This article first appeared in the National Post, Dec 23, 2023.
Holidays offer a moment to reassess your time commitments. Here’s a great article from HBR that I reread every few years: Do Your Commitments Match Your Convictions? (I definitely need to review it this weekend!)
Wishing you all a belated Merry Christmas and a productive and happy New Year!
The federal government chose a right-to-die advocacy group to help implement its medical assistance in dying legislation. It’s a classic case of regulatory capture, otherwise known as letting the foxes guard the henhouse.
In the “Fourth annual report on Medical Assistance in Dying in Canada 2022,” the federal government devoted several paragraphs of praising to the Canadian Association of MAID Assessors and Providers (CAMAP).
“Since its inception in 2017, (CAMAP) has been and continues to be an important venue for information sharing among health-care professionals and other stakeholders involved in MAID,” reads the report.
With $3.3 million in federal funding, “CAMAP has been integral in creating a MAID assessor/provider community of practice, hosts an annual conference to discuss emerging issues related to the delivery of MAID and has developed several guidance materials for health-care professionals.”
Six clinicians in British Columbia formed CAMAP, a national non-profit association, in October 2016. These six right-to-die advocates published clinical guidelines for MAID in 2017, without seriously consulting other physician organizations.
The guidelines educate clinicians on their “professional obligation to (bring) up MAID as a care option for patients, when it is medically relevant and they are likely eligible for MAID.” CAMAP’s guidelines apply to Canada’s 96,000 physicians, 312,000 nurses and the broader health-care workforce of two-million Canadians, wherever patients are involved.
The rise of CAMAP overlaps with right-to-die advocacy work in Canada. According to Sandra Martin, writing in the Globe and Mail, CAMAP “follow(ed) in the steps of Dying with Dignity,” an advocacy organization started in the 1980s, and “became both a public voice and a de facto tutoring service for doctors, organizing information-swapping and self-help sessions for members.”
Prime Minister Justin Trudeau tapped this “tutoring service” to lead the MAID program. CAMAP appears to follow the steps of Dying with Dignity, because the same people lead both groups. For example, Shanaaz Gokool, a current director of CAMAP, served as CEO of Dying with Dignity from 2016 to 2019.
A founding member and current chair of the board of directors of CAMAP is also a member of Dying with Dignity’s clinician advisory council. One of the advisory council’s co-chairs is also a member of Dying with Dignity’s board of directors, as well as a moderator of the CAMAP MAID Providers Forum. The other advisory council co-chair served on both the boards of CAMAP and Dying with Dignity at the same time.
Overlap between CAMAP and Dying with Dignity includes CAMAP founders, board members (past and present), moderators, research directors and more, showing that a small right-to-die advocacy group birthed a tiny clinical group, which now leads the MAID agenda in Canada. This is a problem because it means that a small group of activists exert outsized control over a program that has serious implications for many Canadians.
George Stigler, a Noble-winning economist, described regulatory capture in the 1960s, showing how government agencies can be captured to serve special interests.
Instead of serving citizens, focused interests can shape governments to serve narrow and select ends. Pharmaceutical companies work hard to write the rules that regulate their industry. Doctors demand government regulations — couched in the name of patient safety — to decrease competition. The list is endless.
Debates about social issues can blind us to basic governance. Anyone who criticizes MAID governance is seen as being opposed to assisted death and is shut out of the debate. At the same time, the world is watching Canada and trying to figure out what is going on with MAID and why we are so different than other jurisdictions offering assisted suicide.
Canada moved from physician assisted suicide being illegal to becoming a world leader in organ donation after assisted death in the space of just six years.
In 2021, Quebec surpassed the Netherlands to lead the world in per capita deaths by assisted suicide, with 5.1 per cent of deaths due to MAID in Quebec, 4.8 per cent in the Netherlands and 2.3 per cent in Belgium. In 2022, Canada extended its lead: MAID now represents 4.1 per cent of all deaths in Canada.
How did this happen so fast? Some point to patients choosing MAID instead of facing Canada’s world-famous wait times for care. Others note a lack of social services. No doubt many factors fuel our passion for MAID, but none of these fully explain the phenomenon. In truth, Canada became world-famous for euthanasia and physician-assisted suicide because we put right-to-die advocates in charge of assisted death.
Regardless of one’s stance on MAID, regulatory capture is a well-known form of corruption. We should expect governments to avoid obvious conflicts of interest. Assuming Canadians want robust and ready access to MAID (which might itself assume too much), at least we should keep the right-to-die foxes out of the regulatory henhouse.
As usual you capture what is important in Healh Care. Thank God these zealots have had problems with MAID and Mental Illness. They do not have the expertise to extend their evil tentacles of death to mentally ill individuals. My Psychiatric practice has not revealed one patient advocate for MAID who has a mental illness-most are personality disordered looking for the ultimate (as they see it) attention seeking which they see as coming from MAID. Hopefully your article will lead to more level headed and less vociferous individuals influencing future Government actions in this area. Keep MAID away from mental illness.
Good points, John. Thanks for posting.
There are so many angles — we’d need a book to capture them all.
– patient motivation
– burden of illness
– patient capacity
– and much more
I tried to make one, small point. As one person put it on Twitter/X, we shouldn’t let the chocolate factory write the nutrition guidelines.
If the DWD/CAMAP crowd were wise, they would work to avoid obvious overlap and conflicts of interest. Good governance won’t guarantee we don’t have assisted-death zealots writing clinical guidelines, but at least we won’t have the federal government praising an obviously (to me) corrupt governance.
Thanks again for posting!
Shawn
Hi Shawn,
I have thought about what you just wrote about since before MAID came into existence. There are two major problems in Canada with respect to MAID. The first is what you just reported i.e. regulatory capture or the foxes in charge of the Hen House. The second is Canadians do not understand the law and what happened in 2016 with the Carter Case. For some reason the Supreme Court Struck down two laws to active the MAID program. Section 14 of the Criminal code “No person is entitled to consent to have death inflicted on him ( killed)….” and 241(1) “Everyone is guilty of an indictable offence and liable to imprisonment for a term of not more than 14 years who, whether suicide ensues or not, (a) counsels a person to die by suicide or abets a person in dying by suicide; or. (b) aids a person to die by suicide.”
Striking down two lawsallowed assisted suicide, as well euthanasia to occur under the law. Most Canadians, IMHO, think our law is similar to Switzerland’s and that dying is achieved by assisted suicide MAID. In Ontario last year it was reported that 98% of cases were euthanized. There are problems if the people subject to the law do not clearly understand what’s happening.
I discussed this often years ago with several lawyer friends and each time(i.e. 3 times) they said, “what different does it make the patient got what they wanted.” I am curious how many doctors discuss the real difference prior to choosing the “treatment”.
Great point, Graeme!
I believe only 7 patients chose the assisted suicide route in 2021 and 2022 … people should go and double check the report … I may have remembered this wrong.
California legalized physician-assisted death at the same time as us. But we have 20-times more assisted death/voluntary-active euthanasia in Canada than California precisely because California only allows assisted death.
Definitions matter, but MAiD offers a handy, dandy catch-all phrase under which clinical acts can expand without drawing attention by a change in terminology.
Thanks for taking time to post!
Cheers
Shawn
Informative, thought provoking analysis and your usual impeccable logic, Shawn.
We should probably have known that the fix ( by the Administrative State) was in when the College of Physicians and Surgeons of Ontario made it a professional obligation for every doctor licensed in Ontario to support any individual citizen’s “right” to involve the individual doctor in that citizens suicide: And when the Ontario Court of Appeal endorsed that obligation, and by extension the so called “right”, all the while setting aside such an unimportant legal concept as an individual doctors Freedom of Conscience and Religion.
“The moving finger writes; and having writ
Moves on … ” Omar Khayyam
Mike, fantastic quote — thank you! I hadn’t read that poem by Fitzgerald before. Excellent. I’ll paste it below.
Your ‘moving finger’ perfectly captures our moment. We must know what’s been ‘writ’ but also look forward at how we can shape or even reclaim something similar to what we’ve lost (similar, not identical).
The CPSO used to land on the side of a balanced liberty: patients were free to refuse care; doctors were free to only offer treatment they believed would benefit their patient. Since 2015, the CPSO abandoned balance and embraced coercion.
We shouldn’t be surprised at authorities becoming authoritarian. It is their default position throughout human history. We practiced medicine at the end of a rare epoch and are now in a post-liberal era.
Bill 36 in BC gives government the right to dictate standards of practice and mandate what doctors can and cannot say to patients. Medicine has ceased to be a profession, under this new law. Doctors may continue to act as though they are members of a profession, but the state cannot usurp the defining features of a profession (ie possession of a unique body of knowledge, standards of practice, behavioural codes) and pretend the profession still exists. It has disappeared in the sociological definition of the term.
Sure appreciate you taking time to post — thoughtful, as always.
Here’s Fitzgerald’s poem:
From The Rubaiyat of Omar Khayyam
A book of verse beneath the bough,
A loaf of bread, a jug of wine, and thou
Beside me in the wilderness —
And wilderness is paradise, now.
‘Tis all a checquer-board of nights and days
Where destiny, with men for pieces, plays,
Hither and thither moves, and mates, and slays,
And one by one, back in the closet, lays.
The moving finger writes, and having writ
Moves on; nor all thy piety nor wit
Shall lure it back to cancel half a line,
Nor all thy tears wash out a word of it.