Consultations on Physician-Assisted Dying - Summary of Results and Key Findings

• “Advance care directives must be considered paramount in decision-making as these are the expressed wishes of an individual while competent.” (Representative Sample respondent)
• “A person must be able to make their legal directive for physician assisted dying BEFORE they become incapable of rational decision making.” (Open Public respondent)
• “An early diagnosis of Alzheimer's disease should give the patient the right to decide to end their life. There should be a written request signed before two witnesses, and the doctor assigned to the patient must be included in the steps towards aid in dying. An example is if I do not recognize anyone and have no idea of what is happening around me.” (Representative Sample respondent in French)

Concern about misuse/abuse:

• “As a retired health care professional who taught consent legislation to my colleagues, I am aware that Ontario Consent legislation is still very poorly understood and implemented by health care professionals and ever more poorly understood by the general public. I am deeply concerned about the abuse of advance directives in such an environment of benign ignorance.” (Open Public respondent)

Health care proxy:

• “If a family member with advanced dementia, or other fatal illness, doesn't have a Living Will, there should be a provision for the executor of their will, family members, or whoever holds the enduring power of attorney, to request a doctor investigate the possibility of ending their life.” (Open Public respondent)
• “An individual should be able to appoint someone to make a request for assisted death if included in a legal power of attorney for personal care if they become incapacitated and unable to follow through with their own wishes to make such a request.” (Open Public respondent)
• “In the scenario of Alzheimer's with an advanced directive, the power over that person’s life and timing of death should not be in someone else’s hands despite being a health proxy.” (Open Public respondent)
• “For progressive illnesses, the requests must be made while the person is still able to understand the ramifications on their families, etc. Substitute decision makers should not be making these types of decisions once the person is unable to do so for themselves if they have not previously made such a request.” (Representative Sample respondent)

Age of eligibility:

• “Anyone under the age of 18 should not have this choice. They have not experienced life enough to make this decision for themselves.” (Representative Sample respondent)
• “I think the patient should be 19+ and have a full understanding of their condition.” (Representative Sample respondent).
• “Children, no matter if they are an infant up until they turn 18, should not be eligible. They have not yet formed the complex thought process involved in making this decision.” (Representative Sample respondent)
• “The minimum age should be over 21 years … and it should only include incurable diseases like Alzheimer's or dementia.” (Open Public respondent in French)
• “Age of course is an important factor, but consider the minor who has for example a rare disease, is well aware of their prognosis and conditions (most children with rare diseases are very well informed about their disease), and wants to consider options in consultation/collaboration with their primary care giver(s).” (Open Public respondent)

Parental consent:

• “This type of decision shouldn’t be made by minors, i.e. under age 18. Their parent/guardian shouldn’t be able to make it for them. The individual would have to be 18 and capable of making the decision on their own.” (Open Public respondent)
• “Age of consent should be considered. Perhaps parent/guardians would need to approve for those under the age of majority.” (Open Public respondent)

• “This should be a conversation between the individual and their doctor. All that should be required is informed consent.” (Open Public respondent)
• “Anyone contemplating assisted suicide should, by law, have to have an interview or series of interviews with a psychologist or psychiatrist, perhaps one appointed by the courts, to ascertain the person’s ability to understand their condition and make an informed decision on the subject.” (Open Public respondent)
• “As long as a person 16 years of age or over is able to understand their options and can make their decision with competence and of sound mind, there should be no further debate. However, under no circumstances should anyone be allowed to make the decision on another person’s behalf (i.e., family/guardian of a person with an intellectual, mental, physical or other disability). This decision must be made when a person is competent, of sound mind, understands their options and can give informed consent.” (Open Public respondent)
• “There should be a thorough discussion with professionals and family before an individual makes the final decision.” (Representative Sample Respondent)
• “A person should be terminally ill and be able to make a decision at any point in the illness. Someone who is depressed, mental health issues is not capable of making an informed decision.” (Representative Sample Respondent)

• “It should be the individual’s choice (with physician consultation). Adults suffering with physical ailments (cancer, ALS, Alzheimer's etc.) should have few, if any, barriers to accessing physician-assisted dying and voluntary euthanasia. Those under 18 and those struggling with mental health issues that lead them to ask for physician-assisted dying should have different criteria for eligibility. But mentally well adults should be able to make their own decision on this matter with as few hoops to jump through as possible.” (Open Public respondent)
• “This should be a personal decision. An individual should have the right to determine whether or not they want to live or die. The patient is the one who has to live with their illness, day to day. No one can determine a rating of “Quality of Life” for anyone else.” (Open Public respondent)
• “It’s definitely the patient who decides whether to live or die, and this should be done before they no longer have the strength to say it.” (Open Public respondent in French)
• “I believe it should always be the choice of the individual, regardless of their current medical situation, to be able to end their life. It is their right. I do not believe it IS right, just that it is THEIR right.” (Representative Sample respondent)
• “If your condition is terminal, you should have the right to die with dignity and stop suffering.” (Representative Sample respondent)

Both terminally ill and in intolerable pain

• “A terminal diagnosis with eminent death or very brief life expectancy, accompanied by extreme pain that cannot be controlled by analgesia.” (Open Public respondent)
• “I think the court made it clear: (a) you live in pain and (b) you are about to die anyway. If you have (a) and (b) together, that's the only time the person should be eligible.” (Representative Sample respondent)

Progressive condition

• “A person with a life threatening or progressive degenerative condition is already on a path toward death, which can be “hastened.” A person who is not already at risk of dying due to a medical condition should not be encouraged or supported in choosing death.” (Open Public respondent)
• ”My personal opinion is that only persons with severe, incurable conditions that will not improve, e.g. terminal cancer, Alzheimer’s, ALS, etc. should be considered eligible.” (Representative Sample respondent)

Disability and mental health condition

• “I feel [physician-assisted dying] should only be available to those who are seriously ill, not just having a disability but actually seriously ill and facing intolerable pain with no chance of recovery at all.” (Open Public respondent)
• “I believe one should have the option of physician-assisted death in terminal and exceptional impending death but not because the person’s mental state does not feel life is worth living because of physical disabilities.” (Representative Sample respondent)
• “I think it is important, as shown in your scenarios, that mental health or depression that can be fixed with medication, doesn't get confused with an illness that you are dying from.” (Representative Sample respondent)

Palliative care and alternative treatments

• “All patients should have access to quality palliative care.” (Open Public respondent)
• “There needs to be assurance that necessary care is available immediately as needed, be it mechanical, medication, and/or qualified attendant care, in order to maintain quality of life for the greatest length of time prior to termination as this will be a determining factor in maintaining dignity.” (Representative Sample respondent)
• “Before suicide should be an option, I think every service for mental help and care assistance should be explored. Afterwards the decision should be up to the affected individual.” (Open Public respondent)
• “Many of the people in the scenarios would benefit from better access to mental and physical health care… Along with criteria for assisted suicide, we must ensure that everyone is provided with such access.” (Representative Sample respondent)

Social and financial supports

• “It seems to me that there should be mandatory supports in place for individuals prior to making this decision, for example, social workers, religious supportive community, support groups, counseling, meeting others who face the similar conditions, palliative care professionals, transition counseling, etc.” (Open Public respondent)
• “People should not feel a need to die because of their socio-economic situation, for example poverty or feeling like a burden to family.” (Representative Sample respondent)

Of all the top risks identified, this is the most reflective of respondents’ views in support of access to physician-assisted dying. The most significant concern related to access to assisted dying is that patients will not be able to receive assistance to die because there will be many physicians refusing to participate. In this view, many respondents took issue with a physician’s personal views impacting their access to the service, as they felt that this is “putting beliefs ahead of patients’ needs. Another issue identified by respondents is the level of bureaucracy that will be implemented for physician-assisted dying, which they fear will be too slow, arduous and excessive, leading to the system getting “bogged down” and “making it impossible” to receive assistance to die. If the process is too time-consuming and delayed, it will be especially problematic for patients who are suffering and have “no luxury for multiple options and timelines.”

Respondents were also concerned about unequal and inconsistent access to assisted dying, particularly in rural and remote communities that already experience gaps in access to health care services (e.g. palliative care). As a result, access to assisted dying will “depend on where people live”, and finding the necessary knowledge and skills – let alone willing physicians – could be particularly challenging for individuals living outside of urban areas. More broadly, some respondents also feared that access to physician-assisted dying could be limited or blocked by religious / advocacy group influence and “intimidation” of both individuals and government / politicians, which they felt is unfair as this impacts end-of-life options for everyone.

Both Open Public and Representative Sample groups highlighted the risks around access to assisted dying, although the Representative Sample respondents focused most on the impact of physicians’ beliefs in restricting access (concerns around bureaucracy and geography were not as prominent).

• “A big risk is a doctor making judgement on his religious feelings and therefore not looking after the patient according to the patient's requirements and needs. The doctors opinion on how we choose to live, die or when, should never be involved.” (Open Public respondents)
• “Physicians refusing to assist patients in suicide in accordance with their own moral/religious beliefs, as is sometimes the case with abortion/contraception. This might simply lead to prolonged patient suffering.” (Representative Sample respondents)
• “A major risk is that it will turn into a bureaucratic nightmare - legal in theory, but inaccessible in practice. I can imagine lengthy forms, lists of documents required, consultations required with multiple health care professionals, each of whom with a long wait list; while the patient suffers and deteriorates and ultimately is not able to access assisted suicide.” (Open Public respondents)
• “Changes should be Canada wide. Patients should not have to travel to another province to get the help they want as they now have to travel to other countries.” (Open Public respondents)
• “Concerned that undue influence from doctors that do not support assisted dying combined with fundamentalist religious groups and conservative politicians’ bias, the information and media coverage, preventing a healthy public discourse.” (Open Public respondents)
• “We risk that external influences may be more influential than what an individual actually wants for their life.” (Open Public respondent in French)

Many respondents from both the Open Public and Representative Sample groups expressed concern that more patients will be directed towards physician-assisted dying because of unclear consent parameters and/or influence from other parties, which are closely connected. Many respondents were particularly worried about family influence, as some patients may be encouraged by their family to request this option, or that their family may be more willing to choose it for them if they’re unable to communicate themselves. Financial considerations (e.g. inheritance, less of a burden) were the most common rationales suggested by respondents. Some also expressed concerns with physicians, who can exert significant influence over a patient’s decision making (both for and against physician-assisted dying, depending on their beliefs).

Respondents also identified risks where a patient may not have given – or be able to provide – clear and explicit consent for a wide variety of reasons, yet may still receive assistance to die (which some suggested is occurring in other jurisdictions). As a result, there were many questions around who can provide consent on behalf of the patient, as well as whose opinion takes precedence. Family / loved ones, physicians, substitute-decision makers, and those with power of attorney were all mentioned. Additionally, some felt that there are risks with consent being provided by patients in moments of temporary distress, who may change their mind over time. It is worth noting that some respondents rejected the premise of anyone but the patient being allowed to provide consent, which they felt effectively reduces the risk of physician-assisted dying.

• “Family members may request that a patient be "put out of their misery" when in effect, it is for the convenience of the family. This could involve wanting to get at the estate of the deceased sooner, rather than waiting until nature took its course.” (Open Public respondent)
• “We risk that external influences may be more influential than what an individual actually wants for their life.” (Open Public respondent in French)
• “Physicians and patients have an unequal relationship. A health professional who has the upper hand might pressure a patient who may not be thinking clearly due to drugs or disease to consent to a procedure that the patient might not fully understand even in the well state. That includes consenting to be euthanized.” (Open Public respondent)
• “Questionable competency of the patient requesting assistance to die.” (Representative Sample respondent)
• “From my years working in Palliative Care there have been times the patient has said "I wish I could just die" but the following day they have a change of heart & are ready again to take on life whatever it has to offer. Mental health patients will have many ups & downs but are happy when their suicide attempt fails & they finally get the medical attention they require.” (Open Public respondent)
• “This is a personal decision and needs to remain within the confines of the choices the individual has made, and only that person can agree to participate in any ongoing discussions, ulterior motives, or harassment from other groups or individuals to influence their decision.” (Open Public respondent)
• “I think the only thing that is important is the person’s wishes. If they have made the request and they have a terminal illness, it does not matter what society thinks or the doctors think - if living in pain and having no quality of life is too much for someone to handle then they should be allowed to end it. The only person that knows what they can handle and what they cannot, is the patient and I don’t believe anyone should be allowed to second guess their feelings and wishes.” (Representative Sample respondent)

According to many respondents, one of the most concerning risks of physician-assisted dying is that it will contribute to the devaluing of human life, with people’s views on the sanctity of life diminishing over time. Some feel that this practice inherently threatens human dignity, as some individuals may be stigmatized and influenced to: view their own life as hopeless / less valuable / “not worth living”, feel they are a burden to others, and “need to justify their existence.” Participants expressed particular concern for vulnerable groups, such as the elderly, people with disabilities, and people with mental health issues. As a result, many felt that physician-assisted dying will ultimately change how people view each other in Canadian society: with less compassion and perceived duty to help and care for others. Additionally, some respondents discussed the positives (e.g. personal growth, family bonding) that can come from suffering and dealing with difficult situations.

Of all the concerns identified, this contained the most references to religion and spirituality. While both Open Public and Representative Sample groups identified concerns over devaluing life, it was much more prominent among Open Public respondents. Additionally, it is worth noting that these concerns are closely linked to those articulated in another top theme – Relaxing of Eligibility Criteria.

• “We are talking about a cultural slide, a degradation of everyone's life when human beings are disposable; this will change the way we treat others in general.” (Open Public respondent)
• “Human beings have the right to life simply because they are human -- this is an objectively measurable standard. When the right to life is changed to something subjective, where the right comes from possessing specific abilities or enjoying certain qualities of life that others think are necessary, then the right to life becomes violable. Such a fundamental change makes it logically impossible to draw a fixed line between those who can be killed and those who cannot.” (Open Public respondent)
• “PAD emphasizes that we value some lives over others. We are saying that we agree that your life no longer has meaning and importance. Does this not undermine what it means to be Canadian?” (Open Public respondent)
• “Society should be caring, not killing. We should be showing compassion to those suffering, not encouraging them to end their lives. We should be loving and kind to them and help them through their troubles. God has created humans in His image, and by taking our own life we are not showing respect for God's creation.” (Open Public respondent)
• “As a society we have been conditioned to believe that suffering and pain are things to be avoided, despite the fact that many people attest to positive outcomes despite pain and suffering.” (Open Public respondent)

One of the predominant risks is physicians and other health care workers being pressured or forced to participate in (as well as provide referrals for) assisted dying, even if they are conscientious objectors due to moral, ethical and religious reasons. As a result, there is concern that physicians and others will effectively lose their conscience rights, as their right to refuse the practice may not be heard, respected, or legally protected (there are many questions about how this will work). Respondents felt that this is a significant burden to place on health care workers, especially since they are trained and feel obligated to protect life. Many insisted that these rights must be defended, as physicians and others need the freedom to follow their own conscience and values. There is also the fear that physicians will be discriminated against or punished if they refuse to participate, such as through fines, suspension, dismissal, and loss of their right to practice. As a broader point, some feel that physician-assisted dying will lead to a decline in health care professionals over time, as physicians could start leaving their practices and individuals may be discouraged to enter the field altogether.

Both Open Public and Representative Sample groups highlighted these risks, although it was more prominent (in relation to other identified issues) among Open Public participants. It is also worth noting that some – though far less – Open Public respondents expressed the opposite view: physicians should not be allowed to deny assisted dying due to their personal beliefs.

• “I am concerned with the pressures that will be placed on Doctors who have moral objections to this issue and the possibility that they may be legally forced to assist with assisted suicide, if they wish to keep their careers and practices. It should not be a mandatory service they must provide.” (Open Public respondent)
• “Ensuring the freedom of conscience on this issue for health care providers.” (Open Public respondent in French)
• “Health care providers made an oath to 'cause no harm', there will be physicians who will not want to assist in killing their patients, and will not give a referral to a doctor who will. These doctors should have the right to refuse to help their patients kill themselves.” (Open Public respondent)
• “An incredible burden to place on physicians whether or not they want to assist in the death of their patient - guilt all around.” (Open Public respondent)
• “Physicians who do not want to participate in assisted-suicide in any form need legal protection. They need to be able to remain in good-standing and suffer no legal / social / financial penalties.” (Open Public respondent)
• “Safe-guarding the practice without any discrimination of the physician who is opposed to assisting a patient who has expressed a desire to die; and also safe-guarding the practice without any discrimination of the physician who is opposed to referring such patient to a doctor who is willing to assist a patient who has expressed a desire to die.” (Representative Sample respondent)

Another of the top prevailing risks, respondents emphasized the need to ensure relevant education and training for physicians and other health care professionals in the area of assisted dying. Respondents noted that many physicians are not well informed of the full range of palliative / end-of-life care options more generally, let alone being prepared to effectively handle assisted dying (some indicated that the former is an important foundation / precursor to the latter). Physicians also need training to improve their communications skills in order to effectively assess, inform and discuss assisted dying with their patients. On this note, respondents also expressed concerns with how a physician’s personal traits (e.g. lack of empathy) – combined with their personal beliefs and attitudes – may negatively influence how they inform and counsel discussions around assisted dying. Considering these factors, some respondents worried about the overall subjectivity involved: while some doctors will be well equipped to deal with assisted dying, there are many who will not.

More broadly, some respondents also felt that assisted dying degrades the integrity of medical professions and may change perspectives on the patient-provider relationship, as it conflicts with the notion of providing health care, healing, and saving lives. Many respondents suggested that it should not be one physician who decides whether a patient receives assistance to die because it is “too big of a responsibility”. Multiple physicians, a team of health care professionals, or specialists in the area should be involved or provide support. While both Open Public and Representative Sample groups identified these concerns as top risks, the latter group was less explicit about the need for education and training.

• “All health care professionals need additional training to better discuss a full range of options from full aggressive treatment all the way to natural or assisted death. This should be a core skill of all health care providers to ensure patients are well informed.” (Open Public respondent)
• “Health care providers do not yet have mandatory training and/or protocols around palliative care. Why would physician-assisted dying protocols and training be introduced before physicians have had compulsory training in palliative care, which is aimed at relieving suffering?” (Open Public respondent)
• “Different doctors have very different skills sets when it comes to bedside manners. I would hate to think that patients' choice to end their lives could be so dependent on the way in which the "choice" pros and cons are laid out by their doctor. Some doctors could have a higher "death rate" associated with the patients under their care because of the doctor's own personal beliefs and attitudes.” (Open Public respondent)
• “Doctor personal bias towards ending lives. Some doctors currently push their own personal bias towards ending life on the elderly and will refuse treatment and downgrade dnr levels on their own.” (Representative Sample respondent)
• “A doctor is trained to preserve life wherever that is possible to ask them to participate in assisting suicide is a negation of that training.” (Open Public respondent)
• “As a nurse I'm concerned that schools of medicine and current physicians are either not adequately trained or comfortable with breaching these topics with their patients. In addition I feel this should be approached with the idea of a team approach in mind. One in which, not only the physician, but also the patient, clergy, social worker , nurse, family, physio, psychiatrist etc. is involved in approaching the subject but also carrying out the wishes of the patient.” (Open Public respondent)

There are concerns that the introduction of physician-assisted dying in Canada could lead to the eligibility criteria broadening or relaxing over time, resulting in a “slippery slope” (a term used by many respondents) where the practice normalizes and becomes more common. Respondents are worried that more individuals will become eligible to receive assistance to die, and it will become more difficult to determine who qualifies (e.g. how to quantify suffering). Respondents were most concerned about children and the elderly (especially with the aging population in Canada), but also for individuals with mental health issues, illnesses, and disabilities. Many participants warned that eligibility has broadened and assisted dying continues to increase in other jurisdictions where the practice is permitted – particularly the Netherlands. Additionally, some felt that this will also allow for greater abuse and unintended use of the practice overall. For example, there are worries that financial / economic considerations could influence decisions around assisted dying, with people being pressured to make requests because they feel they are a burden to their family / loved ones or society more broadly.

While these risks were identified by both Open Public and Representative Sample groups, it was much more prominent with the former (and is closely tied to another top theme – Devaluation of life). Overall, this was not one of the top risks highlighted by Sample respondents.

• “I am concerned that as time passes the boundaries will disappear and assisted death would be society's answer to difficult people. As soon as we open these doors others find a way to abuse the rules.” (Open Public respondent)
• “How to counter the illusion that assisted dying is a solution that will quickly become the answer, because people in general are terribly afraid of suffering.” (Open Public respondent in French)
• “There is not a jurisdiction in the world that has been able to successfully respond to the inherent risks with assisted suicide and euthanasia. In fact, peer-reviewed studies show that the number of physician-assisted deaths continue to increase in these other jurisdictions, even in the face of clear evidence that the law is not being properly followed.” (Open Public respondent)
• “Being of Dutch background, I know that in a very short period of time, a person can ask to be euthanized for almost any reason he or she gives. Also, those who are a "burden on society" will feel the need to justify being an expense, not only to the medical care, but also to society as a whole i.e., special education programs in schools. But above all, God has created humanity in His image. We have always been taught that it is not right to murder or to kill another human being. If we cross this line, where do we end? What ground will Society stand on? I would think it will be a shifting ground.” (Open Public respondent)
• “Rather than society viewing the disabled, elderly and dying with respect and compassion, they will be viewed more in terms of a burden on their family and taxpayers and considered selfish unless they seek to end their life (do the honourable thing).” (Open Public respondent)

Many respondents felt that the patient-physician relationship will ultimately change as a result of this practice. They suggested that there will be a significant shift in the physician’s role (e.g. “from caregiver / healer to death facilitator”, “from lifesaving and suffering alleviation to death providing”, “and not as a caring human being”), which will erode patient’s trust and confidence. Respondents identified various ways in which a physician’s approach, motives, and interests could direct patients toward assisted dying in various ways (e.g. feel it is more expedient than long-term care, do not have knowledge of solutions / options, want to be alleviated from being overworked or dealing with a difficult patient). Over time, they feel that more doctors will become desensitized to assisted dying and more likely to suggest it to their patients. It is worth noting that many of these respondents signalled an overall distrust or fear of health care providers and the system, with some citing negative personal experiences. In their view, the introduction of physician-assisted dying amplifies this lack of trust because it gives physicians even more power and authority over patients.

Additionally, some respondents expressed distrust in the health care system more broadly. Given the context of rising costs, significant resource constraints and an aging population, they felt that assisted dying may increasingly be seen as an economic solution for patient care. Both Open Public and Representative Sample groups expressed these concerns but it was more prominent with the Representative Sample.

• “If a doctor brought up the idea of euthanizing me with me, I would never speak to him again. I shouldn't have to die because I have a condition, and no one should ever think that. Worse, he may bring it up with family/loved ones, or they may bring it up with him. I want my doctor to try to save my life and not end it.” (Open Public respondent)
• “Thus fundamentally changes the role if healthcare from a professional striving to enhance quality of life to one making decisions regarding prematurely ending life. This paradigm shift reduces the "helping", "caring" aspects of healthcare and will create a generation if health professionals who will have less regard for working with patients to find viable options to work through challenging situations to healthcare providers who gently encourage end of life as a viable option when life us hard.” (Open Public respondent)
• “Considering the low qualification of many doctors in this country, and the pressure to reduce costs with health care, my concern is that euthanasia be sold as a solution to keep patient's dignity, or as an act of bravery. There's a lot of brainwashing in this country towards making people believe the most cost effective practices are in fact the best practices for the patients. Euthanasia can be seen as a "normal" solution, and be sold as a right of the patient, and even be extended to other non-life threatening situations (such as people suffering from major depression).” (Representative Sample respondent)
• “In the context of budget cuts, health care professionals can be completely overwhelmed. They can be tempted to “cut corners” and go a little too fast when making these decisions.” (Open Public respondent in French)
• “The medical system will always lean heavily on the side of Physician-assisted suicide because in the long run it will be much cheaper and cost effective solution to help someone die rather than support them through palliative care.” (Open Public respondent)

Another important theme that emerged was the identification of broad supports and alternatives which might reduce the demand for physician-assisted dying or turn to this as a last option. Both Open Public and Representative Sample respondents highlighted that there is no reason for a person to suffer either physically or mentally because effective alternatives exist to support living or end-of-life care which is dignified, painless and natural. Palliative care was seen by both groups of respondents as a clear alternative to assisted dying with its focus on the primary goal of optimizing quality of life and helping persons with advanced, progressive, life-threatening illnesses to live as well as possible until they die. Investment in broader societal supports e.g. poverty reduction were also seen by respondents as going a long way to reduce the number of requests for assisted dying.

In the view of many, Canada should develop and/or implement national strategies which support the investment in, and assurance of, available/accessible programs, services and health care providers. Areas for investment include: end-of-life care, palliative, hospice or home care; pain control; mental health treatment and recovery; disability benefits; and, long-term and elderly care. These alternatives were noted to offer a “holistic healthcare system approach” which should be invested in together to offer a full range of options and choice. It is important to note that while some respondents saw assisted dying as “one piece” of this range of options or as a “last resort” others expressed that “assisted suicide and euthanasia should not be presented as or perceived as health care acts or medical interventions, so the providers of these actions should not overlap with health care services.”

Other coping strategies for stress reduction, pain relief and suffering that were identified by respondents of the Issue Book included: faith-based alternatives which shift “social consciousness toward acceptance of death as inevitable and not something to fear”, collaboration with allied health care providers i.e. music therapy, traditional Chinese medicine and Ayurveda.

• “We could go a long way toward reducing the number of requests if we as a nation did much better at reducing income inequality, and improving supports for disabled persons and their caretakers, mental health services, end-of-life-care and food security. We have been ignoring many of the things that make life worth living, and I and many I know would be more than happy to pay more in taxes to achieve a civil society in which everyone can live with dignity.” (Open Public Respondent)
• “An independent, ongoing review of the availability and funding of programs such as home care, palliative care, counseling [mental health], health care generally, and others I likely haven't thought of, the absence or reduction of which might tend in and of themselves to increase consideration of physician-assisted suicide.” (Open Public Respondent)
• “Educate people on the variety of care options and alternatives to physician-assisted dying. Make supports easy to find and access.” (Representative Sample Respondent)
• “More free access to specialized services: psychologists, social workers, occupational therapists. Unfortunately, with the austerity and lack of compassion for others, I do not feel that this will open the doors to the well-being of patients.” (Open Public Respondent in French)
• “Any and all options need to be implemented around giving every individual the help, support, and information that they need so that they do not feel hopeless. Our true goal as a society should be working toward a reality when there would be no one who would want assistance in dying, because they feel fulfilled, wanted, and worthy of the life they are currently living, regardless of disease or condition.” (Open Public Respondent)

Some Open Public respondents expressed the view that safeguards are either not needed (e.g. Supreme Court has made its ruling and now we need to “move on”) or should be minimal because too many safeguards will ultimately prevent access, impede a timely process, or not respect patient wishes. Representative Sample respondents did not express any explicit views in this area.

Some respondents expressed a differing viewpoint concerning the identification of safeguards stating that many of those listed are not actually safeguards but rather should already be in place as necessary parts of the Canadian health care system and independent of regulations that will permit physician-assisted dying e.g. “having good national policies on palliative care and support for people with disabilities is just good health care policy.”

• “A lot of the items on the previous screens just add incredible delay for people who are suffering incredible physical and mental anguish. A national policy on anything takes decades. Referrals to another physician (GP or Specialist) takes months! Let us start with the basis that people know their physical and mental capacity for pain and suffering. It a person wants to go, let them go.” (Open Public Respondent)
• “I believe that strong safeguards must be in place but that they must not be so onerous and time consuming that they serve to delay and put in place so many bureaucratic hurdles that it makes the process too difficult and dissuades the person from pursuing this path or seeking out information. There must be a FAIR balance.” (Open Public Respondent)
• “As I understand the Supreme Court's ruling, citizens must have the right to make the choice to die. Presently, individuals and their families have been denied this right by the safeguards put in place by people who wish to protect themselves professionally and legally. It is time to safeguard the right for Canadian citizens to make this choice without interference.” (Open Public Respondent)
• “By introducing legal roadblocks the patient's suffering will be increased. The less lawyers are involved with PAD the better. Similarly over sight committees will add a significant additional level of bureaucracy and time delay to a decision that should be the patient's alone, in consultation with a medical professional. The power should remain with the patient.” (Open Public Respondent)
• “No, everything is clearly mentioned and ultimately, the patient should have the right to decide on the end of their life if they do not want to suffer physically and psychological and if there is no acceptable quality of life.” (Open Public Respondent in French)

In response to the identification of additional safeguards, a prominent theme which emerged was opposition to assisted dying. Those who were strongly opposed to assisted dying in the Open Public and Representative Samples felt that no safeguards can be put in place to deem this practice acceptable; thus, it should be criminally prohibited with some going as far as counting it as murder.

Opposition to assisted dying is rooted within the following viewpoints:

• Beliefs and Religion: assisted dying was identified by some respondents as an “immoral practice” which goes against one’s basic beliefs of “thou shall not kill” with many emphasizing that only God has the right to end a human life and death is a process which should end naturally.
  • “All the paperwork and legislation in the world will not make physician assisted dying any safer. God is the giver and taker of life. He gives us suffering on this earth to cause us to trust in Jesus for the grace to live each day here. God can also perform miracles and heal people through the power of prayer. The only guidelines that are applicable in this case are in the Bible.” (Open Public Respondent)
  • “The best safeguard is for people to be read in the Bible, and recognize that this is only for God to decide.” (Representative Sample Respondent)
• Relaxing of Eligibility Criteria: this was based on the belief that over time the practice will become more common leading to unintended changes within our health care system and society at large in how we view care options and value human life - “once the line has been crossed, all the safeguards that may be put in place will be subject to constant change and challenge.”
  
  Respondents cautioned of a 'slippery slope' some claim has been experienced in other jurisdictions e.g. Netherlands and Belgium. In particular, respondents were concerned of potential abuses occurring in spite of safeguards - unreported euthanasia deaths, euthanasia carried out without consent, new-born infants born with disabilities euthanized, and obtaining euthanasia without any chronic illness.
  • “Safeguards are only as good as the degree to which they are implemented and enforced. Over time, the acceptance of physician assisted suicide will result in its general acceptance as the norm and the safeguards will slip down the slippery slope.” (Open Public Respondent)
  • “Normalizing assisted death as a solution for end-of-life issues will create a societal expectation that this is an option that should be considered. This will inevitably create a pressure on patients to consider this option, especially where they or their family feels that the care required will be a burden.” (Open Public Respondent)
  • “Our whole society is going to change with a mindset to end it all if they are depressed, terminal or not pain controlled. Our society will shift from supporting each other at the time of mental illness, terminal disease or pain to solving these dilemmas by getting a doctor to assist in suicide. What a sad way to look at troubles in our life! We need to build community!” (Open Public Respondent)
• Protection of the Vulnerable: tied to concerns of relaxing eligibility criteria was the belief that safeguards are not enough to protect and prevent harm to those who are most vulnerable in our society – poor, marginalized, disabled and elderly.
  • “Safeguards mean nothing when one group of powerful individuals (i.e. doctors, family members) are empowered by legislation to kill vulnerable patients. Safeguards do not prevent abuse of the vulnerable. They just make us feel better that we did everything we could when the abuse happens. It's better to say no to all abuse than to let some vulnerable patients slip through the cracks and be killed.” (Open Public Respondent)
  • “The main goal here is to prevent the most vulnerable people from harm. Prohibiting euthanasia is the best way. If not, make restrictions tight and have a judicial review very regularly to make sure the law is being followed in the assisted deaths.” (Open Public Respondent)
• Erosion of Medical Ethics: lastly, arguments against assisted dying were rooted in concerns over asking doctors, nurses or any other health care professionals to engage in activities which would be a violation of fundamental medical ethics and the Hippocratic Oath to cure patients and would therefore “ruin” him or her for the care of others.
  • "Safeguards are only as good as the degree to which they are implemented and enforced. Over time, the acceptance of physician-assisted suicide will result in its general acceptance as the norm and the safeguards will slip down the slippery slope.” (Open Public Respondent)
  • “Physicians are not executioners. Their purpose is to promote health and to heal. They should never be put into a position that they have to execute an individual or recommend and executioner to them.” (Open Public Respondent)
• Broad Supports and Alternatives: Both groups signaled the importance of practicing comfort and treatments which do not include assistance in ending someone's life.

According to many Open Public respondents it is important to ‘protect freedom of conscience’ of all medical and health workers (doctors, nurses, pharmacists). Respondents felt they should not be forced to participate in practices (i.e. assisted dying) which go against their medical ethics but also moral or religious beliefs. This viewpoint was held similarly by a few Representative Sample respondents.

Many noted that physicians should be under no obligation to refer patients to a physician who is willing to conduct this practice rather it was suggested that a self-referral system be implemented to avoid putting the ‘burden’ on the physician to refer. Through this system it was suggested that patients could conduct their own online search or visit a center that provides the names of doctors providing service in their community. Physicians who feel they cannot participate in assisted suicide, need to be supported in their decision free from any legal ramifications (fines or penalties) or discrimination in particular as it relates to job security.

A suggested alternative to participation and referral includes developing a new professional class with the role of assisting with dying and suicide. This alternative helps to “put doctors who are against assisted suicide out of the picture”; however, the exception is that they need to refer a patient to one of these professionals upon request. This new profession would be trained to ensure proper requirements and techniques are employed, just as current professionals such as engineers, doctors, lawyers do…

• “All doctors and health care workers should be able to live by their conscience. We need them. They should NOT have to refer patients for euthanasia if it is against their conscience or religion.” (Open Public Respondent)
• “Explicitly protect the conscience rights of all physicians and health care workers so they have the freedom to refuse to take part in, refer for, or counsel against the killing of any patient. No other jurisdiction that allows euthanasia or assisted suicide imposes a legal duty on physicians who conscientiously object to make referrals for physician assisted death.” (Open Public Respondent)
• “Absolute freedom in all provinces and jurisdictions with no reprisals for Doctors who because of conscious objection who will not refer or participate in euthanasia. I see too much in our country of people being forced to live and work outside of their beliefs or conscience.” (Open Public Respondent)
• “There is considerable risk to the wellbeing of health care providers involved in the provision of this ‘service’. This cannot be a required action in the registration of health care providers or not many of the people you want to attract to this profession will apply. This is not something many health care providers would be comfortable with. It is still a service that is very appropriate within the Canadian health care system, and very much needed to be provided in the correct circumstances.” (Representative Sample Respondent)
• “The requirement on the physician is unreasonable because their oath was to preserve life, this changes their profession and it may become an issue to have fewer doctors. We run a risk of changing and losing valuable physicians to a death cultured breed of physician. I personally will lose faith in the professionals.” (Open Public Respondent)

The view that people should have freedom of choice, including the right to control their own body and life, not prolong suffering, and be free from outside influence, was expressed predominantly by Open Public respondents. It was suggested that after considering the information and issues that affect them and their family, patients should have the right to choose physician-assisted dying. Both groups of respondents expressed the belief that with that choice should come the choice as well to change one’s mind. Others maintained that a patient’s wish to die should be protected, provided they meet the conditions laid down by the Supreme Court.

• “I believe that the only person who should be able to make the final decision should be the person whose life is in question. I believe that a doctor can offer life ending options but should never be allowed to make the final decision for the patient, regardless of metal or physical condition.” (Open Public Respondent)
• “Although decisions should be carefully weighed and follow a defined process, the 'agreement' of a diverse committee on each end-of-life decision threatens to once again remove the autonomy and dignity of the patient. Patients are making a very difficult decision, which should be made with the assistance of their physician and mental health professionals, and should be respected. At no point should they be requesting 'permission' from an external body.” (Open Public Respondent)
• “This should be the right of persons to control and have a say in end of life decisions. That kind of autonomy can only be served by appreciating that most persons would choose life but in situations where it has become unbearable there are ways to be able to end one's life without having to leave your home or Country or suffer by refusing treatment.” (Open Public Respondent)
• “Everyone will have a different threshold for what they define as the "tipping point" I believe this must be considered and respected. Physicians must learn to respect and uphold the patients wishes.” (Open Public Respondent)
• “There must be an easily accessible, always available, none punitive and simple mechanism whereby the patient can change his or her mind regarding any request to terminate his or her life at any point in time right up to the final moment. In other words, a person should have the right and ability to change their mind right up until it is too late to do so.” (Representative Sample Respondent)
• “NO pressure from family or caregivers should be experienced when making such a personal decision to end their life. DOCTORS should be making referrals for their patient if they REFUSE to participate, its the patients request.” (Open Public Respondent)
• “Once the patient has made their decision and it is deemed reasonable and undertaken with full knowledge, the next of kin should not be allowed to interfere. It is my understanding that currently next of kin can override a patient's wish to be an organ donor. This is wrong and it should not be allowed in end-of-life situations.” (Open Public Respondent)
• “Safeguards need to be introduced to ensure that access is not denied to any competent adult who is suffering in a manner which is unacceptable to THEM. It doesn't have to be unacceptable to a psychologist, a doctor, their family, or any other person. You cannot judge for somebody else.” (Open Public Respondent)
• “The ability to die should be a choice of the individual, after that individual is informed of their options and still chooses to die. Assisted dying should NEVER be a decision that a committee of professionals needs to approve.” (Open Public Respondent)
• “The most significant safeguard that we need to consider is to create a system that safeguards the patient's expressed wish to die, provided they meet the conditions laid down by the Supreme Court. This fundamental right must not be subverted by inaccessible, bureaucratic systems created to appease concerns of the medical profession and religious groups.” (Open Public Respondent)

In sharing their views on how to mitigate perceived risks and harm of physician-assisted dying for those most vulnerable, respondents identified processes or entities that would provide a review or oversight function before physician-assisted suicide could be provided. It was also suggested that review or oversight should take place afterwards for monitoring and evaluation purposes.

Key processes for review and oversight suggested by respondents of the Issue Book included requiring:

• Counselling: physicians refer patients that may be suffering from psychiatric or psychological disorders or depression for counselling. Death may not be granted until it can be confirmed by the counsellor that the patient is not suffering psychologically or from depression.
• Consent: It was suggested that consent be witnessed by at least two others (one of the witnesses must not be a relative or someone entitled to a portion of their estate), with the entire process video recorded from beginning of request, discussion with doctors, panel hearings, lethal injection and pronouncement of death. These video's must be regularly and independently reviewed by a joint panel of doctors, lawyers and ethicists and must be immediately and full accessibly to any judge, officer of the court or Parliamentarian upon request.
  
  It was also noted that consent must be given both orally and written, no less than 15 days apart, and can be rescinded at any time and in any manner without regard to his or her mental state. While it is important that we have a formal, written process in order to document a request by a patient to end their life, it must not be designed in such a way as to cause an impedance to any individual who seeks to end their life - for example, people with low literacy or language barriers or those who have suffered a severe stroke. As such, all efforts must be made to ensure the process is as inclusive as possible, including providing alternate forms of documentation to those patients who are incapable of physically writing a request (video, sign language). Conversely, many people who are capable of clearly communicating their wish to die may be intimidated by the task of writing a formal request and may not have experience writing formal documents themselves. Therefore, it was suggested that or providing resources to allow these individuals to write a request without relying on the help of friends/family who might influence them.
• Validation: It was suggested that the onus must be on those who are involved in administering physician-assisted dying to provide evidence from third parties that the request for death is not coerced, in every case. Failure to provide this should result in sanctions and other repercussions potentially including criminal charges.
  
  As a mechanism to support ongoing monitoring, Open Public respondents overwhelmingly identified the need for a judicial review every three years of all assisted suicide deaths. Should it be found that the law is not being followed it was suggested that an immediate moratorium of all assisted deaths be put in place and not lifted until the law can be amended to fully prevent harm.
  
  It was also widely suggested that an agency be created (reporting to the Minister of Justice or be formed through the Canadian Medical Societies/Association) with the mandate of monitoring assisted suicide deaths to ensure the law is being followed. A "Center of Excellence" approach was suggested to provide better control nationally to ensure established protocols are consistently applied and would better enable a reliable statistical data bank for evaluation purposes.

Additional or alternative review and oversight processes or entities suggested by respondents of the Issue Book included:

• Audits and Data Reporting: audits should be conducted with severe penalties for anyone who takes or assists in taking a human life without reporting it; public records should also be maintained on who has received assisted dying services or who has aided in this practice, directly or indirectly.
• Ethics Committees: the role of Ethics is paramount in the formulation of policy related to safeguards.
• Review Committees: to oversee and discuss each request submitted by the doctor; this would be a collaborative committee potentially including, physicians, nurses, public, pharmacists, clergy etc. to obtain unbiased evaluation and approval in a timely manner. Such a committee would serve as a support to physicians so that they are not left with the primary decision. The committee should be knowledgeable about the laws as well as medical and moral implications of the decision. There should also be an appeal process for the patient. Patients whose life expectancy is greater than 3-6 months should require a separate and more formal process, including a review board of expertise (legal, medical, ethicists) or hearing.
• Compliance reviews: appointed by an external commission this review would be conducted to ensure that all guidelines are being followed (should be conducted before the death has taken place, rather than afterwards) but this should not impose unreasonable delays - i.e., the review shouldn't add more than a few weeks to the process.
• Random Checks: to ensure all policies by patient and physician are being followed.
• Peer Reviews: for doctors (not Administrators or HR personnel) to evaluate other doctors, in order to establish and informally certify the health and robustness of the presiding doctors’ reasons for engaging in providing assisted-dying services.
• Federal and provincial Ombudsmen: to ensure appropriate and needed legislation and supports are in place.
• Consideration of a cultural and diversity lens in access to physician-assisted dying: issues should also be considered in the process and monitored e.g. Canada already has a disproportionate number of Aboriginal and First Nations people dying by suicide. It would be important to ensure this was not a factor (either way) in access to physician-assisted suicide and therefore any oversight body should include the capacity to monitor with this lens. Consumers/patients/families/citizens should be involved in the design and ongoing monitoring of the process from a purely neutral perspective (i.e. not medical. legal or economic).