Nova Scotians eligible for medical assistance in dying (MAID) will soon be able to choose to self-administer medication rather than relying on a clinician to do it for them.
The option, often referred to as the oral protocol, will be made available in the province in “early 2022.”
“Currently in Nova Scotia medications for medical assistance in dying are administered intravenously (IV) by a provider (doctor or nurse practitioner) to an individual who has been approved for MAID and provided written consent for the MAID procedure to take place,” Dr. Gord Gubitz, medical lead for Nova Scotia Health’s MAID Access and Resource Team, wrote in an email.
“Nova Scotia Health’s MAID Access and Resource Team is working to implement a self-administered (oral) MAID option for eligible patients who may request it.”
Gubitz said it’s important to note that when offered in this province, the oral option will require that a pre-established IV method be available as a backup.
The MAID provider will also have to remain nearby “as the oral option does not always result in death.”
While Gubitz anticipates the oral option will be available in Nova Scotia in the coming months, there’s no set date because they have to engage and train MAID providers who might consider this as an option for their patients.
In addition, he said most of their clinicians are currently dealing with Omicron in their day-to-day practices. Gubitz said an information session is being planned for late January or early February “to get things rolling.”
While Gubitz doesn’t expect many patients will opt for the self-administered medication option, he said they plan to run a trial of the new process with a few providers before opening it to a wider group.
This is great news for Dalhousie University professor Jocelyn Downie, who teaches in the faculties of law and medicine. She described the move as the next stage in the implementation of a legal framework for MAID in Canada.
“Ultimately it’s grounded in the twin values that should be behind our MAID decisions, which is respect for autonomy, so the capacity for self-determination, for charting the course of your own life and death, and then the alleviation of suffering,” Downie said in an interview.
“This is just another element in respecting autonomy. It’s providing another pathway for people to realize their goal of alleviating their suffering on their own terms. It’s not the kind of development that we’ve seen in the past few years. It’s not seismic. But I think it’s consistent and it’s a completion.”
Pushing the oral protocol
In November, Memorial University of Newfoundland medical ethics professor Daryl Pullman published an Impact Ethics piece comparing the number of deaths due to MAID in Canada in 2020 to the “dramatically lower” number that occurred in California under its end-of-life option.
In it, he argued for wider use of the oral protocol in Canada.
“…Given the significant number of patients in California who meet the criteria for an assisted death, who receive the lethal prescription, but then never follow through, for some simply knowing they have the option seems sufficient,” Pullman wrote.
“The decision not to follow through with ending one’s life is also a matter of autonomous choice. But it is a choice that seems all too rare in the Canadian context, and we should worry that some who initiate the MAiD process might then feel compelled to follow through.”
In an interview, Pullman said one of his concerns is the physician-administered MAID process can lead to “unintentional” coercion, whereas the oral protocol allows patients to choose when and how to administer lethal medication on their own terms.
“Doesn’t this disturb anybody that these numbers are so blatantly different,” he asked.
“It could be that the criteria are just so restrictive in the States that they need to be more liberal in that respect, or it could possibly be that we have become too liberal too quickly here.”
While the Canadian MAID legislation allows for the oral protocol, Pullman said it’s rarely used even in jurisdictions where it’s currently allowed. It’s not permitted at all in the province of Quebec.
Pullman has also expressed concerns about changes coming into effect March 17, 2023 that will allow Canadians whose only medical condition is a mental illness to access MAID.
“The Canadian Parliament seems more interested right now in waxing the runners on the sleigh than in actually trying to assess whether or not the hill we’re going down is pretty steep. We seem to be rushing headlong for a precipice here,” Pullman said.
“We’re medicalizing suicide in Canada, effectively, so that people who, for whatever reason, judge their life to be unacceptable they can, under this legislation, get medical assistance in ending their life and that’s a little bit disturbing.”
Pullman said as someone who has worked in the bioethics field for many years — and long before the MAID legislation came into effect — he remembers when supporting medical assistance in dying was a position held by a minority.
“Most of us could see that there were these exceptional cases … where even though it might be illegal, it would be moral to do so. Well, we’ve changed the law now, and now the cases aren’t exceptional,” he said.
“I’m not totally opposed, but I have a much more conservative approach. We’re in the minority … kind of seen as being not on the ethical high ground, you’re somehow on the low ground. It’s been quite a shift in Canadian perspectives.”
While Pullman applauds the province of Nova Scotia for its decision to make the oral protocol available, he has concerns that requiring a pre-established IV and a clinician nearby might present the same “implicit coercion” that concerns him about the physician-administered MAID process.
‘Protocol is sensible for now’
Downie, who teaches health care ethics and law, has a different take on Nova Scotia’s approach to the oral protocol. She also disagrees with Pullman’s Impact Ethics piece, noting the difference in the laws in California and Canada.
In California, patients must be within six months of dying. Under Canada’s current eligibility criteria, patients can’t make a MAID request unless they “experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable.”
Downie said if Canadians were eligible before their suffering was unbearable, there would be “massive” numbers of people who would make a MAID request, but not die as a result of that request.
“No wonder we have a much smaller number of people (than in California) who actually ask for it and don’t go through with it, because by definition you have to be experiencing enduring and intolerable suffering,” Downie said.
“That’s not anywhere in his piece, and that is an elephant standing next to a mouse. You just can’t compare them and draw the conclusion about people being coerced or people changing their minds. They’re just fundamentally different moments in time.”
Downie said Nova Scotia’s approach to the oral protocol is consistent with the position taken by the Canadian Association of MAID Assessors and Providers. That protocol also requires a clinician be present if a patient chooses the oral (self-administered) option.
Although Downie initially believed it was a limit on patient autonomy and questioned whether that approach might be too medicalized, her position has shifted.
“People are trying to figure out how to make this work. What is the ideal cocktail? The ideal instructions? What is the failure rate? How long does it take? And so on,” she said.
“We are (then) able to give patients the full picture of what is involved if they do go for self-administered rather than clinician-provided in the future, when perhaps the clinicians are not required to be there.”
Downie points to issues that may arise if the self-administered oral medication doesn’t work and paramedics need to be called to transport the patient to hospital.
She also said having an IV in place makes sense because if the oral cocktail doesn’t work, there’s a risk the patient’s veins won’t be accessible for an IV.
“I think the protocol is sensible for now, and I think in a few years time when we have much more information, I would say that that’s the information that should be given to people and then they can make the choice about the risks,” she said.
“The criminal law does not require a clinician to be present at all. These are protocols that are happening more at the local level and by professional associations. Those you can anticipate shifting over time as we come to know and understand it better.”
Despite this, Downie believes the oral protocol requiring a clinician’s presence does still provide a degree of autonomy for patients who may elect that option.
“You can say ‘Fine, I don’t want you in the room,’ put in your IVs, and then say ‘Go be over there, and then I am going to drink this,’ and they feel it is less clinical, less medical, to drink a cocktail,” Downie said.
“They are the final actor, and some people would choose that.”
‘Not a slide down a slippery slope’
When it comes to mental illness being a sole underlying condition for MAID becoming legal next March, Downie said people shouldn’t use the word “expansion” to describe the inclusion of mental illness because it was allowed at the beginning under the Carter decision.
“It has been taken away, and so now (next) March it’s going to be given back. But people keep talking about it as if this is an expansion and a slippery slope,” she said.
“And it’s just not. It’s climbing back up. It’s an uphill battle. It’s not a slide down a slippery slope, it’s just returning us to Carter.”
The Expert Panel on MAID and Mental Illness is required to submit its conclusions and recommendations to the federal government by March 17 of this year.
That independent panel was tasked with conducting a review and making recommendations about protocols and safeguards required when mental illness is included in the country’s MAID legislation next year.
Downie said she’s looking forward to reading that report when it’s publicly released. She’s also closely watching the province of Quebec where legislation is expected to be announced this spring that will enable people to make MAID requests in advance.
This means they can request MAID before loss of capacity and likely before all eligibility criteria are met and intolerable suffering has set in.
“There’s huge public support for advance requests across the country,” Downie said.
“If you see that (happen) in Quebec, there’ll be enormous pressure on the federal government to also allow that. That’s an issue that Nova Scotians want to start thinking about.”
According to Nova Scotia Health, since 2018, of the 1,389 patients, 29 (2.1%) who were referred for MAID have paused or withdrawn their MAID requests.