When Quebec allows advance requests for medical assistance in dying this week, Dr. Claude Rivard will not be participating. Indeed, even if Ottawa changes its laws to legalize the practice, he says he will not participate in them.
“It’s a new ball game,” said the palliative care physician, who performed Quebec’s first medically assisted death in 2015. “It’s not the same as MAID assessment and provision that we usually do for the last nine years.”
Advance requests — which are illegal under the federal Criminal Code — become legal in Quebec on Oct. 30.
With advance requests, patients who are diagnosed with illnesses such as Alzheimer’s or dementia, and who have the ability to consent, will be able to describe a future point in their illness when they would like an assisted death — even if they are not able to consent at that time. With the help of medical professionals, patients will list symptoms that they must experience before having an assisted death.
In September, the province said it is “not in the public interest” to pursue criminal charges for assisted deaths that occur under advance requests.
On Monday, the federal government announced it would not challenge Quebec’s law legalizing advance directives. It also announced it would launch a national consultation on advance requests, beginning next month and running until the end of January.
‘Future self’
This is not the first time Quebec has been the first Canadian jurisdiction to introduce practices related to MAID.
In June 2014, Quebec passed a law legalizing MAID. That law was declared in-force in December 2015, after the Supreme Court of Canada struck down Criminal Code prohibitions on physician-assisted suicide. The Supreme Court’s ruling paved the way for MAID to be practised across Canada, beginning June 2016.
Canadian law allows patients to waive their final consent for MAID if there are concerns they will lose their capacity to do so. But waivers are only allowed for patients seeking Track 1 MAID — where death is reasonably foreseeable. And these waivers must be renewed every three months between a patient and health-care provider, says Rivard.
The Quebec government’s website says that filing an advance request does not guarantee someone will qualify for MAID. A patient will still need to meet all other eligibility criteria. Patients will also be able to cancel their advance requests at any time.
But Quebec doctors — including some MAID providers — have raised concerns about administering MAID to someone who cannot give final consent to it.
Dr. Catherine Ferrier, a gerontologist and professor at McGill University, says “there’s a lot of hesitation” among gerontologists about advance requests. Ferrier, who opposes MAID herself, says she has heard concerns from doctors who support MAID.
A patient cannot know with certainty what they will want in the future, she says. Their views of what is intolerable suffering may change. “You’re making a decision for your future self, who would see things very differently.”
Quebec’s decision also raises legal concerns.
“The Criminal Code is very clear that [advance requests are] not legal,” federal Minister of Health Mark Holland told reporters Monday. But he said he could not intervene in a province’s application of the Criminal Code.
“I can’t direct a province how it’s going to direct its judicial system,” he said.
Quebec has raised “legitimate and fair issues” about advance requests, Holland said, but there needs to be further study to see if the medical system is ready. Complete consensus among medical professionals about advance requests is impossible, he said.
MAID is popular in Quebec. Between April 1, 2023 and March 31, 2024, there were 5,717 MAID deaths — accounting for seven per cent of the province’s deaths during that period.
MAID providers disagree
Supporters of advance requests for MAID say they will allow people who have been diagnosed with diseases such as dementia or Alzheimer’s to decide how much suffering they want to experience.
“I think it’s very important, because [advance requests] will give patients serenity, peace in their mind, because they know that they have the disease, they know what is going on, they know how it will finish,” said Dr. Georges L’Espérance, a retired neurosurgeon and president of the Association québécoise pour le droit de mourir dans la dignité.
“They will be able to say, ‘Well, now I’m pretty good. I can enjoy life with my family or my friends. I know where I’m going, but for those years, I will be able to enjoy life’,” said L’Espérance, who is also a MAID provider.
Other MAID providers say they will not participate in advance requests.
Rivard, who estimates he has performed more than 600 assisted deaths since the practice became legal, says patients always willingly give him their arms to receive the lethal intravenous injection.
“When you’re going to come and try to insert the IV on a person who’s not capable of understanding what is going on, he will be hurt by that,” he said.
Quebec law says the MAID process must be stopped if a patient refuses it.
However, in the Netherlands — which also allows advance requests — there have been reported cases of Alzheimer’s patients being forcibly restrained so the lethal drugs can be administered.
Rivard is not willing to do that.
“I cannot start tying people up to insert [an] IV,” he said. Often, families have expressed gratitude to him after their relatives’ assisted deaths. But if a patient has to be restrained for MAID, that could be traumatic to the patient, the family and the medical staff, he says.
More information needed
Thaddeus Pope, a bioethicist and health law professor at Mitchell Hamline School of Law in Saint Paul, Minn., supports advance requests because of the personal autonomy he says they provide. “Each of us should be the captains of our ship,” he said.
But there needs to be more information about when a patient would like MAID administered, he says.
The draft forms for advance requests released by the Quebec government are four pages. While these forms are not much longer than those used for regular MAID requests, Pope says more thorough forms should be required for advance requests.
“The sole basis and permission to do this is memorialized in this form,” he said. “I think the burden of careful reflection, deliberation, informed consent, is much, much higher, because this is it. We can’t double check with [the patient].”
It would be better if patients had to make a video in which they specify their diagnosis and prognosis, explain the medical advice they sought and explain their advance request, he says.
Opponents of advance requests say the whole idea needs to be scrapped.
“This will be the very first time in the history of MAID in Canada that we have a category of people that won’t be able to go back on their decision,” said Jasmin Lemieux-Lefebvre, a coordinator at Vivre Dans La Dignité, an organization that raises concerns about MAID.
Ferrier, of McGill University, worries about the inability of patients to consent.
“There’s no other situation in which you direct somebody to end your life when you’re not able to consent to it at the time,” she said.
Ferrier, who works with many dementia patients, says it is possible to learn what is causing them distress — and to relieve the causes of suffering. Good gerontology nurses know how to do this, she says, adding that she gets a lot of satisfaction from watching caregivers learn how to care for loved ones with dementia.
“Why don’t we focus on ways of caring for people that are vulnerable … instead of ending their lives?” she said.
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