Doctors from Toronto’s Sick Kids Hospital have outlined policies and procedures for medically assisted death for children. Photo from Wikipedia

Assisted suicide plans for children unveiled at Toronto's Sick Kids hospital

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  • October 4, 2018
TORONTO – In a prestigious medical journal, doctors from Toronto's Hospital for Sick Children have laid out policies and procedures for administering medically assisted death to children, including scenarios where the parents would not be informed until after the child dies.

The article appears just three months before the Canadian Council of Academies is due to report to Parliament on the medical consensus about extending voluntary euthanasia in circumstances currently forbidden by law. The Canadian Council of Academies is specifically looking at extending so-called assisted dying to patients under 18, psychiatric patients and patients who have expressed a preference for euthanasia before they were rendered incapable by Alzheimer's or some other disease.

The Sept. 21 paper written by Sick Kids doctors, administrators and ethicists was published in the British Medical Journal's J Med Ethics and backed by the University of Toronto's Joint Centre for Bioethics.

In a flowchart that outlines how a medically induced death would occur at Sick Kids, authors Carey DeMichelis, Randi Zlotnik Shaul and Adam Rapoport do not mention conversation with family or parents about how the child dies until after the death occurs in the "reflection period."

Patient confidentiality governs the decision about whether or not to include parents in a decision about an assisted death, the authors said. If capable minors under the age of 18 stipulate they don't want their parents involved, doctors and nurses must respect the patients' wishes.

"Usually, the family is intimately involved in this (end-of-life) decision-making process," they write. "If, however, a capable patient explicitly indicates that they do not want their family members involved in their decision-making, although health care providers may encourage the patient to reconsider and involve their family, ultimately the wishes of capable patients with respect to confidentiality must be respected."

The proposed policy for Sick Kids argues that there is no meaningful ethical distinction between a patient choosing to refuse burdensome treatment and accepting an inevitable death versus patients who choose to die by chemical injection before the disease brings on death. Legally, Ontario does not require parents to be involved in a capable minor's decision to refuse further treatment, therefore there is no legal reason to require parent involvement in an assisted death, according to the Sick Kids policy.

Bioethicist Bridget Campion said she is neither surprised nor shocked by the article.

"The fact is medical assistance in dying is now legal. And it's legal in many places around the world," said the researcher, lecturer and writer with the Canadian Catholic Bioethics Institute. "Now that it is legal, many practitioners are saying, 'How do we do this?' I'm not surprised at all."

Opponents of assisted suicide are concentrating their efforts on a fight for conscience protections, she said, both for individual clinicians and for religious health care institutions.

"It's a tough thing to know what to do next under the circumstances. This is now legal," she said. "In my opinion, if we are committed to building a culture of life, forget the legislation. That ship has sailed. There are some things that we absolutely must make sure stay in place – that there can be Catholic health care, that there can be conscientious objection. But, to me, the biggest thing is, 'OK, how do we build a culture of life? How do we build a culture of care?' If we can do that and make it so that people don't want medical assistance in dying, then we will have achieved something."

Like other Catholic bioethicists, Campion finds the assisted suicide argument based on patient rights and autonomy simplistic and overly narrow. But the Sick Kids policy seems to take no account of collective rights or values, as it concentrates on patient autonomy.

"These days, what I'm thinking about is that we tend to think of medicine as a highly private thing – between the patient and the clinician," she said.

"We have to be thinking about communities of health as well, communities of wellness."

Comments (3)

  1. Sharon

This is exactly, precisely, what was forecast when abortion was made legal in the US. The idea was dismissed as hysterical, over-the-top, right wing hyperbole. I wish I'd kept those news articles, but I myself thought it was a bit over the top....

This is exactly, precisely, what was forecast when abortion was made legal in the US. The idea was dismissed as hysterical, over-the-top, right wing hyperbole. I wish I'd kept those news articles, but I myself thought it was a bit over the top. But this is where we are now. I was in my early 20s at the time and was dismayed even then. The official line was that abortion would be only for those most difficult cases, the hard cases, and wouldn't be used as birth control or past the first few months. Can nobody see that the same delaying tactics happen over and over again?! Slippery slope is not a logical fallacy; it is exactly what has happened through the inexorable pushing of the Left. No one is safe. We are all at one time or another zygotes, fetuses, babies, teens, middle aged, and/or elderly. Anyone can be handicapped, or senile, or depressed, and probably will at some time or other. Either life is sacred or it isn't. Either we love or neighbors or we don't. And loving our neighbors has never meant to kill them.

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  1. Dr. Jeff Myers

In their article Drs. DeMichelis, Shaul and Rapoport comprehensively review the unique ethical complexities surrounding pediatric MAiD. In this piece Mr. Swan has omitted key considerations described by the authors related to family member...

In their article Drs. DeMichelis, Shaul and Rapoport comprehensively review the unique ethical complexities surrounding pediatric MAiD. In this piece Mr. Swan has omitted key considerations described by the authors related to family member disclosure.

The authors pose and respond, "Would we really allow a capable patient receiving care in our paediatric hospital to receive MAID without the knowledge or consent of their parents? In other circumstances in which capable young people make medical decisions that result in the end of life, the answer is ‘yes’, although, again, clinicians would strongly encourage the patient to discuss this decision with their family."

Note that the authors do not communicate a stance that relates directly to MAID. They go on to question: "Is MAID meaningfully different from these practices? Is it sufficiently different to justify violating existing confidentiality standards? Again our working group found itself uncertain about the nature of MAID with legal, professional and scholarly sources all pointing in different directions or remaining silent."

To underscore, the authors in fact express uncertainty around the issue of family disclosure. This is a highly delicate and sensitive topic and at the very least deserves a level of respect and accuracy when representing perspectives.

Dr. Jeff Myers
Head, Division of Palliative Care
Faculty of Medicine, University of Toronto

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  1. Patricia Torngren

I understand that some people are frightened of things getting out of control. But it is highly unlikely that the Canadian government would ever allow anything like the above to happen and it appears that whoever wrote the article is afraid of...

I understand that some people are frightened of things getting out of control. But it is highly unlikely that the Canadian government would ever allow anything like the above to happen and it appears that whoever wrote the article is afraid of the so-called "slippery-slope" which is not happening anywhere where assisted dying is made legal. If anything, doctors tend to err on the side of caution, and many people who are suffering beyond belief and for whom palliative care is not enough, are falling through the cracks. The benefits of assisted dying are that once someone in great pain knows they have a way for it to end sooner, many people relax (which makes the pain less) and die peacefully with their loved ones around them. About one third of the people who qualified (in Oregon where it was studied) either don't collect the medication or don't take it and after they have died, their families return it. When the option of assisted dying is not available, people sometimes get desperate and attempt suicide in violent ways like shooting or hanging themselves. When the option of assisted dying is available there are fewer desperate people, fewer unnecessary deaths and more peaceful passings.

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