By Marie-Andrée Chouinard

Editorial. February 18^th, 2023

With the introduction this week of Bill 11 on medical assistance in dying (MA), Quebec is continuing a tradition of changes proposed on the basis of wise expertise and prudence, all for the good of suffering people who wish to die with dignity. By extending the eligibility criteria for end-of-life care to people whose condition will not allow for free consent at the very end of life, we are about to take a major and necessary step.

Since 2009, Quebec has been almost exemplary in its reflections and development of legislation governing access to MA. The Minister for Health and Seniors, Sonia Bélanger, is following a path laid out by solid precursors from other parties. She seems to want to maintain a non-partisan line in the pursuit of exchanges. This is salutary. Questions of life and death are above any political duel.

The law’s clear guidelines and founding notions of respect and empathy have encouraged Quebecers to use the MA. In 2021-2022, 5.1% of deaths in Quebec are associated with MA, making it a champion state in the world. Bill 11 corrects an important inequity. People with degenerative diseases could not apply for MA because of the mandatory “end-of-life” criterion. This criterion required applicants to be absolutely at the point of death, which was purely impossible for these patients. This salutary correction is the logical and sensible follow-up to the judgment rendered in 2019 by the Quebec Superior Court in response to the lawsuit led by Nicole Gladu and Jean Truchon.

Requested by the Court to do so, Quebec is opening the door to allowing certain people burdened by certain conditions – the list is not provided, but Alzheimer’s disease comes to mind – to make an early application for MA. Among other advances included in the bill, we should also note the possibility for people suffering from a serious neuromotor disorder to be able to do so. This will, of course, be the subject of consultation and dialogue during the detailed study of the bill, but this is a rich subject for study.

The prohibition on all hospices and private hospitals refusing to provide MA, which unfortunately still occurs in a minority of places, should also be given serious consideration. Minister Bélanger reported Thursday that very ill patients still had to be transported by ambulance to a place where their request will be granted, because they did not get the green light where they were.

However, Quebec has closed a door that the Quebec College of Physicians would have liked to open: access to the MA for people whose only condition is a mental disorder. This is an incredibly delicate and complex issue, from the need to obtain informed consent when making such a crucial decision to the importance of not substituting a request for MA for suicidal thoughts. In the just-released second report of the Special Joint Committee on Physician Assistance in Dying – Physician Assistance in Dying in Canada: Choices for Canadians – the federal government maintains that it is not ruling out this possibility, but it is asking for more time to conduct a detailed analysis. Ottawa announced just before the holidays that it would delay the expansion of Canada’s MA regime in order to carefully consider the pros and cons of this specific group of candidates.

Quebec is not ready to venture into this minefield. It therefore agrees with the recommendation made in December 2021 by the Special Commission on the evolution of the Act respecting end-of-life care, which stated that it did not want to enter this field, in the name of a precautionary principle. “We believe that the risks associated with extending access to medical assistance in dying to people whose only medical problem is a mental disorder would involve too many variations and could therefore not be closely controlled,” the Commission wrote. The experience gained in Quebec since 2009 has shown that time and reflection sometimes change perspectives, even on seemingly unfathomable ethical issues. Perhaps this will be the case here too.

Let us not let all this debate about medical aid in dying deprive us of thinking of all the others, all those who will not choose MA for a way out, but who should have the right to quality palliative care that is easy to obtain. The tragic end of Andrée Simard, widow of former Prime Minister Robert Bourassa, who died after three days of terrible suffering without having access to the palliative sedation that she requested, is unfortunate proof that this crucial sector of end-of-life care must not be neglected in terms of resources. It is also a question of dignity.

Translated by DeepL and validated by Michel Virard