DO NOT CAST ME OFF IN THE TIME OF OLD AGE;
DO NOT FORSAKE ME WHEN MY STRENGTH IS SPENT.
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 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 the anxiety arising from 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, those most in need and those most isolated. We could then be able to reassure persons who dread becoming “a burden” on their loved ones or society on account of age or illness.
Long ago and quite courageously, Quebec decided to institute a public healthcare system that was both universal and free. This was a priority for our society. Our elderly, like all of our fellow citizens, having worked all their lives to secure this system, it is only fair that that system should in its turn support them when the time comes for the inevitable moment of their death. The work of repairing the health and social services network must therefore be painstakingly undertaken.
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 intervention 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 previous Bill should be redeveloped, which was tabled in the spring of 2022 and provided for instances where the Minister of Health would be able to authorize exceptions for certain palliative care hospices. In that case, it would be necessary to stipulate the criteria justifying the said exceptions.
3. What are the ramifications of broader access to medical assistance in dying?
Based on these aspects of our reflection, two further provisions of Bill 11 attracted our attention: on one hand, the possibility of submitting an advance application for medical assistance in dying upon receiving the diagnosis of an illness that could lead to disability and, on the other hand, the possibility for persons with a serious and incurable debilitating neuromotor condition to apply for medical assistance in dying. In both cases, we are sensitive to the suffering of the persons affected.
At the conclusion of the special Commission on the drafting of the Act Respecting End-of-Life Care in October, 2021, we forwarded a letter to the Commissioners, in which we addressed the issue of including euthanasia in advance medical directives. Our position remains unchanged. We continue to maintain that there are limits to the individual’s ability to “transpose” him- or herself into a hypothetical situation which has not yet transpired and may perhaps never do so. Every person lives the present in his or her own way, in the grace of the given moment. If we foresee today an eventual situation in which we are afflicted with a disease, e.g. Alzheimers, we will react in accordance with the state of mind in which we are today. However, we have no way of knowing what our reaction will be to that condition once we are in the situation, if indeed we ever have to experience it.
The possibility for persons with a serious and incurable debilitating neuromotor condition to request that their lives be terminated appears to us to be based on the frightening but persistent logic of ever broader accessibility to euthanasia. We must not forget that the dignity of these individuals is the same as anyone else’s, and that their heightened vulnerability should rather induce us to be particularly vigilant and caring with regard to the quality of care they receive and the effective solutions for adaptation that are recommended to them, such as subsidies for the purchase of specialized equipment and the support of natural caregivers.
Recently, the fact that Canadian Armed Forces veterans have been callously counselled to put an end to their lives demonstrates that we are confronting a process of banalization of euthanasia in the current discourse. Given this context, we invite all persons and organizations who will be speaking on Bill 11 to weigh carefully the impact that their words may have on people who are presently living with such symptoms as those which, in the view of the Legislature, would justify an application for medical assistance in dying. Will this process of banalization continue to spread more and more, in spite of the Commission’s reminders about end-of-life care and statements of the fact that seeking medical assistance in dying should remain “the exception?” Is this exception not in fact on its way to becoming a new norm?
The “slippery slope” so often referred to in reference to the widening applicability of the Act is not an exaggerated concern; it is a phenomenon that is being observed, as documented in the medical assistance in dying dossier in Quebec and elsewhere. The fact that the end-of-life criteria are no longer a prerequisite for putting into practice the provisions of the Act Respecting End-of-Life Care indicates how radically the parameters of the discussion are shifting. Should the title of the Act not be modified? From the point of view of palliative care, for which the universal approach is based on attending to the comfort of the patient, the intervention is not restricted to the final moments of his or her life. This ought to be emphasized, and especially with the healthcare personnel. In addition, we would recommend that the section of the Act dealing with medical assistance in dying be redesignated the “Act Respecting Euthanasia.”
4. How can we discuss our relationship with death?
At this time, the main criterion proposed by the Legislature in promotion of broader access to medical assistance in dying seems to be the evolution of a consensus between politicians and the media. That consensus is then supposed to reflect an evolving social and medical consensus. Thus, regarding the potential inclusion of mental illness as a diagnosis on which to base an application for medically assisted dying, the only reserve on the part of the lawmakers appears at present to be the “interim” absence of a sufficient consensus on the matter. Nevertheless, the question reappears on the agenda regularly and with ever-increasing urgency. As a result, what is to prevent legitimate fears from being silenced, fears which since the outset have been voiced by many presenters concerning the negative effects of legalizing euthanasia on suicide prevention efforts, despite the scourge that the death wish represents in our society, particularly among young people who belong to vulnerable communities?
Given the uniqueness of the context, we have every right to ask questions. How can we escape the logic of limitless expansion, other than by conducting an in-depth reflection on fundamental principles such as the inviolable dignity of every human being from birth to death?
We believe it is our duty to speak out on behalf of our values and our hopes concerning the question of end-of-life care, bearing in mind the dignity of all persons and the additional care that every society must provide for those most vulnerable. We must not fail to listen to opposing voices in the debate about a Bill such as this, particularly when the impression of a consensus can silence the many nuances and objections that continue to surround such a vital issue.
Bishop of Saint-Hyacinthe
President of the Assembly of Quebec Catholic Bishops