1. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
Derryck H. Smith, MD FRCP(C)
Clinical Professor Emeritus
Department of Psychiatry
University of British Columbia
Vancouver, British Columbia
dhsmith@dhsmith.ca
BC College of Family Physicians
2014 Spring Family Medicine Conference
Vancouver, British Columbia
Four Seasons Hotel
June 7, 2014
Faculty: Dr. Derryck H. Smith
 I have no financial or academic conflicts of interest
to declare
 I am a Board Member and Chair of the Physician
Advisory Council for Dying with Dignity
 I am not affiliated with any religious groups
 I have been involved in the Gloria Taylor case as an
expert witness
 I have presented to the Liberal Senate Caucus on
these issues.

2. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
• No Commercial Support
Mitigation: The act of reducing the severity, seriousness or
painfulness of something.
• My goal is to mitigate the effects of a painful,
meaningless death.

3. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 Why should we allow Medically-Assisted
Dying in Canada?
 What are the common arguments against
Medically-Assisted Dying, and are they valid?
For:
1. Individual autonomy
2. Relief from pain and suffering
3. An obligation to assist patients
Against:
1. Intrinsic wrongness of killing( mostly religious based)
2. Integrity of the profession
3. Potential abuse of the vulnerable
4. Would detract from Palliative care
There is no evidence to support 2,3 or 4 from jurisdictions
where euthanasia in all its forms are legal.

4. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
• The Principle ethical principle in medicine and in
western civilization is individual autonomy.
• Competent patients who are in the terminal stages of
dying should be able to have control over when they die
and the interventions that are being used to keep them
alive.

5. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
The wise man lives as long as he should, not as
long as he can. He will always think in terms of
quality, not quantity. Dying early or late is of
not relevance, dying well or ill is. A prolonged
life is not necessarily better, a prolonged death
is necessarily worse.

6. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)

7. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 Sample was the City of Lethbridge and area
 “Legalize Doctor-Assisted Suicide”
 Agree 77.5% 2014
60.7% 2004
• Non religious 89.5% Agree
• Highly religious* 53.2% Opposed
* Attends church more than 2 – 3 times/month

8. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
Source: Forum Research Inc. December 2011
 Sample
1,160 adults –
December 13, 2011
 67% favored
physician assisted
suicide of terminally
ill patients
 “I don’t know how I want to go, but I do know that I
want to be the one who decides.”
Wayne Sumner, Assisted Death: A Study in Ethics and Law
 Polls routinely show that 60-80% of Canadians
support the legalization of Physician-Assisted
Dying
 Support across all regions, genders, age groups,
languages, income, and party affiliation
 These numbers have remained steady since 1993
 Highest support Quebec 79% , British Columbia 76%
Environics Institute, October 2013

9. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
CMA Poll of 2125 members – Physician Assisted Suicide
CMAJ , March 5, 2013 185(4) pp 357
Yes No Not Certain No Response
If euthanasia
was legal would
you participate
20% 42% 23% 15%
Participation in
Physician
Assisted Suicide
16% 44% 26% 15%
Should assisted
suicide be legal
24% 36%
59% had withheld life sustaining intervention following a request from a
patient.

10. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
CMA Policy 2007
“Canadian physicians should not participate in euthanasia
or assisted suicide.”
CMAJ , March 5, 2013 185(4) pp 357
 Timing and manner of death are arbitrary
 Withdrawal of Life Support
 Withholding of Life Support
 Artificial feeding and hydration
 Causation is subjective
 Requests for assisted death are also related to terminal
illness
 Why should people have to wait for a fatal
complication?
 Potential for symptoms, trauma to family members

11. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
Frequently in my experience the debate is really
about religious beliefs.
My view:
In modern pluralistic society public policy should
not be driven by religious beliefs, but by
maximizing the autonomy of the individual
citizen.
 Not physical
symptoms
◦ 2/5 in importance
 Loss of control
 Dependence on
others
Ganzini. J Gen Intern Med 2007;23(2):154–7

12. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
• Death with Dignity Act passed 1993
• 2013, 71 people “hastened their death”
• 0.2% of all deaths
• 87% were in a hospice (versus 45% in other deaths)
• 97% died at home
• Number one reason “wanting control over their final
days”

13. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 Assisted
suicide
◦ Oregon (1998-
2012)
◦ Washington
(2009-2012)
 Does this
describe a
vulnerable
group?
Characteristic Washington Oregon
Number 255 935
Age 85+ 15% 11.9%
White 95.2% 97.6%
High school
graduate
94.1% 93.2%
No health
insurance
2.7% 1.7%
End of Life concerns
Loss of autonomy 90.6% 90.9%
Inability to engage
in enjoyable
activities
88.6% 88.3%
Burden on family 38.6% 36.1%
Financial
implications of
treatment
4% 2.5%
1990 1995 2001 2005
Voluntary
Euthanasia
1.7% 2.4% 2.6% 1.7%
Assisted
Suicide
0.2% 0.2% 0.2% 0.1%
Life-
terminating
acts without
explicit
request
(LAWER)
0.8% 0.7% 0.7% 0.4%
Total 2.7% 3.3% 3.5% 2.2%
End of Life Decision-Making in Canada: The Report by the Royal Society of Canada
Expert Panel
On End of Life Decision-Making 2011 Page 62
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265521/
The Dutch Experience
Legal Termination of Life introduced 2001
This 73-page report concludes there is no evidence of a “”slippery slope”.

14. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 Need to be vigilant
 Non-voluntary euthanasia
 No law will stop people breaking the law
 Assisted death/LAWER in countries where it is illegal
 5.6% of deaths in NZ are assisted suicide or euthanasia
 1/3 of Australian surgeons have given medications with the
intention of causing death, often without a request
Denmark Italy Sweden
Doctor-
assisted
Dying
1.82% 0.1% 0.23%
LAWER 0.67% 0.06% 0.23%
Van der Heide et al. Lancet 2003;362:345-50.
Mitchell and Owens. N Z Med J 2004;117:U934.
Douglas et al. Med J Aust 2001;175:511-5.
2001
• 20% of deaths involve withholding treatment
• 20% use of opioids
• 2.4% active euthanasia
• 0.2% physician assisted death
• Public support for euthanasia - 90%
• Doctors - 57% have performed euthanasia
- 10% would never perform euthanasia
There is no evidence that the availability of euthanasia
undermines palliative care.

15. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
http://www.telegraph.co.uk/health/healthnews/9631334/Doctors-to-investigate-use-of-controversial-Liverpool-Care-Pathway.html
 Oregon MDs who opposed Physician-Assisted
Death were 2x as likely to report a patient
becoming upset or leaving their practice as a
result of their position compared with
physicians who supported Assisted Suicide
 13% of MDs became more supportive of PAD
with time, compared with only 7% who were
less supportive
Ganzini et al. JAMA 2001;285:2363-9.

16. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 What is “symptom
control”?
 Transient statistical
improvement?
 97% of patients in
Oregon who
received Assisted
Death were enrolled
in hospice care
Oregon Death With Dignity Act, 2012 Annual Report http://www.healthoregon.org/dwd.
Meyers FJ et al. JPSM 2004;28:548-556.
http://www.assnat.qc.ca/en/actualites-salle-presse/nouvelle/Actualite-25939.html
 Dying with Dignity – an
exhaustive 175 page
report on assisted dying
 “unrealistic to believe that
palliative care will be
universally available in the
near future (p 59)
 In Europe “the legalization
of euthanasia has boosted
the development of
palliative care”
 The committee visited
Belgium and Holland and
were reassured that there
was no evidence of abuse
or a “slippery slope”

17. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 PC available to only 30% of Canadian
population
Carstairs, Raising the bar (2010)
 Oregon – 0.2%
 Holland – 2.2%*
 Belgium – 3.8%*
◦ * lower than pre-legalization
levels
Oregon Death with Dignity Act 2011 Annual Report
Van der Heide. N Engl J Med 2007;356:1957-65.
Bilson et al. N Engl J Med 2009;361;1119-21.

18. The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. Smith, MD FRCP (C)
 Netherlands and Belgium
 Growth in PC and hospice services
 Oregon
 Among highest rates of hospice referral, opioid
prescription and EOL communication
 Increased referral to hospice since legalization
 Increase in MD self-education about PC practices
 Clearer distinction between PC and PAD
Quill T. NEJM 2007;356:1911-3.
Ganzini et al. JAMA 2001;285:2363-9.
1. The majority of Canadians (and many dying
physicians) want to be able to decide when to end
their lives – PAD is the most reasonable option.
Only 20% of Canadian doctors are in favor.
2. There is no evidence that
a) Vulnerable citizens are being killed
b) PAD undermines PC
c) There is no huge increase in PAD over time
In summary, there is “NO SLIPPERY SLOPE”.
3. Jurisdictions with PAD report general satisfaction
from both physicians and patients.