Dr. Jeff Blackmer, vice-president of medical professionalism at the Canadian Medical Association, spoke to Maclean’s this week about the complicated grey area in which doctors now find themselves when it comes to assisted death, and why it is difficult, if not impossible—ethically, professional and emotionally—for most physicians to contemplate helping their patients to end their lives.
Q: From the CMA’s point of view, what is the current landscape with no legislation in place and the Supreme Court deadline passed?
The parameters set forward in the Carter decision become the de facto law at the federal level. It’s really not reasonable to expect the Supreme Court of Canada to lay out the clinical parameters that physicians would be expected to follow—that’s really not part of their job. So to have to defer to a court judgment when it comes to something as serious as assisted dying and how that will be applied at the bedside is incredibly challenging for the vast majority of physicians.
Carter says this is reserved for competent adult persons, but it doesn’t say who an adult is. It doesn’t say if they have to be competent at the time of the request or the assisted dying, or both. And it says they have to have a “grievous and irremediable medical condition.” I’ve spoken to thousands—probably tens of thousands—of Canadian doctors on this issue, and I’ve asked every one of them, “Have you ever used ‘grievous’ in a clinical context?” And none of them have. So the first challenge is for doctors to figure out what those terms mean, and how to use those to determine who qualifies for assisted dying.
The second challenge in this interim period is the lack of clear legal protections. So if you’re a Canadian doctor and you go ahead in this interim period and help someone to die, and you think they met those criteria, and then you get taken to court and a judge finds that in fact the patient did not meet those very vague criteria, you will face federal sanctions. So we’re not talking about a slap on the wrist—we’re talking about jail time.
For the average physician who’s trying to navigate this ethical minefield, it’s just one bridge too far to say that not only am I going to participate in something that I’ve always been taught is anathema to the medical profession, but I’m going to do it without any federal law in place to protect me.
Q: So are things just in a state of suspended animation where really no one will have access at the moment?
A: There absolutely are some physicians stepping forward. Some of them have been quite vocal in the press and said, ‘We think this is something Canadian patients should have access to,’ and they feel very, very strongly about it for what I have no doubt are reasons of compassion and caring.
There are also doctors who, in this interim period and beyond, absolutely will not participate in this. That’s really the majority of the profession. We’ve done some polling that shows that’s somewhere around 70 per cent of physicians who have said, ‘I will not make this a part of my medical practice.’
Then there’s a group in between, and they’re the ones who are waiting for the legal protections offered by the federal law, as well as to see what type of patients will qualify.
So obviously the end result of all this in that interim period is questions around access, and whether patients who otherwise would qualify will have difficulty finding a doctor. And we just don’t know. This is a completely novel situation for the public and the profession alike.
Q: It seems like the opinions of doctors are different from the general public on assisted death. Can you explain how doctors see their role? Why might this be, as you say, anathema to what they see as their mission?
If you ask the public, what you’re really asking them is, ‘Do you want to have a right to access these interventions if you come to the end of your life and you’re suffering?’ That’s a very different question than if you ask a medical professional, ‘Do you want to kill your patients? Or do you want to assist in the death of your patients?’ One is a right, the other is an obligation. Those are intricately related. If someone in society has a right to something, it means someone else has an obligation to provide that. So basically the Supreme Court that has told Canadian physicians, after centuries of this being illegal and completely in opposition to all teachings in medical ethics, ‘We are now going to make this legally available, and you as a profession have an obligation to step forward and provide it.’
I think, to the profession’s credit, we have responded to that in a very constructive way. We’ve taken part in all of the conversations, we’ve helped to frame the legislation and the regulations, we have not opposed this. But we have also tried to make clear how very, very difficult this is for most doctors.
Imagine you go into the profession of medicine and you’re being told your obligation is to preserve life, to improve quality of life, to cure whenever possible, to care always. Then all of a sudden, overnight a court decision tells you, ‘Now everything’s changed. Everything you believe in medicine is a little bit different today.’ That’s very, very challenging for the average doctor to just do a 180 in terms of their belief system and their approach to care at the end of life.
Q: Do you think there has been adequate acknowledgement of what a burden there is on physicians with assisted death?
A: No. No, I really don’t. I think that’s gotten lost in the discussion. I had some meetings with some very senior federal politicians who have actually used not very nice language in saying that they really don’t believe when I tell them this. I even had one tell me, ‘I think doctors love to play God, and you’re all gonna be just fine with this because it’s just an extension of your desire to play God.’
Q: What’s your reaction when you hear something like that?
A: I told this federal politician I was very offended by that, and that to suggest that— even behind closed doors—was incredibly insulting to a profession that’s now being asked to do this. This was a politician who in public was saying how much we trust the medical profession.
I think when we explain this to people, they get it. When I’m able to sit down with senators and MPs and walk them through it, the vast majority come away with a real understanding of the profound and lasting impact this will have on the profession.
This is why, when we’re having these conversations about what should be in the bill or how we should approach this, we really wanted to be an important voice at the table because we’re the ones who are being asked to do this. I go to legal conferences and I hear from lawyers, ‘It should be this,’ and, ‘It should be that,’ and I say, ‘Well, how many of you are going to be participating in this? None of you.’ So they’re coming from a very theoretical perspective—and I respect that, because the legal voice is very important. But try and temper that with some compassion for physicians who are being asked to participate in that.
Q: What do you think will be the psychological needs of doctors who decide to provide assisted death, and what will be the best way to serve those needs?
A: We do know from experience in other jurisdictions that it has a profound psychological impact. Some physicians are very resilient and they just incorporate this into their mindset, and they just look at it as alleviating suffering, and those physicians are okay. But there’s been recent surveys in the Netherlands that show in physicians who participate in assisted dying, eight out of 10 experience anxiety or greater as a result.
In Canada, each provincial and territorial medical association has physician health programs, sometimes for physical illness, often for psychological or emotional struggles. We’re already letting them know that we’re anticipating that some physicians might be reaching out.
At the CMA, we’re in the process of planning courses that are going to teach physicians how to care for patients at the end of life, including assisted dying, and we will be developing a community of support, where physicians that take these courses will be forever linked together. They can reach out to a colleague and say, ‘I’m really struggling. I had this terrible case today, and it’s really impacted me. How are you dealing with this?’ There’s nothing like connecting with someone who knows exactly what you’re going through.
I’ve been talking about this non-stop for the last two years, so I get a lot of doctors reaching out to me personally, saying, ‘I’m willing to participate in this, but I can tell you, I’m already losing sleep over what it’s going to feel like.’ We recognize the impact this will have even on those colleagues who are very supportive of the right to choose—it is still going to be very difficult for them on a very fundamental basic human and moral level.
Patients share with us their deep secrets and things with us that they may not share with family members. They are so vulnerable in that context that physicians really struggle at the best of times with those relationships and how to respect that vulnerability and make sure we maintain that trust and that we live up to that standard people expect of us. This is so fundamental to the whole ethos of medicine and the practice of medicine, it becomes a part of who you are as a person. So to incorporate this new way of thinking into that centuries-old traditional context, it’s even more difficult.
Q: Why was medicine the right career for you?
A: Well, I wanted to be a fireman in Grade 5, but ever since then I knew I wanted to go into medicine. It’s just such a caring and humane profession, and there’s no greater compliment you can be given than that you’ve truly made a difference in someone’s life on such a fundamental level. I look after patients with spinal cord injuries and different types of neurological conditions, and to see some of my patients succeed in the way they have, and to be even a small part of that, is just indescribable in terms of the professional and personal satisfaction that it gives. That’s all related currently to seeing patients get better or see them achieve things in the face of adversity, or having some sudden clinical insight that helps someone. And now, we have to think about potentially helping them with death as a positive sort of intervention. That’s a really different mindset.
Q: Have you decided if you would be comfortable providing assisted death to any of your patients should they ask?
A: I’m actually not talking about that. It’s a perfectly reasonable question to ask—it’s just so personal, and I do have patients talk to me about it because of the populations that I serve. I guess what I can say is: I’m still struggling with it, just like so many of my colleagues are.
Q: What are you hearing from doctors as far as whether they are comfortable discussing their own views publicly?
A: In 2014, before the Carter case was heard, I met with our members in a whole bunch of Canadian cities. And we locked the doors to the rooms and we said, ‘Okay, there’s no media, there’s no members of the public, it’s just us doctors here. Let’s have an adult conversation about assisted dying and end of life.’ In that context, people really shared, because we’re all in this together. But it’s hard—just like any profession, I would imagine, but maybe medicine more than some—it’s hard to help people from outside of that profession understand the context. So physicians are very reluctant to open up publicly. It’s because it is so personal, and doctors also don’t want to be seen as complainers. We don’t want the public to see this as a burden on physicians.
Although I honestly don’t believe there will be any threats to safety, I think we’ve learned the hard way—the very hard way, through deaths and disability from the abortion debate—that is unfortunately a remote but real possibility. Some public lectures that I give, there are armed police in the crowd, and we had a debate at one point about whether I should wear a bulletproof vest at one event. Not because there were ever any specific threats—that’s never happened—but because of the sensitivities.