Juliet Guichon, Christopher Doig and Ian Mitchell are faculty members in the Cumming School of Medicine, University of Calgary; Pauline Alakija is a forensic pathologist and clinical professor at the University of Alberta medical school; Pascal Thibeault is a master of laws student at the University of Toronto.
As the Supreme Court of Canada considers arguments about physician-assisted dying, and other governments and health service organizations give effect to or create law, policy and medical standards, one challenge arises that can easily be addressed.
The challenge is how to operationalize the Supreme Court's requirement that physician-assisted dying must have stringent limits that are "scrupulously monitored."
The Collège des médecins du Québec has addressed this challenge by putting physicians in a conflict of interest and then requiring them to complete the medical certificate of death – "the attestation of death" – inaccurately. The Quebec government, the Canadian Medical Association and the Provincial-Territorial Expert Advisory Group have unnecessarily recommended new monitoring agencies.
The best way to monitor physician-assisted dying is surprisingly simple: Accept that the existing coroner and medical examiner offices receive notification of every physician-assisted death, and permit coroners and medical examiners to continue to do their job of accurate death reporting.
Accurate death reporting reflects the value Canadian society places on human life – satisfying the community that the circumstances surrounding the death of any one of its members will not be overlooked, concealed or ignored – by investigating deaths occurring in dangerous and preventable situations; making recommendations that can prevent deaths; and aggregating and publishing data of public interest and concern. Coroners and medical examiners are experts in accurate death reporting. This simple solution of mandatory notification of every physician-assisted death in Canada to local coroners and medical examiners will solve four problems.
The first problem is potential conflict of interest. Mandatory reporting will ensure that the medical certificate of death is completed not by the physician who gives the prescription or injects drugs, but by the independent coroner or medical examiner. The need for a second pair of eyes was underscored by the British inquiry into Dr. Harold Shipman's actions in completing the medical certificates of death himself for the more than 200 patients whom he killed. The inquiry concluded that "to afford the public a proper degree of protection," a new system of death reporting must minimize any risk of concealment. There is a similar need for monitoring of physician-assisted death to ensure that it is used only in accordance with the Supreme Court's decision.
The second problem is the accuracy of death reports. Coroners and medical examiners are independent officials who are experts at accurately recording the cause and manner of death, even in sensitive types of deaths such as suicides and child homicides. The Collège des médecins du Québec has issued practice standards that tell physicians to omit the term "medical aid in dying" from the death certificate and to record these deaths as natural deaths to protect the family from the truth. Truth-telling by public officials is important because, among other reasons, it will maintain public trust in physician-assisted dying.
The third problem is expertise. Mandatory reporting will ensure that physician-assisted deaths are reported to people who are qualified to receive the information, to investigate when necessary and to recommend further investigation when warranted.
The fourth problem is prudential use of government funds. Quebec, the CMA and the provincial-territorial group have each either legislated or proposed new public offices for death reporting and investigation in the specific case of physician-assisted death. But such expenditure is unnecessary. Physician-assisted dying is likely to be a very small practice in Canada. In jurisdictions that already permit the practice, such deaths are reported to total between 0.23 per cent and 4.5 per cent of all deaths. There is no good reason to establish new oversight offices to monitor these non-natural deaths, given the experience and expertise of the existing death reporting and investigation offices and the risks of creating untried – and possibly unqualified and expensive – alternatives with overlapping jurisdiction.
In at least 10 of 13 provincial and territorial jurisdictions, it's already mandatory to report physician-assisted deaths. This is because of provincial and territorial legal systems that by law require notification of some natural, all non-natural and any suspicious deaths. In the three provinces in which toxicity is not explicitly a cause of death requiring reporting (Quebec, Nova Scotia and Newfoundland and Labrador), the law should be revised specifically to require mandatory reporting of physician-assisted death to the coroner or medical examiner.