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MAiD and Modern MedicineMAiD and Modern Medicine

MAiD and Modern Medicine

Two years ago, on June 1, 2016, federal Justice Minister Jody Wilson-Raybould was escorted to her seat in front of Canada’s Senate to explain her government's rationale for Bill C-14, a legislative concoction with a name from a high school chemistry class and the full power to transform Canadian society forever.

Peter Stockland
22 minute read

Two years ago, on June 1, 2016, federal Justice Minister Jody Wilson-Raybould was escorted to her seat in front of Canada’s Senate to explain her government's rationale for Bill C-14, a legislative concoction with a name from a high school chemistry class and the full power to transform Canadian society forever.

The justice minister’s opening remarks were a similar blend of insistence that the bill was a shining example of clarity, reason, and balance while at the same time offering reassurance it would not tie the hands of doctors tasked with killing their patients on request. C-14 married strict safeguards with what Wilson-Raybould, reaching into her velveteen bag of political jargon, called “purposeful flexibility” in the delivery of medical death. 

“It builds in clear statutory parameters around the types of individuals who are eligible (and) was carefully crafted to provide as much flexibility as possible to medical practitioners to determine when and how a person's death has become reasonably foreseeable,” the minister appeared to explain.

What should have been a momentous moment in Parliamentary history became a slipstream of ambiguity, a muddled all-will-be-well juggling act, that reflected the fatal flaw in the legislation. The weakness continues to plague MAiD even now on the second anniversary of its introduction. 

In fairness, the justice minister could have justifiably put up her hands and told the assembled Senators: “It’s not my fault.”

The failures in the actual writing of Bill C-14 are on the Liberals. But the underlying defects caused by the scramble to get it completed to meet a deadline set by the Supreme Court of Canada belong squarely with the previous Conservative government. During the election year of 2015, in the aftermath of the Supreme Court’s decision, the Harper Tories resolutely refused to touch, much less move on, the re-writing of Canada’s laws regarding assisted death.

As one senior operative in the prime minister’s office told me privately: “That issue is not even on our radar.”

Of course, it did not require sophisticated tracking technology to foresee what would follow from the Court’s February 6, 2015 ruling in the so-called Carter case. The outcome of Carter, now known by the anodyne acronym MAiD (Medical Assistance in Dying), was a moment of radical change for Canadian law, medicine, and our common life. For the first time in our history, doctors and patients, not nature and fortune, could legally and precisely fix the appointed time of death.

In Carter, the Court unanimously tossed aside its Rodriguez ruling from 1993. Laws against assisted suicide that were ruled constitutionally valid in Rodriguez were deemed constitutionally invalid by the time Carter rolled around 22 years later. 

Out went the “sanctity of life” relied on by the Court in Rodriguez to uphold existing laws against assisted suicide. In came the Carter criterion of “intolerable suffering” as legal justification for medically administered death. The sheer speed of the change was as unsettling as its revolutionary legal, medical, and moral implications. In mere months, Canada’s long-standing understanding of how life properly ends disappeared faster than a frozen corpse on downhill skis.

No great mystery, there was subsequently enormous pressure on the Harper government to use the Canadian Constitution’s notwithstanding clause to buy time to draft an adequate response to Carter. No dice. There were then calls for a Royal Commission to sound out what Canadians really wanted. Deaf ear. There was pressure on backbench Tory MPs to introduce private members bills to help frame the response. Dead on arrival. 

By the time Justice Minister Wilson-Raybould appeared in Parliament’s chamber of sober second thought, as the Senate is often called, the last call clock was ticking on a Supreme Court-imposed June 17, 2016 deadline to make MAiD the law of the land. B.C. Conservative MP Mark Warawa still fumes when he talks about the committee process that was quickly put together to review the draft legislation. The urgency to pass the bill, he recalls, allowed a heavy skewing toward those who favored medically administered death, and boxed out many of those opposed. He notes, for example, that the Dying With Dignity lobby group had three different witnesses appear at different times before the committee. Yet he was blocked from inviting prominent opposing groups to express their concerns. 

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“When Dying With Dignity showed up a second and third time, I said ‘Hmmm, we’ve already heard from your group. Has your position changed?’ And they said ‘No, we’re here with new information.’ It was the same information reinforced three times. Yet a number of socially conservative experts were not permitted to testify because there wasn’t enough time. It indicated a very strong, very unhealthy bias.”

The result, Warawa says, is deep confusion across the country about what the law actually is concerning MAiD. It’s uncertainty that is exacerbated by a patchwork of provincial regulations, constant pressure from advocates for medically assisted death to remove remaining barriers, and lack of precision in C-14 itself.

“What we have right now has been described as the Wild, Wild West,” Warawa says. “When you have legislation that’s not clear, you get overzealous promoters who try to take it as far as they possibly can, even if that means going over the line. Their defence is always, ‘Well, I thought the law permitted it.…’ If we’re not enforcing the law because we don’t know what the law means, then we’re not acting like a democracy.”

The Langley-Aldergrove MP cites as an example Dr. Ellen Wiebe, a Vancouver-area physician who caused controversy last winter when she went into an Orthodox Jewish nursing home in the city and administered MAiD to an elderly patient despite the facility’s refusal to allow it on the premises. Warawa is incensed that there wasn’t even a criminal investigation into her action, which he believes clearly went “over the line” of what C-14 allows. 

For her part, Wiebe categorically rejects any hint of impropriety. On the contrary, she says, she works within the law to protect the rights of patients to receive MAiD whether or not the facility permits the procedure.

“To me, places don’t have moral rights. Places don’t have consciences, only people do. It’s not just any place. It’s (the patient’s) home. Someone (denying MAiD) is taking (a patient’s) rights away to die in their home. That’s why a place should never have rights.”

But even Dr. Wiebe, a prominent voice for Dying With Dignity and a committed MAiD provider, acknowledges that she often “works at the edge of the law” because the legislation itself lacks specificity. She concluded within the first year of legalization that she would have to rely on her personal best judgement about whether or not to administer death. 

Neither the re-written federal legislation, nor provincial regulations that followed it, define with clarity when a patient can receive MAiD, she says. At the same time, Dr. Wiebe believes wholeheartedly that any mentally competent person who requests medically assisted death for the relief of suffering has a right to receive it. And suffering, she says, is a subjective judgement for the patient to make. 

Dr. Wiebe says when she undertook training in the Netherlands for administering euthanasia, she saw the issue as one of a clear-cut human right to autonomy. Falling back on personal judgement felt paternalistic to her. Leaving it to the personal judgement of some professional authority—even a doctor like herself—felt like interference in a fundamental human right to die when one chose. 

“Then when I started doing it, I realized that I personally must be convinced in each case. I provide what is right up to the edge of the law, and never beyond, of course. I’m working beyond where some providers would work…it varies on how risk-averse people are. We have to submit 17 pages of paperwork, and we are being scrutinized line by line.”

She acknowledges, however, that the line, or edge, has already shifted significantly since she provided her first medically-assisted death in February 2016, four months ahead of the law being changed to make it legal. Part of the challenge is the federal legislation now permits­ (or limits, depending on perspective) MAiD to when death is in the “foreseeable future” but does not clearly define what that means.

The personal definition Dr. Wiebe initially worked from was based on Justice Minister Wilson-Raybould’s testimony to the Senate. Kay Carter, the central figure in the 2015 Supreme Court decision, would qualify under the “foreseeable future” wording, according to the justice minister. 

Dr. Wiebe notes that Carter was 89 when she died, and had suffered from spinal stenosis, a painful though not life-threatening, condition. Her life expectancy would normally have been about five years, she says.

“If that was natural death in the foreseeable future according to our justice minister, then that was good for me,” Dr. Wiebe says. 

Just over a year later, however, in June 2017, Ontario Superior Court Justice Paul Perell ruled in a case called A.B. versus Canada that a 77-year-old who suffered from inflammatory arthritis faced death in the “foreseeable future” and was eligible for MAiD even though, as Wiebe points out, the woman’s life expectancy was about 10 years and she was still an avid hiker. 

Dr. Wiebe says she adjusted her personal judgement accordingly, though she remains “very, very careful” in such cases where pain relief is the primary objective and non-terminal conditions are involved. She is confident the oversight system of the B.C. coroner’s office and the province’s College of Physicians and Surgeons acts as an effective public safeguard. “I expect,” she says, “to be scrutinized.”

But at least one of Dr. Wiebe’s fellow Vancouver doctors is highly dubious that she and “five or six” other health professionals in the city are as bound by scrutiny as they are determined to push the limits of MAiD legislation to the maximum.

Dr. Will Johnston, a family physician and veteran pro-life advocate, recalls being part of a discussion at Vancouver General Hospital in September 2016 where Wiebe showed power point slides about the 100-plus patients to whom she had already administered MAiD. She was unabashed, Johnston says, that one of the dead was a psychiatric patient.

“Ellen has no apology about euthanizing someone where the primary indication, in her mind, was psychiatric, and she’s willing to put that up on a slide,” Dr Johnston says. “I e-mailed her recently and said, ‘Ellen, what did you mean by psychiatric (patient) in September, 2016? That’s not really legal, right?’ She hasn’t replied.”

For her part, Dr. Wiebe acknowledges she’s the only doctor who has legally assisted a psychiatric patient, heavy emphasis on legally. 

“Four judges had to agree that (the patient known as EF) was eligible before I was able to. I felt very good about helping her. She was suffering so terribly. It was hard to be in the presence of that suffering…physically and emotionally draining. I had all her medical records so I could review (her) treatments for several years. Nothing worked.”

Dr. Wiebe says she has refused all subsequent requests from psychiatric patients for MAiD because they did not meet legal criteria. EF’s case was “really unusual” because of the degree of suffering and lack of alternatives.

“People sometimes say ‘why didn’t she just kill herself?’ But she was religious and had a large family who were religious, and that wasn’t acceptable. At the death, 10 people were with her, supporting her, loving her, and giving her up to God because her suffering was unbearable.”

Dr. Wiebe readily admits that she would like the law expanded to allow MAiD for psychiatric patients judged competent to make decisions in their own interests: “I wish I could help them.”

She’s adamant, however, it must never include those whose “brain isn’t functioning” well enough to be aware of what they’re deciding.

“If your brain isn’t functioning, you need to have society protect you to the point of taking all your rights away from you over your own person. I know what it’s like when people’s brains don’t function. I have a stepson who’s schizophrenic.”

For Dr. Johnston, however, Dr. Wiebe’s sense of her own capacity to make such distinctions suggests a health care “messiah complex” that the law must restrain. The same is true of other doctors in the city who promote MAiD as medicine, he says.

“It’s not just Ellen. She is completely replaceable by anyone else with a similar messiah complex who feels there is suffering out there that the pusillanimous medical profession will not address adequately. (They have) a clear idea in their own minds that ‘foreseeability’ is a very elastic concept meant to be used to grant death to anyone.”

In his own practice, Dr. Johnston says he has seen the way that legal elasticity has inverted the obligation to meet MAiD safeguards, and created pressure on hospital administrators to show why it should be denied. 

“The administrative anxiety now is to be accused of obstructing access, not of killing someone inappropriately or facilitating an inappropriate death,” Dr. Johnston says. “The real risk here is the precedent that creates.”

Affirmation of Dr. Johnston’s warning comes from Quebec, where Dr. Paul Saba says he was personally put on the hot seat by local hospital administrators fearful that he might have inappropriately denied MAiD. 

Dr. Saba says a patient wanted MAiD, but asked only for a referral to another doctor. Dr. Saba, who was fighting a legal battle with the Quebec government over the constitutionality of its assisted dying legislation, refused to do the referral too. Another doctor was brought in who agreed to provide the procedure, but then the medical direction of the hospital intervened and ruled the patient didn’t qualify under Quebec law anyway. 

“The (second) doctor was livid and insisted the patient had a right to MAiD. I said, ‘Listen, the director (of) the hospital says no.’ It created quite a battle in which I was accused by the administration of impeding a person’s access to rights. I wasn’t impeding anything. I was just passing on information from the director of the hospital.”

In the end, Dr. Saba says, the patient was ruled ineligible for MAiD under Quebec law, received palliative care, was eventually taken off a respirator, and died peaceably. But the example shows, he says, how the ambiguity of the law is creating pressure cooker situations within Canadian medicine. He has argued in his court battles that there are 33 differences between the Quebec assisted dying law and the federal statute alone. And each clause of each law, beginning with how to define “foreseeable death,” is open to interpretation, breach and abuse.

“There’s no clear delimitation right now. We’re constantly in a morass. We don’t know what applies, and what doesn’t apply. The fact is, it shouldn’t apply because this is not medicine. This is bad public policy. It is putting people in danger.”

Dr. Saba says he sees a grievous danger already arising as MAiD becomes not merely acceptable, but also a solution for resource-strapped health care systems. He attends meetings, he says, where “cold management” of patient cases is discussed between doctors, nurses and hospital administrators. What’s meant is rationalizing the public health care dollars spent on patient care.

“It’s used all the time. They say, ‘We only have so much money, we have to set a limit, enough is enough, we don’t do the investigation to find the treatment necessary for the patient.’ That’s already there. I’ve been in a meeting where that’s been brought up in a very strong way. Physicians who have crossed the line that benefitted the patient but used too many resources have been told their privileges will be withdrawn.”

Saba’s concerns are hardly his alone. In late May, Quebec’s Collège des Médicins, which worked supportively with the provincial health ministry to adopt the province’s own assisted dying legislation ahead of the new federal law, sounded a startling warning note.

In a published letter to Health Minister Gaétan Barrette, Collège President Dr. Charles Bernard expressed serious concern that patients are “choosing” medical assistance in dying purely because their preference for palliative care isn’t available. 

“End-of-life care cannot be limited simply to medical aid in dying,” Dr. Bernard wrote in French that was diplomatic-bureaucratic but left no doubt about his urgency. “That option makes no sense, from a medical point of view, unless it is part of a robust and complete system of palliative care in Quebec.” 

Provincial foot-dragging on plans to expand palliative care services substantially is actually denying patients the very choice that was promised in the shift to MAiD, and making it increasingly problematic to discern which patients truly wanted to have a doctor deliberately end their life, Dr. Bernard warned. 

“In certain identified cases, patients, for the lack of (palliative) care, might have had no choice but to ask for medical aid in dying to end their days ‘in dignity,’ which deeply concerns us,” the Collège president told the minister. 

Worse, he added, the Collège has been hearing increasing concerns from its member doctors about re-direction of already scarce resources from palliative care to Medical Aid in Dying, which risks a violation of both the letter and the spirit of Quebec’s law governing end of life care.

For Dr. Paul Saba, those words are vindication for the argument he and many of his medical colleagues began making long before the federal or Quebec laws were on the books. Indeed, Saba says, the fears being expressed by the Collège were predicted by opponents of MAiD that once allowed, it would change the very nature of medicine in Canada and Quebec.

“The whole health paradigm has been turned upside down,” Dr. Saba says. “We’ve turned medicine upside down. We’re no longer looking at treating, alleviating symptoms, at curing. We’re looking at ending people’s lives.”

Even as committed and vocal a proponent of MaiD as Nova Scotia law Professor Jocelyn Downie recently acknowledged that Bill C-14 has “led to confusion” and been a source of  “alarm” because of its unclear language. 

A column Downie wrote jointly with University of Ottawa law Professor Jennifer Chandler, and which was published as an op-ed in the April 24 Halifax Chronicle Herald, said the Liberal government was warned before the legislation was passed that the term “reasonably foreseeable” death is medically meaningless.

The law professors note that Monica Branigan, chair of the Canadian Society of Palliative Care Physicians, told the House of Commons Standing Committee on Justice and Human Rights that: “‘Reasonably foreseeable’ does not have a medical meaning because it is reasonably foreseeable that we will all die.” 

Last February, the “perplexing” and “unfamiliar” language in C-14 forced Nova Scotia’s College of Physicians to amend its own professional standard regarding medical assistance in dying to try to clarify what the federal law requires. The College adopted the finding of the Ontario Superior Court’s AB decision in declaring that “natural death need not be imminent, and what is reasonably foreseeable is a person-specific medical question…the physician need not opine about the specific length of time the person requesting medical assistance in dying has remaining in his or her lifetime.”

Downie and Chandler urge the provincial and territorial regulatory bodies for health care providers to follow Nova Scotia’s lead and adopt similar language which, they argue, will both clarify the federal law and extend it to cover circumstances where there’s significant doubt about MAiD’s legality.

“For example, when a paraplegic patient decides to refuse the skin care and changing of positions required to prevent bedsores and then antibiotics to treat the infections that will inevitably result…or when a patient with multiple sclerosis refuses food and liquids,” they write. 

They also note that someone diagnosed with Huntington’s Disease could decide 20 years ahead that the prognosis for death makes it reasonably foreseeable.

“Obviously, they will not meet all the eligibility criteria for MAiD on the day of diagnosis. For example, their decline in capability will not yet be advanced and their suffering not yet enduring and intolerable. But they will have an incurable condition and their natural death will have become reasonably foreseeable.”

For Alex Schadenberg, executive director of the Ontario-based Euthanasia Prevention Coalition, such clarifications are simply a way of saying in different words what Bill C-14 was intended to do all along. Schadenberg, who has been waging the fight against legalized medical death for almost 20 years, says the legislation’s confusions, ambiguities and uncertainties are features, not bugs.

“The law is designed to expand over time,” Schadenberg says. “I don’t like to say that because I wish it wasn’t true. But it’s exactly what’s happening. It uses language you can’t define, and that was intentional.”

As an example, Schadenberg points to an early version of the bill, which required a 15-day waiting period between a request for MAiD and its administration. Later, the waiting period was cut to 10 days.

“But then it says a doctor can waive the 10-day waiting period. So, in fact, there’s no waiting period. It says there must be physical or psychological suffering, but that’s limited to your death being reasonably foreseeable, right? That means you can’t have it for psychological suffering alone. Or does it mean that? Who knows?” 

He points out that the Netherlands pushed the expansion of euthanasia to include psychiatric conditions, including the desire for suicide. If someone was deemed suicidal, they qualified for euthanasia because they were going to die anyway. 

“That’s how it’s going to end up here because the law is designed to have no limits. It’s just a matter of time.”

Schadenberg is sharply critical of the media for failing to scrutinize the medically assisted dying narrative more stringently. He blames that failure, as much as the Harper government’s foot dragging or the Supreme Court’s deadline, for the panicked push to get C-14 through Parliament. He notes that in 2010, half of Canadians polled voiced concern that euthanasia would be abused. 

Five years later, the Supreme Court ruled it had to be allowed. Eighteen months after that, in 2016, it was made the law of the land. Polls showed that by then a strong majority of Canadians welcomed it with few reservations. MAiD for children, for example, is off the table at least for now. The speed of change was no accident, Schadenberg says.

“There was all these stories of people who were suffering, and they were the reason we needed to get on with this euthanasia bill quickly. We were inundated, and you get to a tipping point where it just seems unreasonable to remain opposed. We were conditioned by group think to accept the concept of euthanasia. When (the Liberals) took action to legalize it, and then produced a bill with language like (C-14), why would there be any question of resistance?” 

Though he continues to work for euthanasia prevention, and has begun developing his own documentaries to bypass the media and get the message out, Schadenberg struggles with pessimism about turning back the assisted dying tide. He thinks social pushback is possible yet sees ground being lost in an obvious source of resistance such as palliative care. 

“The battle over palliative care is a serious battle because the other side has infiltrated it and there’s pressure being put on (palliative care) physicians to refer (patients for MAiD). If a palliative doctor says ‘I’m not participating in any way, shape or form, but they’re forced to refer, then palliative care is not a safe place either.”

In Langley, B.C., businessperson Tamara Jansen abruptly found herself in the fight of her life earlier this year precisely over keeping palliative care safe and MAiD free. Jansen’s family arranged last Christmas to work with a local hospice on a successful fund-raising event but were shocked to learn after the holidays that it would be providing medically assisted dying to patients. A phone call to let the hospice know future fundraising ventures wouldn’t be possible for a facility offering MAiD was met with a plea for help to stop it, she says.

“The lady I spoke with said, ‘You need to start calling the newspapers. You need to let people know we’re doing this because of a directive. It’s going to cost us donors. It’s going to cost us volunteers. Help us.’ I had assumed they were all for, but it was decided for them with absolutely no consultation. The directive was just sent out and bam, everybody was supposed to do it,” Jansen says.

The order in question came from the Fraser Health Authority following the provincial NDP government’s edict that any hospice receiving 50 per cent or more public funding had to allow MAiD. Within hours, Jansen had swung into political action. She met with neighbors and members of her church that night. She helped to organize a town hall meeting that attracted a standing room only crowd in a local school gym, and an equally successful one a few weeks later further up the Fraser Valley in Chilliwack. The growing opposition brought its strength in numbers to an information session organized by the health authority. 

“They did it on a Friday at about 10 o’clock in the morning expecting about 10 people would show up. We just started letting everyone know: “Guys, come to this meeting. We need you.”

The result was another standing room only crowd: “They had to open the doors to a second room so they could fit more people in because otherwise everybody would have been standing in the hallway.”

But despite a heart-wrenching appeal from a woman with a terminal brain tumor who begged to be able to go to a MAiD-free hospice, Jansen left the meeting with the taste of political ashes in her mouth.

“When we walked out, I was upset. The (health authority) board listened very politely, and said, ‘Yes, we know this is a very complicated issue.’ We’d been played.”

It did not, however, stop Jansen from fighting. She began a letter writing campaign. Ultimately, she wound up with her picture on the front pages of newspapers as she stood outside the B.C. legislature in Victoria rallying participants in the March For Life to try to stop what she saw as an assault on palliative care. The intention was to make as much noise as possible to alert people to what was happening with palliative care, and why it was so wrong.

To begin with, she says, many medical staff working in hospices have no training in administering MAiD. Forcing them to provide medically assisted dying is “a botched euthanasia” waiting to happen, she says. 

“You wouldn’t dare go for a facelift to someone who has no training as a plastic surgeon. You wouldn’t go to a dentist who knows nothing about dentistry. But you’re going to make people who have not been trained in killing to now suddenly kill someone? It truly is the Wild, Wild West.”

Even more compelling, Jansen says, is the need for Canadians to understand exactly what palliative care is so they can grasp why MAiD is so out of place in a hospice environment.

“When most people think about hospice palliative care, they think ‘oh, you go there to die.’ A lot of people were afraid, even before euthanasia to go to hospice because they didn’t want to die there. In actual fact, hospice care, when it’s well done, helps you to spend the last moments as lucid and as pain-free, with your family, with your loved ones, as best you possibly can. The point of palliative care is really to give you the best moments you can have at the end of your life.”

Jansen firmly believes that’s worth making community political noise over. But she’s also wary of an eerie silence that’s now coming from the Fraser Health Authority over the status of the MAiD directive. 

“They’re basically keeping it on the down low as much as possible. I think they want people to start assuming it’s happening anyway, and just accept it. If the hospices think everybody is doing it, then they might feel they have no choice except to do it too. That’s why we have to keep making noise.”

For Sarnia-Lambton MP Marilyn Gladu, even a simple reassuring signal on palliative care from the Liberal government would be welcome. Gladu herself earned national applause last winter by getting an opposition private member’s bill through both the House of Commons and the Senate with unanimous approval. It was a rare feat, and seemed to bode well for the Liberal government’s acceptance of a commitment in the bill to produce a national Framework on Palliative Care by December of this year.

Since then, Gladu says, it has been crickets. A promised “national consultation” turned up as a call for submissions on a Health Canada website two days after Gladu asked a question in the House as to its whereabouts with the six-month deadline for undertaking it looming. An obligation under the legislation for the federal health minister to meet with her provincial counterparts to discuss the palliative care framework has yet to be met as far as Gladu knows.

“They might have met, and I might have missed it, but I’ve been paying close attention,” the southwestern Ontario Conservative MP says. “There hasn’t been anything made public as far as I’m aware.”

Even more disconcerting, she adds, was the lack of attention specifically to palliative care in the last federal budget. Health Canada points out that the Liberals promised $6 billion over 10 years for home care and palliative care in the 2017 budget, as well as an additional $184 million targeted to Indigenous home and palliative care. Well and good, Gladu says, but where’s the emphasis on palliative care by itself required by her Bill C-277?

“On a whim, they can come up with $4.5 billion to buy a 65-year-old pipeline so it’s obviously not a money shortage. It does give me pause that they’re not clear on how much they’ll spend on palliative care.”

Health Canada insists work is proceeding on schedule to develop the palliative care framework called for in Bill C-277. Gladu says she’ll continue pressing forward to make sure that happens, but meanwhile is deeply concerned by what she sees as missed opportunities to develop new approaches to palliative care.

For example, she says, Nova Scotia ran a successful pilot project to train paramedics to administer pain control medication during non-emergency hours. A request of $55 million was made to expand the training. Ottawa anted up $6 million. 

Beyond the apparent lack of funding, which is how politicians signal what they consider significant, Gladu shares the deep concern of Tamara Jansen and others about B.C. mandating MAiD in palliative care. Additionally, she says, there’s the “trampling of conscience rights” in Ontario where doctors opposed to MAiD are now legally bound to refer patients to colleagues who will administer it. And then there are the cases such as Dr. Ellen Wiebe’s where it appears, to some at least, that the spirit if not the letter of Bill C-14 was broken but nothing was done.

“I think we’re at the point of normalizing illegal behavior because there’s no enforcement,” Gladu says. “I’m concerned because I’m seeing more and more of these examples. The system that’s been put in place must be respected. The rules have to be enforced.”

But what happens when the rules themselves are drafted with such “purposeful flexibility” that no one knows what they mean, and physicians like Dr. Wiebe realize they’re essentially on their own, with little help from the law, in deciding what it means to go too far? 

B.C. MP Mark Warawa says if that’s a conundrum on the second anniversary of Bill C-14, it has the potential to create legislative paralysis when the legislation comes up for a mandatory review in three years.

“The law needs to be amended to provide greater clarity but what we have already are proper protocols, proper enforcement, being ignored. How do you amend and clarify what’s being ignored anyway? When the safeguards aren’t respected, and the enforcement doesn’t happen, when you can’t control what you already have, what can you do? As a legislator, I have no answer to that.” 

What remains, perhaps, is the ancient reminder that speed kills, and the novel realization that MAiD kills absolutely.

We hope you have enjoyed this piece. We look forward to enlarging the conversation on important public issues with a long form series entitled Convivium Explorations throughout 2018. 

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