Jaro Kotalik

Annual Reports on Medical Assistance in Dying (MAID) issued by Health CanadaCanada on behalf of the Government of Canada strive to make essential information public, on this large national program that over five years has provided death to over 30,000 Canadians. The source of the information is self-reporting by physicians and nurse practitioners who offer to act as MAID assessors and providers, as well as self-reporting by cooperating pharmacists. Focus of this discussion is the latest available document in this series, the Third Annual Report on MAID published in July 2022 and providing data on 10,064 deaths by MAID in 2021. In addition to reviewing essential information about MAID recipients and MAID providers, the discussion is centered on the method of data collection, the rapid and unexpected annual increase of cases, the underlying medical conditions, the nature of suffering reported by MAID applicants, the use of palliative care, the decision-making about one’s eligibility, the role of the reflection period, necessary requirement to obtain informed consent and the denial of assisted dying. In each case, the attention is drawn to missing or indeterminate elements, and essential but unavailable analysis of data, in order to identify further information that ought to be collected and used to generate future annual reports and to refine the delivery of MAID program and its oversight.

Monitoring of MAIDMonitoring of MAID was recognised as an essential component of the MAID program. However, monitoring started late in the rollout of the program, and even at present is missing some essential elements that would be important for effective oversight and public accountability. Health CanadaCanada is using some of the data obtained from practitioners and pharmacists to produce Annual Reports on MAID, but these reports aim at providing only a “societal perspective,” rather than an in-depth assessment of the program’s performance. A major deficit is lack of monitoring and reporting on the compliance with eligibility criteria and procedural safeguards that should be coming from territorial and provincial governments, and that would provide assurance that MAID delivery complies with the Criminal CodeCriminal Code of Canada. Monitoring is based entirely on self reporting and therefore it is recommended that Health Canada obtain supportive data by initiation of on-site retrospective reviews of randomly selected MAID deliveries across the country. In addition, it would be useful to enhance the quantity and quality of data collected from MAID assessors and providers. Organizations involved in MAID provisions (hospitals, regional health authorities and so on) should also report annually on MAID activities to their respective communities. Improvement of monitoring and reporting would address serious concerns among professionals, people with disabilities and advocates for vulnerable populations while providing for a higher level of transparency and accountability.

This book, written both for a Canadian and an international readership, provides a multidisciplinary review of the framework and performance of the Canadian Medical Assistance in Dying (MAID) program. In the first five years (2015-2021) of operation, this program delivered voluntary euthanasia and assistance in suicide to over 30,000 Canadian residents, presently representing a 30% annual growth. Looking back on these first five years, the 30 Canadian scholars and clinicians contributing to this volume raise important issues and attempt to answer key questions that have arisen in regards to its operation and its stated objectives. This volume strikes the most appropriate balance between the autonomy of persons who seek medical assistance, versus the interests and protection of vulnerable persons. Finally, the book makes suggestions on how the program can presently be improved. It identifies gaps in knowledge about MAID’s operational program and its impact on individuals, families and society in order to stimulate the necessary research that is essential to the evolution of a healthy and well-balanced program. As a first, comprehensive examination of medically assisted deaths in Canada, this publication will be of great value to lay, professional, academic, political audiences both domestically and internationally, especially in jurisdictions that are examining their options of permitting assisted deaths.

The authors led the development of a framework for ethical decision-making for an Academic Health Sciences Centre. They understood the existing mission, vision, and values statement (MVVs) of the centre as a foundational assertion that embodies an ethical commitment of the institution. Reflecting the Patient and Family Centred Model of Care the institution is living, the MVVs is a suitable base on which to construct an ethics framework. The resultant framework consists of a set of questions for each of the MVVs. Users of the framework are expected to identify two or more possible decisions to address the issue at hand and then, by applying the provided sequence of questions to each, examine these options and determine the overall ethically preferable decision. The construction of such a framework requires the creative involvement of the institution’s staff. Thus the development of the framework can represent a training process in ethical decision-making as well as advance the ethical atmosphere of the institution. This novel approach has the advantage of placing the MVVs on active duty, at the centre of ethical decision-making, and lifts it from its otherwise relative obscurity in most institutions

The Canadian medical assistance in dying program, based on an ambitious piece of legislation and detailed regulations, has failed to provide Canadians with sufficient publicly accessible evidence to show that it is operating as mandated by the requirements of the law, regulations, and expectations of all stakeholders. The federal law that was adopted in 2016 defined the eligibility criteria and put in place a number of safeguards that had to be satisfied before providing assisted dying to a person in order not to transgress the Criminal Law. The responsibility of monitoring for the purpose of investigating compliance with the eligibility criteria and procedural safeguards was assigned by the Federal Ministry of Health to the provincial and territorial governments. Some of the governments have released statistical data concerning the program, but none have yet issued a comprehensive report on adherence to the eligibility criteria and its safeguards as required by the law and regulations. This paper explains the process, explores the possible reasons for this shortfall, and offers some suggestions for actions that could rectify this aspect of the MAID program. Accountability and transparency are integral to the delivery of MAID and the publications of the mandated federal as well as provincial/territorial monitoring reports are one important approach to achieving confidence and trust in the program.

There is a significant omission in the whole endeavor of moral analysis as commonly used in bioethics. Whether the analysis is based on a set of moral principles grounded in common morality, on a deontological or a consequentialist theory, or on other considerations, the focus has been to assist moral agents in making ethically appropriate decisions. Little or no attention has been paid to the issue of who the appropriate moral agent or decision maker is in any given situation. Yet, how to make a decision and who should make that decision are equally important, albeit separate, issues. The principle of respect for autonomy, which favors self-determination of the patient or the surrogate, generally is invoked when ..

In the near future, experts predict, an influenza pandemic will likely spread throughout the world. Many countries have been creating a contingency plan in order to mitigate the severe health and social consequences of such an event. Examination of the pandemic plans of Canada, the United Kingdom and the United States, from an ethical perspective, raises several concerns. One: scarcity of human and material resources is assumed to be severe. Plans focus on prioritization but do not identify resources that would be optimally required to reduce deaths and other serious consequences. Hence, these plans do not facilitate a truly informed choice at the political level where decisions have to be made on how much to invest now in order to reduce scarcity when a pandemic occurs. Two: mass vaccination is considered to be the most important instrument for reducing the impact of infection, yet pandemic plans do not provide concrete estimates of the benefits and burdens of vaccination to assure everyone that the balance is highly favorable. Three: pandemic plans make extraordinary demands on health care workers, yet professional organizations and unions may not have been involved in the plans' formulation and they have not been assured that authorities will aim to protect and support health care workers in a way that corresponds to the demands made on them. Four: all sectors of society and all individuals will be affected by a pandemic and everyone's collaboration will be required. Yet, it appears that the various populations have been inadequately informed by occasional media reports. Hence, it is essential that plans are developed and communication programs implemented that will not only inform but also create an atmosphere of mutual trust and solidarity; qualities that at the time of a pandemic will be much needed

Contemporary bioethics recognizes the importance of the culture in shaping ethical issues, yet in practice, a process for ethical analysis and decision making is rarely adjusted to the culture and ethnicity of involved parties. This is of a particular concern in a health care system that is caring for a growing Aboriginal population. We raise the possibility of constructing a bioethics grounded in traditional Aboriginal knowledge. As an example of an element of traditional knowledge that contains strong ethical guidance, we present the story of the Gifts of the Seven Grandfathers. We note a resemblance of this Ojibway teaching to virtue ethics in European traditions, but we suggest that there are also important differences in how these two traditions are currently presented. We hope that further engagement with a variety of indigenous moral teachings and traditions could improve health care involving Aboriginal patients and communities, and enrich the discipline of bioethics