terminal conditions has thrown the medical community into civil war. Some doctors are passionate defenders of a patient’s right to choose when to die. Others are just as passionate that it goes against a doctor’s purpose to preserve life. 

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He left soon after breakfast on a July morning. The 26th was warm, with a few clouds drifting high. Alan Nichols, gaunt and bearded, wore a green hospital gown. His sister-in-law, Trish, remembers sun glinting off the room’s yellow walls. Through the billowing white curtains, they could see three storeys down to the parking lot of the Chilliwack General Hospital.

Alan was livid that morning in 2019, recalls his brother, Gary. He was yelling at the doctor, “This is my moment! If you can’t do it here, then get me to someplace that can!” Later, gesturing to Gary and Trish, he blew up again, shouting, “We’re not even the same blood!”

Trish turned to his doctor, asking, “This is a sound mind?” The doctor soon left the room. They didn’t see her again.

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Nurses chattered in the corridor. A medication cart rumbled by. Trish and Gary gazed wordlessly at Alan perched on his bed. A few days before, he’d removed the cochlear implant from his right ear. He refused to talk to them. Only the beeping of his IV line broke the room’s silence. Their eyes burned dry. They’d done most of their crying already, wondering how 50 years of looking after Alan could end without their consent, authorized by hospital staff they’d never met.

The two brothers had spent the previous day together, sharing meals, walking and talking. As a young man, Alan had worked for Cannor Nurseries, where he was a proud member of the Bulb and Burlap crew. That’s where he’d met his close friend, Bob, whose climbing death hit Alan, a lifelong bachelor who struggled with relationships, hard. He suffered another blow in 2004 with the death of their father. During their visit, Gary told Alan that if he wanted, Gary could retire and move back home from Edmonton to be close by. Alan had answered, “I wish I would have known that.”

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“We were numb. It was like a dream,” Gary recalls. A nurse got emotional. She had to leave the room. After the first of three intravenous injections Alan slipped into sleep. He was dead 15 minutes later.

* * *

From left, Alan Nichols, in his 30s, with his sister-in-law, Trish, and brother, Gary.
From left, Alan Nichols, in his 30s, with his sister-in-law, Trish, and brother, Gary. Photo by Courtesy Nichols Family

Alan was once “a bloody great goalie,” says Gary. But he faced a lifetime of challenges after his first brain surgery for a benign tumour at age 12 left him with a weak right side and hearing loss. Step by step, he learned to grasp a pencil and write with his left hand before completing high school.

Alan gave up hockey and picked up a Pentax camera instead. He became a loner who shot film, including beautiful prints for his parents’ silver wedding anniversary. He worked for years as a janitor before things got bad.

As an adult, he depended on his family for emotional as well as practical support. Once, when he didn’t show up for dinner and refused to open his door, they called a locksmith. When they rushed inside, they found him waiting in bed. “I knew someone would show up,” he said.

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He was suspicious of authorities, refusing to accept his disability cheques. The family tried unsuccessfully to obtain guardianship over his affairs. His brother, Wayne, picked him up weekly to buy groceries and do his banking.

In June, alerted by his neighbour, Sharon, RCMP officers found Alan dehydrated and delirious. They quickly transported him to the hospital, where he was admitted under the Mental Health Act. Gary flew out to Chilliwack immediately. He was concerned but figured things would play out as usual — it wasn’t the first time Alan’s baseline depression plummeted and landed him in hospital. But he always got better, returning to his small, sparsely furnished condo, where Sharon kept an eye on him.

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This time, things ended differently.

* * *

They killed our brother

Wayne Nichols

After five days in the psychiatric unit, Alan was discharged to the regular ward. Uncharacteristically, he refused to see or speak with his family. When reached by phone, staff assured them he was improving. On July 22, a doctor called Gary to say that Alan was scheduled to die in four days by medical assistance in dying.

Gary started to cry. How could a suicidal man who’d been involuntarily admitted be eligible for MAiD? He wasn’t facing imminent death. Despite the family’s pleas, the hospital insisted this was Alan’s decision, that his medical records were confidential, and they were lucky that Alan had grudgingly agreed to let them know.

A few days later, Gary and Trish, who’d spent decades helping Alan live, watched him die.

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A year later, despite getting legal advice and pressing the hospital and coroner for answers, they’re no further ahead. The Fraser Valley Health Authority told them the law doesn’t require patients to be actively dying to be eligible for MAiD.

Gary’s not a rich man and lawyers are expensive. He says he’s haunted by how families are shut out of these crucial decisions. He says Alan could have lived longer, that the system erred terribly. When he called Wayne to tell him what happened, Wayne was stunned.

“They killed our brother.”

* * *

Gary Nichols’ grief demonstrates the heartache medical assistance in dying can inflict on family members. For many doctors like myself who’ve sworn to uphold life, decriminalizing the deliberate act of ending a patient’s life is an ethical turning point that’s transformed the very nature of the profession.

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In 2015, the Supreme Court unanimously ruled that the prohibition of physician-assisted death was unconstitutional. Parliament responded by enacting 2016’s Bill C-14, which allowed doctors to euthanize competent adults with a severe, irremediable condition facing a reasonably foreseeable natural death (RFND). Parliament also promised to delay any new legislation until completion of a June 2020 review — not just of MAiD, but also of woefully underfunded mental health and palliative care — a review that never occurred.

Some doctors applauded the legislation as a logical progression based on societal values of personal autonomy. Others feel that their personal perspectives are immaterial; that the law is the law and we’re bound to follow it. Family members have publicized the “good deaths” underwritten by individual agency. Well-intentioned MAiD providers have published heartfelt accounts of helping patients achieve such deaths. The overriding narrative is that physician-assisted death — what Europeans call euthanasia — is not only a done deal, but a societal good.

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But that’s not the whole story.

Doctors expressed their concerns in private forums but most — apolitical, sensitive to charges of paternalism and afraid of being labelled unprogressive — were reluctant to speak publicly. Soon, another high-stakes court case upped the ante. Plaintiff Jean Truchon, who was confined to a wheelchair by debilitating but non-fatal cerebral palsy, enlisted the support of Dying with Dignity Canada (DWDC) to challenge the law. In 2019, the Quebec Superior Court ruled that the RFND provision violated his charter rights. Worried disability advocates feared this ruling would pressure those with chronic but non-terminal conditions to request death. They urged the federal government to appeal.

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Instead, the Liberals introduced Bill C-7, which stakeholders say is a different beast altogether. It doesn’t just amend C-14. It redefines medical aid in dying to permit death for those who aren’t dying by eliminating the RFND clause. It also removes safeguards such as the 10-day reflection period. Instead of two independent witnesses to corroborate MAiD requests, only a single witness, be it a medical professional or paid caregiver, is needed. Critics warn such changes leave vulnerable patients open to coercion by the unscrupulous.

Bill C-7 was signed into law in March 2021. DWDC is petitioning lawmakers to expand MAiD eligibility for mature minors and honour advance requests from those with dementia. The Senate hastily added a sunset clause to permit those with sole psychiatric illness to qualify by March 2023. Parliament has already begun to study these expansions to the law.

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The new law allows non-terminal patients 90 days to secure needed specialist care. Doctors say inadequate health resources make this care nearly impossible to obtain. Other stakeholders charge that the law stigmatizes the disabled by assuming that a life with disability isn’t worth living. In contrast to other jurisdictions, patients can decline available treatments before opting for death.

For millennia, it’s been taboo for doctors to kill their patients. In many places it still is. As western societies hurled off the shackles of religious authoritarianism, an ethical void was created. This gap’s been filled by humanist creeds that teach that the greatest good flows from personal independence. This libertarian ideal posits the individual as the master of his universe, however lonely that universe may be.

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Canada’s Charter of Rights and Freedoms guarantees a litany of expanding rights, which now include the right to die at a time of one’s choosing. As of 2020, MAiD accounted for nearly 22,000 deaths nationally.

The mainstreaming and precipitous expansion of MAiD over just six years has intensified unexamined moral distress in physicians, says Dr. Leonie Herx, the Division Chair of Palliative Medicine at Queen’s University. This secrecy doesn’t surprise anyone in a profession where stoicism is a cardinal virtue. MAiD to MAD is an online statement signed by 1,486 Canadian physicians opposed to Bill C-7. She says hundreds more won’t sign publicly for fear of professional repercussions. Some doctors pulled back from providing MAiD even before C-7 was tabled. Some, like Dr. Natalia Novosedlik from Scarborough, Ont., left palliative care, where the increasing pressure to consider MAID an option in routine end-of-life care caused emotional fallout for many practitioners.

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Canada decriminalized abortion in 1988. It’s an emotionally loaded topic no one will talk about.

MAiD, which targets living people outside the womb, not fetuses, is even more explosive. Perhaps that’s why there’s been so little honest dialogue around it. Yes, MAiD answers the call for ultimate control, but at what cost? Now that we’ve upended the ancient social contract between doctors and society, let’s contemplate what we’ve lost — the sense of connectedness that comforts and gives meaning to life’s most anguished moments.

* * *

What happens to doctors for whom a deadly injection becomes a monthly routine?

Boudevijn Chabot

The progressive Dutch legalized euthanasia for adults in 2002. Before this, doctors who euthanized willing patients weren’t prosecuted. In 2020, Dutch legislators extended eligibility to terminally ill children under the age of 13. They’re also mulling a “completed life” track, to permit death for those who believe their lives are concluded.

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Psychiatric euthanasia, which allows death for mental distress, has even the phlegmatic Dutch concerned. The data shows a steep rise in these cases. Personality disordered and autistic patients have been euthanized. The trend worries Dutch psychiatrist and pioneering euthanasia provider Boudevijn Chabot, who asks, “What happens to doctors for whom a deadly injection becomes a monthly routine? They are surely well-intended, but do they realize how they are fanning a smouldering fire that can become a blaze because they fuel the death wish of vulnerable people who are still trying to live with their disabilities?”

* * *

Dr. Sonu Gaind is troubled, too. A professor at the University of Toronto, he’s not a conscientious objector. In fact, at the Humber River Hospital where he’s head of psychiatry, he’s the physician chair of the MAiD committee. He emphasizes that he’s speaking on his own behalf as an individual psychiatrist.

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Pretending there’s no difference between physical as opposed to mental illness for the purposes of MAiD borders on “delusional,” he says. He can’t fathom why the statement of the Canadian Psychiatric Association, which declares that excluding access to MAiD for mental illness is discriminatory, makes no mention of the troubling suicidality that characterizes untreated psychiatric illness.

Language crystallizes key concepts of sweeping movements that reshape societies. But it can also mislead and flatten knotty issues such as euthanasia. Terms like discrimination and autonomy become missiles, annihilating debate. Offering death to the mentally ill, whose unique symptomatology includes pathological despair, is both illogical and unjust.

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Gaind’s Senate testimony emphasized psychiatry’s essential incompatibility with the “irremediable” element of the MAiD framework. Society should recognize and address this contradiction, he insists. Doing otherwise is an exercise in obfuscation. Cardiologists know how heart disease works. But psychiatry hasn’t elucidated the pathophysiology of depression or schizophrenia. It’s impossible for clinicians to predict prognosis in individual cases, meaning that some who seek death would have gotten better.

He cites metrics that show a demographic divide. Those terminal patients who’ve lived a good life and have the privileged autonomy to choose a “good” death are overwhelmingly white and affluent. Unfortunately, their rights magnify the vulnerability of those who’ve never had a good shot at life. In the Netherlands, those marginalized by poverty and trauma are the ones seeking psychiatric euthanasia. Of these, 70 per cent are women. Gaind says these sad, lonely individuals need suicide prevention, which costs time and money and is mostly unavailable. Instead of the “right to die,” he wants to legislate the “right to live.” As for personal choice, he calls it a cruel fallacy. Guaranteed access to death in the setting of absent mental health treatment is no choice at all.

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“You shift to MAiD to avoid a painful death — then you shift to MAiD to avoid a painful life. It’s like a Jenga tower — when you pull out one block, the tower comes tumbling down. It’s all connected.”

In challenging the CPA’s position on psychiatric MAiD, Gaind says he’s articulating what most of his colleagues are afraid to express. The fallout is real. A respected colleague who refused to attend Gaind’s presentation on MAiD requested nevertheless that his displeasure with Gaind’s invitation to speak be read out to the audience. Most recently, he’s learned that the CPA board is seeking to suspend his CPA membership, citing his comments as being “damaging to the reputation of the organization.”
There’s a steep price to be paid for voicing dissent.

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* * *

Nothing about this felt OK. It felt like putting a dog down.

Jayde Curts

Jayde Curts’s long hair frames her sombre face. One November afternoon in 2020, she sat alone in her London, Ont., living room, cut off from the rest of her family. She heard the clock strike one. She remembers thinking, “I guess my grandpa’s dead now.”

She refused to attend his scheduled death by MAiD. She says her mother wouldn’t discuss it afterwards, while her grandmother isolated herself and refused to talk about it. Jayde says it didn’t feel right.

“Nothing about this felt OK,” she says. “It felt like putting a dog down.”

Her grandfather, Arthur Cole, was in his 80s. During surgery for thyroid cancer, doctors discovered it had spread. After being discharged home with a tracheostomy and without home care, his elderly wife had trouble managing the breathing tube. When the cancer spread to his brain, he requested home palliative care but was told it wasn’t available. Instead, a doctor offered to make a house call to administer MAiD.

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His granddaughter says Arthur worried aloud about burdening his family. Post-surgery, breathing through a tube, Jayde questions his psychological competence to make the critical decision to end his life.

“You read about this in the news. But it’s shocking when it happens to your family,” she says. She’s paid a heavy price for her outspokenness. She no longer speaks to her mother or her grandmother. She regrets the estrangement but stands by her conviction that the medical system blundered badly.

“They played on his emotions … He was vulnerable and it feels like they took advantage of him,” she says. She wonders why the health system offered death instead of help. She wants people to hear Arthur’s story so other families can speak up, too.

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* * *

Dr. Balfour Mount is the retired father of Canadian palliative care. He lives not far from the gothic towers of Montreal’s Royal Victoria Hospital, where the surgical oncologist established the new specialty after being taught hospice care in the 1970s by Dame Cicely Saunders. The British physician pioneered whole-person care of patients the profession discarded as medical failures. Her revolutionary approach addressed each facet of an individual’s pain.

“Total pain” encompasses suffering across dimensions, especially the spiritual, where conventional medicine falters. Palliation supports patients through the arc of incurable conditions such as multiple sclerosis and heart failure. Mount believes the simple act of being present soothes existential pain and chases dread away, that once we slow down to appreciate each moment, the end of life holds infinite potential for joy. He once explained, “When pain and other symptoms are controlled, there really is limitless potential for quality of life at the end of life. … It’s not about ending things; it’s about the present moment. That’s all that any of us have — is just now. And, it turns out, that there’s endless potential in the present moment.”

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He calls MAiD a euphemism that confuses the public and muddies both the benefits of palliative care and the reality of euthanasia. He’s endorsed a joint statement by the Canadian Society of Palliative Care Physicians and the Canadian Hospice Palliative Care Association that rejects conflation of the respective practices, which are distinct in philosophy and intent. The latter exists purely to hasten death, while the former focuses on enhancing life.

Fewer than 30 per cent of Canadians have palliative care access, whereas 90 per cent could benefit from it, according to the McMaster Health Forum. In contrast, MAiD is enshrined as a health right, accounted for 2.5 per cent of deaths in 2020 and is universally available. The 2017 National Framework for Palliative Care in Canada notably tied zero funding to its action plan.

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A coalition of faith groups, including various Christian denominations, rabbis and a national council of imams, released a statement denouncing Bill C-7. These unapologetic theists affirm that society can’t abandon the suffering. They specifically endorse palliative care.

* * *

Dr. Leonie Herx is waiting for an appliance repairman to show up. She sports spiky, unfussy hair and is the mother of five children, one with special needs. She misses skiing the peaks that surround Calgary. Since relocating to Kingston, Ont., her family kayaks the lakes and rivers pulsing around the university town.

“We’ve come so far in palliative care,” she says, adding that many patients either fear palliation will accelerate their deaths, don’t realize MAiD is a lethal injection, or both. She laments that even colleagues don’t appreciate how effective early palliation can be. Because of its absence from the conversation, too many patients opt for MAiD instead.

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As a board member and past president of the Canadian Society of Palliative Care Physicians, she submitted Senate briefs on Bill C-7. She says Bill C-14 was flawed, but the new law goes beyond removing RFND to fundamentally alter how Canadians view death. She feels the value of life is being diminished, especially lives challenged by physical or mental deficits.

Herx attributes rapid expansion to the ideology of groups like DWDC. Reducing two independent witnesses to someone who’s part of the health care team opens the door to coercion, which is impossible to detect if the family is legally shut out of discussions.

She reminds me there’s no proper MAiD oversight, that the now eliminated reflection period was designed for patients who might change their minds, not for those who are adamant about dying.

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She’s withstood relentless attacks on her professional integrity by other physicians. She’s weary, despairing even as she wades into dangerous waters, citing hospital colleagues who complain they’re pressured, even bullied into going along with policies that trouble them. Doctors across the country call her to report that some MAiD providers refuse to assume transfer of care as the “most responsible physician,” thereby implicating them in a practice they are philosophically opposed to. Some institutions, perhaps lacking sufficient MAiD providers, even expect the MRP-conscientious objectors to conduct the initial MAiD assessment. All worry about professional ramifications. Some who’ve voiced doubts about MAiD in certain clinical scenarios have been called obstructionist, of trying to block access to a legal service. There’s no protection for whistleblowers. She knows of many doctors who’ve left the specialty or retired early. Her colleagues know of more. Some have left medicine for good. But they’re not talking. Few were willing to speak to me.

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Herx warns that the implications of C-7, which expands MAiD from terminal to chronic conditions, will fan out to involve doctors across specialties. This tightening of the moral screw will likely precipitate more departures from the profession. With effective referral, mandated in only two provinces — Ontario and Nova Scotia — the pressure on these doctors to participate may become unbearable.

She describes the loss of moral integrity, “which is how we keep our resilience in medicine.” Dispensing with medical care to offer MAiD amps up moral distress. Herx speaks almost dispassionately about how she might have to quit medicine to avoid complicity.

“If I had to leave medicine, I’d regret not doing everything I could do to raise awareness,” she says. Palliative care emphasizes relational autonomy, the connectedness that affirms meaning even at the end, when all seems lost. She considers the families shamed into silence when MAiD is touted as the panacea to suffering.

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“There’s a lot we don’t know about the complicated nature of grief,” she tells me.

* * *

Dr. Karen Ethans directs the Spinal Cord Unit at Winnipeg’s Health Sciences Centre, following spinal cord injury (SCI) patients over their lifetimes. She’s witnessed some individuals counselled to die before they have a chance to live.

“My biggest concern,” she says, “is that people can’t initially see what their quality of life will be once they’ve adapted to their injury.”

It takes six months just to get out of the hospital, to go through denial and grief. Then comes vocational rehabilitation. Patients on ventilators within a week of injury are sometimes told their quality of life as quadriplegics will be poor, to turn off their breathing machines. One young man’s weeping mother followed Ethans outside the intensive care unit, looking for hope. Four months later, her son walked out of the hospital.

“Why does it have to be doctors involved in giving death serums?” she asks. Many of her colleagues are angry. They believe doctors should not be doing this work.

* * *

From left, the Nichols family: Wayne, parents Betty and Alex, Gary and Alan, when he was in his 30s.
From left, the Nichols family: Wayne, parents Betty and Alex, Gary and Alan, when he was in his 30s. Photo by Courtesy Nichols Family

Gary and Trish lived in Chilliwack for years. It used to be home. He describes how empty he felt when Alan’s body collapsed into lifelessness. The couple couldn’t understand what had happened. They stumbled out of the hospital, climbed into their beige 2007 Toyota Corolla and drove the 11 hours straight back to Edmonton.

After the numbness wore off, the hurt set in, uneasy layers roiled by a gathering rage. Gary says that Alan wasn’t of sound mind, that his case warrants a thorough review. He’s bewildered by how patient confidentiality can trump common sense, bypassing grieving families in life-and-death scenarios such as MAiD.

Each institution they’ve appealed to for a review of Alan’s case denies jurisdiction. That includes the RCMP, the coroner’s office, the provincial and federal ministries of health and B.C.’s College of Physicians and Surgeons. Doors keep slamming shut. “They Ping-Pong you” back and forth, he says.

Immediately after Alan’s death, the social worker advised Gary to move on. A 2020 meeting scheduled with members of Parliament was cancelled, first because of the pandemic, then by the 2021 federal election. The official indifference galvanizes him. He can’t understand how easily, with minimal voter turnout, politicians who come and go with election cycles can enact legislation with such weighty consequences. He’s furious at Justin Trudeau and the doctors given so much discretion over who lives or dies.

* * *

I wait for Dr. Stefanie Green, the head of the Canadian Association of MAiD Assessors and Providers (CAMAP) to phone me. She didn’t give me her number, saying she’d call me. Ten minutes later, she messages me. An urgent MAiD case has come up. She has to reschedule our conversation.

We eventually speak on a wet Christmas Eve as the cobalt lights strung on conifers brighten the damp air and reflect a blue glow in the rain-slicked street outside my window.

She’s impassioned, clearly committed to MAiD and agrees with jurists that C-14 was constitutionally flawed from the outset. Bill C-7 will improve the process, she declares. She applauds the removal of the 10-day reflection period; it only makes patients fear losing capacity to consent. Requiring only a single witness who may be a paid caregiver is “a logistical improvement.” She says, “this is a very smart decision which will increase access.” She believes MAiD providers have the expertise to detect potential conflicts of interest that could compromise a patient’s voluntary assent to MAiD.

She has no quibble with the 90-day assessment period for those who aren’t dying. She says European laws that require patients to exhaust treatment options before receiving euthanasia may be “paternalistic.” Green also believes that “assessment shopping,” where patients who are denied MAiD requests continue to search till they find a willing doctor is rare, and that the law is for “the masses, not for the exception.”

She believes doctors should leave their personal ethics at home. “If you can’t practise medicine because you can’t do an effective referral, then you shouldn’t be in medicine.”

I ask her about allegations of professional pressure to comply with MAiD requests. She says bullied doctors ought to stand up and report this to their college. When I mention power differentials and repercussions, she’s unequivocal. “Yes, there are power differentials, but they have nothing to do with C-7.”

Does she worry MAiD health care savings could sway clinical decisions? Traditional end of life care gobbles up scarce resources. An October 2020 report by the Parliamentary Budget Office projected 2021 net savings from MAiD at $90 million.

“I’m not privy to the economics of MAiD,” she replies.

Are there, in her opinion, circumstances when MAiD would be iffy? She thinks this over. She’s not in favour of a “free-for-all.” She thinks Canadians aren’t ready for the “completed life” stream being contemplated in the Netherlands.

We say goodbye. Later, I find a followup email in which she references other frustrations that may have produced “not her most elegant interview.”

Medical assistance in dying is a fraught topic; there’s often distrust across the divide. When we speak again a year later, after the passage of C-7, Green is contemplative. She describes how non-terminal (Track 2) patients have “created a moral tension” for some CAMAP members. Meeting the criteria is hard. Getting them needed consultation and appropriate treatment is often difficult to do within the minimum 90 days stipulated by the legislation. She can’t give me numbers but does admit that “some people have pulled away from providing MAiD to this subset of patients” while others who agree in principle with the law can’t see themselves doing it.

* * *

On a sunny September afternoon two months after Alan’s death, the Nichols family, along with relatives from Vancouver and an uncle from Fernie, buried Alan’s ashes in Chilliwack’s Little Mountain Cemetery. Gary sent me a final photo taken of Alan in his hospital room. His long grey hair spills out of his baseball cap as he squints through his glasses. He’s flanked protectively by Gary, who continues to mourn his brother’s interrupted life.

* * *

Our lives are cheap because we’re non-contributors.

Elizabeth, 71

Elizabeth is the pseudonym of a retired teacher. She’s 71, divorced and lives alone, far away from her son in the United States. She suffers chronic pain from multiple fractures sustained in a fall 30 years ago.

Elizabeth lays it out for me. She confesses that although she’s a devout Catholic, she plans to seek MAiD once her pain becomes unbearable, or she loses her independence. It’s not that she wants a doctor to put her to death. It’s that she has no other choice. She can’t move to the U.S. because, among other things, she’ll lose her pain specialist. And she can’t ask her son to upend his life for her. She says she’s a member of the growing ranks of the forgotten elderly, dismissed because they’re no longer productive.

“Rights don’t apply to us,” she says. “Our lives are cheap because we’re non-contributors.”

The inequalities in society scare her. She won’t use her real name because she hasn’t told her son yet. He’s an only child. She doesn’t want him to feel abandoned.

* * *

It’s Christmas Day and Dr. Sandy Buchman is on call. He’s the past president of the Canadian Medical Association and primary caregiver to his elderly mother. He’s devoted his life to palliative care. He reflected for a long time before becoming a MAiD provider. He believes it alleviates suffering but understands why most palliative care physicians distinguish between the two practices.

Once he’s addressed someone’s “total pain,” he finds their wish for a hastened death usually, though not always, diminishes.

He discusses C-7. He’s fine with a single witness as opposed to two independent witnesses. He thinks eliminating the reflection period “won’t cause a huge amount of harm.” But he isn’t sure if he could continue providing MAiD if natural death was not reasonably foreseeable. Resuming our conversation after C-7 became law, he’s arrived at his “own ethical boundary,” which is to restrict his MAiD practice to terminally ill patients. He says he thought he was “all alone out there,” but has since discovered other doctors who also refuse to perform MAiD on those who aren’t dying.

I describe Elizabeth, who believes MAiD is her only option.

“No one in this country should ask for MAiD if they can’t get the social and medical supports they need,” he says, sounding sad. He contemplates the gaps in health care resources that condemn the chronically ill to prolonged suffering. The health care savings generated by MAiD, which costs a fraction of traditional care, he thinks, should be reinvested in these supports, especially in palliative care.

His patients hail from various backgrounds. He cites Judeo-Islamic medical ethics that derive from relational autonomy, where patient, family, and community are entwined. Perhaps, he muses, we need to re-evaluate the supremacy of personal autonomy that underpins western philosophy.

So far, he hasn’t regretted providing MAiD. He believes professionalism is one of the finest safeguards against abuse, though he agrees vigilance is needed so that “we don’t cross boundaries.” He thinks over past mistakes made by the profession and repeats, “we can’t let our guard down.”

* * *

Sometimes a picture is painted of MAiD being beautiful. … These deaths were not beautiful.

Dr. Natalia Novosedlik

Recent decades have seen seismic shifts in medicine, but none as game-changing as the legalization of medical assistance in dying. The moral distress Herx cites is real. But it’s hidden away. After C-14, few physicians voiced their qualms. With C-7, the anxiety’s ramped up, but many physicians, worn out by the 24/7 demands of the coronavirus pandemic on top of what they see as steady attacks on their professional integrity are just trying to stay afloat. Backlash against those who oppose MAiD keeps others tight-lipped. Many vote with their feet, by leaving practice or retiring early.

After putting her three children to bed, Novosedlik calls me. She’s soft-spoken but full of quiet conviction.

“I oppose euthanasia in any case.” She says there’s a human need for contemplation, that this bill has been “rushed.”

She pauses. “Sometimes a picture is painted of MAiD being beautiful. The cases I saw — one involved pronounced social isolation — these deaths were not beautiful.”

She felt cornered by a patient who refused symptom management and insisted on a MAiD referral. Although he ultimately died naturally, she was terrified that every new patient would request MAiD. The anxiety was unrelenting.

“I knew I couldn’t do this again, it was so emotionally draining,” she says, so after the birth of her second child, she didn’t return to work.

When care coordination came up, many doctors asked to be taken off the list of providers and assessors. She feels guilty about pulling back, leaving patients to suffer. She hopes to eventually resume practice in a different field.

Dr. Mark D’ Souza left his palliative care practice soon after C-14 was passed, though his departure exacerbated access. His colleagues recognized the opening of a “Pandora’s box,” but administrators couldn’t understand why he needed to leave if MAiD was legal.

He couldn’t square his conscience with MAiD, a term he pronounces “Orwellian,” a form of “doublespeak” that’s critical to what he describes as the marketing of death. He calls such terms euphemisms for what’s really going on, which is “killing our patients,” so he settles for euthanasia, a less inflammatory term. He’s convinced that doctors have lost their way, that the radical left has taken over the profession. There’s an embargo on debating, much less opposing MAiD. He’s not sanguine about the profession, saying we “aren’t leaders anymore.

Doctors are gullible. We’re agents of the government, we’re not independent professional thinkers.”

When MAiD was legalized, Dr. Viren Naik, medical lead of the Ottawa Hospital’s MAiD team, researched military best practices to enhance resilience for providers. Since the enactment of C-7, of the 30 clinicians who provide MAiD for terminal cases, only five accept non-terminal patients. He describes how medically and ethically complex these patients are, and how emotionally taxing for clinicians, who question whether their MAiD requests are driven by underlying illness or vulnerability. He predicts that this exquisite challenge, what he terms “a grey area of practice,” will become more fraught once psychiatric MAiD is factored into the mix.

One doctor, who requested anonymity for fear of professional consequences, stepped away from MAiD before C-7. He says that someone should research MAiD’s effect on doctors and nurses.

No one talks about it after it’s done, he says. There’s “no discussion of tricky cases or retrospective review.” He adds with stunning candour, “I’m pretty senior, so even those dissenting would likely have not confronted me.”

The doctors I spoke to are driven by altruism. Their compassion is compelling. But a number of MAiD providers refuse to offer death to those who aren’t dying. Personal autonomy as the overriding principle in this discourse overlooks the reality that state-sanctioned MAiD is not an autonomous act; involving doctors sanitizes it, makes it more palatable for everyone: lawmakers, patients, and society.

Herx believes the profession is flailing. There’s a “bit of a civil war going on in medicine now,” she says, “a schism” she sees splintering into the future, where two distinct camps might operate in parallel: one that honours the Hippocratic tradition by offering hope and affirming life, and another led by clinicians comfortable with administering death as part of their therapeutic arsenal.

In the headlong rush to satisfy the individualistic need for control, we’ve glossed over MAiD’s practical, philosophical and moral harms. We’re on the cusp of sanctioning the deaths of the most helpless members of society — the mentally ill, children and the elderly — instead of caring for them. That existential nadir, when we’ve outlived our usefulness, is exactly when we should not, cannot abandon each other.

* * *

“We’re in a deep freeze here in Edmonton,” Gary tells me late on a December afternoon in 2021 as he surveys the deer venturing to the edge of his snow-covered acreage.

His family’s faced roadblock after roadblock. But they’re pushing on. The RCMP have opened a new case file. The Nichols family is angry at the way Alan — in equal measures volatile and vulnerable — was dispatched to death. They’re furious at the doctors who approved MAiD and the politicians who enacted the legislation that permits it. He says a lot of people care about this issue, but “so far, there’s been no accountability.” They’re fighting for safeguards to prevent the abuse of patient confidentiality by the profession.

If all else fails, Gary’s considering posting a YouTube video to warn complacent Canadians what can happen to them or their families under Bill C-7.

“We can’t save Alan now, Alan’s gone,” he concedes. “We’re trying to make some noise here to prevent other families going through this.”

After we ring off, he pulls on his jacket against the chill of the winter twilight to feed the hungry deer.



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