We’re way beyond the slippery slope. We need new criteria for MAID

Doctors driving requests for MAID, vague criteria, weak monitoring: we’re on a new slope altogether. Image by Canva

I’d rather pretend MAID doesn’t exist. This article (National Post) emerged after MLI prodded me to consider it again. I did not receive payment, and MLI helped with editing.

Two radio interviews followed:

Nov 2, Roy Green Show

Nov 1, Afternoons with Rob Breakenridge (starts at 25:00)

Please follow this topic. It is painful, but MAID policy will impact your family at some point.

Thanks for taking a look!

There’s a big difference between what we imagine about Medical Assistance in Dying (MAID) in Canada and what actually happens to patients.

In 2015, the Supreme Court of Canada’s Carter decision overturned the ban on physician-assisted suicide and voluntary euthanasia for specific patients. The SCC cited “grievous and irremediable medical conditions” and “enduring suffering that is intolerable to the individual” as the criteria for obtaining MAID. The 2016 legislation that followed upon the decision required that death be “reasonably foreseeable.” But today, we see MAID offered proactively to vulnerable patients as part of the range of “treatment” options, and in situations where death is nowhere in sight. If we were first slipping down the terminal illness slope with increasing MAID usage, we’re now skiing down another hill altogether.

Leaving aside the inherently vague and non-medical nature of terms such as “intolerable suffering,” actual patient experience looks different than what the law suggests. Last week Canada made international headlines (again) after a 51-year-old woman in Nova Scotia was offered MAID twice during two separate pre-operative assessments for breast surgery, 15 months apart.

As reported in the National Post, Dr. Gus Grant, registrar and chief executive officer of the College of Physicians and Surgeons of Nova Scotia, said it was “clearly inappropriate and insensitive” for a doctor to raise MAID as a person was being rolled into a surgical suite. “I can understand why the patient was upset,” Grant said.

Similar cases abound: veterans offered MAID for PTSD, a Paralympian offered MAID after delays to get a wheelchair lift installed, a patient dying with “hearing loss” as their only reason for MAID, and a 41-year-old man receiving MAID for COVID “post-vaccination syndrome” — a debatable diagnosis.

In 2022, MAID was the sixth leading cause of death of death in Canada after cancer, heart disease, trauma, COVID and strokes. Absent COVID, MAID becomes fifth.

Dr. John Keown, professor of ethics at Georgetown University, argues Canada is “Skiing down euthanasia’s slippery slope.” We started by allowing voluntary euthanasia for terminal disease in adults and are now considering it for chronic disease and mental health issues, in some cases for children, too.

The slippery slope explains many things but leaves out too much. Slopes imply we have similar things along the slope. For example, terminal versus chronic disease, or physical versus mental suffering.

In Canada, we are way beyond slippery slopes. MAID is now considered viable treatment for all conditions that cause intolerable suffering, where what is deemed intolerable has no objective contours, only defined by the subjective assessment of a likely vulnerable and distressed patient. Furthermore, the suffering from a disease need not be real — simply the fear of potential suffering warrants consideration for MAID.

Instead of patients asking for MAID, as originally imagined, we now have medical regulatory colleges mandating that physicians inform patients about MAID as a treatment option, as in the case from Nova Scotia mentioned above. The College of Physicians and Surgeons of Ontario policy on Human Rights in the Provision of Health Services states that: “Physicians must provide patients with accurate, complete and unbiased information about all available and appropriate options to meet their clinical needs or concerns … Physicians must not withhold information about the existence of any relevant service, treatment or procedure because it conflicts with their conscience or religious beliefs.”

We have redefined which patients can access MAID, when they can ask for it, and what criteria qualifies them for it. Voluntary euthanasia and assisted suicide are no longer patient-driven requests; they flow from regulatory mandates that physicians must mention as available options. The slope does not seem slippery; it seems entirely new.

The right-to-die lobby spent much of the 20th century trying to normalize death. But nothing could convince the public that euthanasia was simply a “good death.” Normalizing death is hard to defend, so the plaintiff in the Carter case took a different approach. They used new language — “grievous” and “irremediable” conditions with intolerable suffering — in their criteria for “physician-assisted dying.” The lobby had found its way in. It framed the ban on assisted suicide and voluntary euthanasia as equivalent to condemning a patient to “intolerable” suffering.

Of course, this is not a medical reality. Pain can be very well-controlled, and even when it cannot, terminal sedation can eliminate conscious suffering without intending death. Nevertheless, the court accepted the bait and sided with the plaintiff, adopting their language in its ruling.

We need to revisit MAID criteria based on what patients actually experience, compared with other medical conditions. No one equates hearing loss — an irremediable and irreversible condition — with terminal cancer. We need criteria that can capture the difference and we need mechanisms to ensure criteria are followed. We need limits to MAID based on the reality of what exists, not on images conjured from the Carter case 10 years ago.

Premiers’ meeting was a fight about federalism, not funding

Source: YT: Council of the Federation-Conseil de la fédération

The Premiers’ meeting in Halifax looked like a fight about money and control. It was actually an attempt to save federalism in Canada.

The latest premiers’ meeting looked different. Instead of begging for handouts, they talked (briefly) about refusing federal handouts. Does this signal real change?

Note: this piece was published with True North.

Premiers expressed intense frustration last week over the lack of federal support and partnership on healthcare. The premiers’ Council of the Federation met for three days in Halifax, and as usual, healthcare topped their list of priorities.

The frustration falls only four months after Quebec signed its own side-deal with the federal government – the last province to settle details from last year’s $196.1 billion healthcare-funding agreement.

Since the Council formed in 2003, meetings have centred on money and control. Provinces want more federal money and less federal control. The federal government wants more control, while continuing to pay the provinces as little as possible.

This year, discussions seem to have gone beyond funding to address the deeper causes of frustration.

Alberta Premier Danielle Smith called attention to provinces rejecting federal funding aimed at boutique programming. Smith said provinces end up funding the “lion’s share” of operational costs.

Historically, the provinces have grumbled at federal funding offers – bribes designed to build programs the provinces could not afford to build on their own. Grumbling aside, provinces usually accept federal cash and do so willingly, with one notable exception. The final pillar of medicare, the Medical Care Act (1966), came with an offer to fund 50 per cent of medical services funded by a new federal ‘social development’ tax. Taxes would increase whether or not provinces accepted the new funding. Ontario Premier John Robarts called it, “The greatest machiavellian fraud ever perpetrated on the people of Canada.”

The current group of Premiers have taken a different tack. They reject federal bribery cloaked in the constitutionally questionable use of federal spending power. The provinces can neuter federal power, if they stick together. The federal government knows this, which might explain the use of “side deals” in the 2023 federal-provincial funding agreement mentioned above.

In fairness, not all funding is bribery. It hinges on how it is structured.

Premier Tim Houston, Chair of the Council, sent a letter to Justin Trudeau on behalf of the premiers. In it, he calls for “true partnership to revitalize cooperative federalism in Canada.”

True partnership, according to Peter Block, organization development expert, includes four things:  an exchange of purpose, the right to say no, joint accountability, and absolute honesty. This means provincial and federal leaders should meet and build a shared purpose, before planning any new program. Each party should have the right to stop plans at any time.  Joint accountability would mean neither federal nor provincial governments could blame the other for poor performance. And neither side would conceal information about resources or true intentions.

True partnership captures the essence of what federalism was meant to be in Canada. Federalism was never a rigid protocol to delineate absolute rights between one level of government and another. Canadian federalism offers a place to start negotiating. It sets the table and gives everyone a voice.

Federalism is meant to be the basis of our ability to work together as a unified nation, not as a power play to force governments to do what they never wanted to otherwise.

Yuval Levin, Director of AEI, makes this same point about the American Constitution in his new book, American Covenant: How the constitution unified our nation – and could again. Negotiation frustrates political idealists. The constitution exists to facilitate peace and cooperation given a plurality of interests. Though different than American republicanism, Canadian federalism serves the same purpose – peace and compromise, not power and force exerted by one government on another.

The Premiers’ call for “true partnership to revitalize cooperative federalism in Canada” will require compromise by all. We cannot tolerate one level of government wielding anything against the other, be it ‘spending power’ or power of any other kind. Governments must embrace true partnership, or Canadian federalism becomes a charade.

The premiers have taken the high ground and asked for change. Will Justin Trudeau listen?

Politics trumps patient care when governments are failing

Patients on gurneys line the hallway due to an over-capacity at the Humber River Hospital emergency department in Toronto on Jan. 25, 2022 during the COVID-19 pandemic. PHOTO BY NATHAN DENETTE / THE CANADIAN PRESS
Much of medicare’s dysfunction comes from compromises made to win votes in moments of political weakness

A few weeks ago, I was chatting with a popular talk-radio host about the 177-to-2 vote on the Medicare Care Act, 1966. He said, “Who were the two who voted against it?”

This sparked a short trip into parliamentary records to uncover events around the “unanimous” and “near-unanimous” votes that gave us medicare.

As always, the details reveal a different story. The article is on the National Post site.

Enjoy!

Politics trumps patient care when governments are failing

Policies that are not necessarily the best for the long term, including those affecting health care, are often implemented by weak governments only concerned about votes, writes Shawn Whatley. (from the photo caption)

Medicare emerged during failing and minority governments, much like the time we find ourselves in now. Three pillars of medicare legislation passed with near unanimous support during periods when the opposition could not risk debate.

The first pillar of medicare, the Hospital Insurance and Diagnostic Services Act (HIDSA), passed unanimously in 1957. The majority Liberals had been in power since 1935. HIDSA introduced dollar-for-dollar cost sharing between the federal government and the provinces. The Diefenbaker Progressive Conservatives offered unanimous support, and months later won an upset minority. In 1958, Diefenbaker won again — the largest majority in Canadian history, up to that point.

By 1963, voter sentiment had reversed, and voters had tired of Diefenbaker. The minority Liberals tabled the Medical Care Act. The MCA promised to expand Parliament’s 50:50 funding to include doctors’ services. Provinces needed to nationalize medical insurance and create publicly-funded, single-payer provincial insurance plans to qualify for federal funds. Parliament passed the Medical Care Act in 1966 by a vote of 177 to two. The two “nays” came from Social Credit MPs: Robert N. Thompson, from Alberta, and Howard Earl Johnston, British Columbia. The Liberals, Progressive Conservatives and NDP offered unanimous support. Pierre Elliott Trudeau won a majority in June 1968, and the MCA took effect weeks later on July 1.

The last pillar of medicare, the Canada Health Act, came when Pierre Trudeau faced historically low voter support, much like his son does now. The Canada Health Act, 1984, leveraged public fury over hospital user fees and physician “extra billing,” even though extra billing accounted for only 1.3 per cent of total physician billings under medicare. An amendment to the MCA could have fixed the issue, but new legislation presented a perfect wedge.

Mulroney saw through the trick. He ignored the bait and whipped the vote. The CHA passed unanimously, and the PCs went on to redefine “landslide election” victory that fall. It remains the largest majority government in Canadian history.

Much of medicare’s permanent dysfunction comes from compromises politicians made to win votes in moments of political weakness. Medicare escaped meaningful debate.

Remember, the Diefenbaker PCs supported social programs and even appointed the first Hall Commission on universal medical insurance, 1961-1964. But they abandoned program design to left-leaning visions in a failed quest to regain voter support. Again, political survival became the only concern and compromise knew no limit.

As Carson Jerema, National Post’s Comment Editor, recently put it, “All governments debase themselves for partisan advantage, but it isn’t clear that (the current Liberal) government is capable of doing anything else. Every policy, every action, every pronouncement is designed, not to achieve a particular goal, but to wedge the Conservatives, or appease the NDP.”

Wedge-and-bait politics creates serious risk for Canadians. Radical ideas escape debate and run unopposed. Weak governments do not worry about long-term impact. They only worry about how to make the opposition look bad. The opposition also ignores long-term impact, while fretting about whether critique could weaken voter support. For example, Conservative Leader Pierre Poilievre held back criticism of the capital gains tax until days before the vote in Parliament, no doubt to lessen time for the left to foment negative press.

All politicians face a fundamental dilemma: stick to principles or pursue popular support? Stand up for what you believe, and never get elected, or compromise to get into power?

Minority governments generally require compromise. But compromise leaves voters shackled with ideas we can never adjust or abandon, especially when passed with “unanimous” or “near-unanimous” support.

Polling shows Conservatives have strong support in Canada right now. Let’s hope Poilievre feels strong enough to oppose the inevitable wedge-and-bait politics we can expect this fall.