Montreal, March 16, 2023 - Bill 11, the Act modifying the Act Respecting End-of-Life Care, along with other legislative provisions presented February 16, 2023, by Quebec Health and Seniors Minister Sonia Bélanger, obliges us as Quebec citizens and Catholic bishops practising our ministries throughout this province to speak out today on this question which is of the utmost importance.
End-of-life care is an issue that involves our society, regardless of our beliefs: As the debate on Bill 11 begins in the form of a parliamentary commission, we wish to take this opportunity to present our own questions concerning the present situation.
1. What level of importance should be given to palliative care?
Our position on end-of-life care is well known. Along with many of our fellow citizens, both non-believers and believers, we maintain that every human being possesses an inviolable dignity. On these fundamental grounds, we vigorously support any and all advocacy and measures, the purpose of which is to improve access to good quality palliative care, particularly in the home, in all regions of Quebec. Accessible palliative care is essential in order to assist persons to live their last moments in decency and dignity.
Considered against the demographic backdrop of our aging population, it is imperative that every resource necessary be invested by Quebec society so that each person may approach his or her last days free of anxiety caused by the threat that any care to which they have access will depend on their socioeconomic circumstances. Moreover, we recommend that particular attention be given to the care provided to the most vulnerable, the most in need and the most isolated. We would thus be able to reassure those who dread becoming “a burden” on their loved ones or society on account of age or illness.
Quebec long ago and quite courageously opted to institute a public health system that was both universal and free. This was a priority for our society. Our elderly, like all of our fellow citizens, have worked all their lives to secure this system, and it is only fair that that same system should in its turn support them when the time comes for the inevitable passage which is death. The work of repairing the health and social services network must therefore be undertaken conscientiously.
We reaffirm the primacy of a health system that is public, universal and free of charge, so that our fellow citizens are not forced to opt for hastening death out of fear, based on a lack of resources, of being subjected to living conditions - and end-of-life conditions – deemed to be degrading. Is such a choice not solely determined by factors outside the individual’s control, as opposed to being an autonomous decision? How can we be assured that this choice is not merely another of the “false choices” becoming commonplace in present-day Quebec?
Viewed in this way, the concern expressed recently by the Commission about end-of-life care in terms of the “popularity” of medical assistance in dying (currently accounting for 7% of deaths in Quebec) should be taken very seriously and should indeed form the basis of an in-depth investigation that comprises an examination of the sociological dimension. Let’s not forget the obvious fact that simply because “medical assistance in dying” is legally condoned does not impel anyone to have recourse to it.
2. Why do we continue to draw the distinction between “palliative care” and “medical assistance in dying?”
Our conception of the inherent dignity of every human being makes it impossible for us to accept the reasoning behind Bill 11 as a whole. We do not agree that medical assistance in dying constitutes “health care.” We are aware that, in the current context, our voice in this matter is practically inaudible. That being said, we hold that any action which intentionally induces the death of a human being is in fact a denial to provide him or her the potential end-of-life care that he or she required. Such intevention cannot be termed “care.” Perhaps countries where the intervention is still referred to as “euthanasia” have a stronger claim to integrity.
It is important that those elected representatives and advocates who are most vocal in their support of Bill 11 should realize that consensus around this question in no way represents unanimity. It is therefore imperative that any person employed in providing care shall be permitted, without fear of reprisal, to refuse, on conscientious grounds, to participate in the injection of substances intended to cause the death of a person who has asked to have his or her life terminated.
Bill 11, section 9, states that palliative care hospices may no longer exclude “medical assistance in dying” from among the services they provide. This would force a palliative care hospice to hire new staff, if all its employees had chosen this work precisely for its palliative approach. Why not let each hospice decide which types of care it provides since, as we know, these facilities are already required to advise every incoming person about the care options available to her or him? At the very least, the proposal in the previous bill, introduced in the spring of 2022, that the Minister of Health authorize exceptions for certain hospices should be revisited. In this case, the criteria that could justify such an exception should also be specified.
3. What are the impacts of expanding access to medical assistance in dying?
On the basis of these considerations, two other provisions of Bill 11 are of particular interest to us: the possibility of making an advance request for medical assistance in dying following the diagnosis of a disease that could lead to incapacity, and the possibility that persons with a severe and incurable neuromotor disability may make a request for medical assistance in dying. In both cases, we are sensitive to the suffering of the persons concerned.
At the conclusion of the Special Commission on the Evolution of the End-of-Life Care Act in October 2021, we wrote a letter to the Commissioners addressing the issue of including euthanasia in advance medical directives. Our position remains unchanged. We continue to believe that there are limits to "transposing" ourselves into a hypothetical situation that is not yet our own, and may never be. Each person lives the present moment in their own way, in the grace of the moment. If we are facing the possibility of a disease like Alzheimer's today, for example, we will react with our mindset today. We cannot know, however, how we will experience the condition when we do, if indeed we have to experience it.
The possibility that people with severe and incurable neuromotor disabilities may ask for their lives to be ended seems to us to follow the formidable logic of the gradual but constant expansion of access to euthanasia. Let us remember that these people have a dignity equal to that of all others and that their increased vulnerability must lead us to be particularly vigilant and benevolent with respect to their access to quality care and effective accommodation measures, including subsidies for the purchase of specialized equipment and support for family caregivers. Otherwise, we risk sending a troubling message to these individuals that their lives are not worth living.
The recent suggestion that Canadian Armed Forces veterans take their own lives in cold blood shows that we are facing a trivialization of euthanasia in the current discourse. In this context, we invite all individuals and organizations who will speak out on Bill 11 to carefully consider the impact that their words may have on people who are currently living with symptoms that, according to the legislator, would justify a request for medical assistance in dying. Is this trivialization destined to increase, despite the reminders of the Commission on End-of-Life Care that recourse to medical assistance in dying should remain "exceptional"? Is it not becoming a new norm?
The "slippery slope" often mentioned in relation to the expansion of the law is not an exaggerated fear; it is an observable phenomenon, as the issue of medical assistance in dying in Quebec and elsewhere rightly demonstrates. The fact that the end-of-life criterion is no longer a condition for applying the provisions of the Act concerning end-of-life care clearly demonstrates that the very framework for reflection is changing radically. Shouldn't the title of the Act be changed? From a palliative care perspective, whose overall approach is based on comfort care, intervention is not limited to the last moments of life. This could be emphasized, especially to health care personnel. In addition, we recommend that the part of the law that deals with medical assistance in dying be referred to as euthanasia legislation.
4. How do we discuss our relationship to death?
At the present time, the main criterion put forward by the legislator to promote the expansion of access to medical assistance in dying seems to be the evolution of the political and media consensus, which is said to reflect an evolving social consensus and medical consensus. Thus, with regard to the possible inclusion of mental disorders in the diagnoses that could be used to request medical assistance in dying, the hesitation of elected officials at present seems to be based solely on the "temporary" non-existence of a consensus deemed sufficient on the issue. However, this issue is nevertheless regularly and increasingly on the agenda. In so doing, will the justified fears expressed from the outset by several stakeholders about the deleterious effects of legalizing euthanasia on suicide prevention efforts not be increasingly ignored, despite the scourge of the desire to die in our society, particularly among young people in vulnerable communities?
In such a singular context, we are justified in questioning ourselves. How can we escape the logic of limitless expansion, if not by returning to a deeper reflection on fundamental principles such as the unalterable dignity of every human person from birth to death?
We believe that it is our responsibility to speak out, in the name of our values and our hope, on the issue of end-of-life care, constantly reminding ourselves of the dignity of all persons and of the increased benevolence that any society must show towards the most vulnerable. We must not hesitate to listen to the voices that oppose a bill like this one, especially when a sense of consensus can obscure the many nuances and disagreements that persist on such vital issues.
