It's been six months since Quebec's right-to-die law took effect, and the experience there can provide some useful information for the rest of Canada, where assisted-dying legislation passed just more than two weeks ago.
One lesson is that, on an emotion-laden issue such as this, passing a law does not end the debate – if anything, the arguments of opponents and proponents are amplified once there is legislation to pick apart.
The second, and perhaps most important, lesson is that a law has to be interpreted and implemented and that rarely happens in a seamless fashion. Some of the decisions that will impact patients most are made quietly in the backrooms.
There was a striking example last week when it was revealed that the palliative-care unit of the McGill University Health Centre (MUHC) was allowed, by the hospital's board of directors, to opt out.
Practically, what that meant is that if a dying patient requested an assisted death, they would be transferred to another part of the hospital.
On the surface, this is not a big deal. But it's an unnecessary hurdle that sends a clear message that the concerns of practitioners trump the rights of patients – and that's wrong.
On Monday, palliative docs defended the decision, saying it benefits patients. That's nonsense.
The rules clearly violate the spirit, if not the letter, of the law.
Quebec's law clearly states that individual physicians can refuse to provide assisted death, but that publicly-funded institutions cannot. (However, the province has allowed standalone, not-for-profit palliative-care facilities to refuse to provide assisted death, even though they receive significant public funding.)
The opposition of many palliative-care specialists is well-known.
But Quebec Health Minister Gaétan Barrette reacted angrily to the MUHC allowing one unit to opt out, a move he dubbed "philosophical obstructionism" and "almost childish."
It is worth noting, too, that another large hospital, the Centre hospitalier universitaire de Québec, has in-house rules that assisted deaths must be carried out in the palliative-care unit, so the opposition is not universal.
These kind of skirmishes are only just beginning for the federal law.
If there is one certainty, it is that there will be lawsuits. Within days of Bill C-14 being adopted, the B.C. Civil Liberties Association launched a constitutional challenge, saying the "reasonably foreseeable" clause is discriminatory. A group of Christian doctors has challenged the requirement in Ontario that physicians who have a "conscientious objection" to providing assisted death themselves must, minimally, refer patients to another physician who will. (Quebec resolved this debate by allowing objecting physicians to refer to a neutral third party, to a hospital administrator who will, in turn, find a physician who will carry out a patient's final wishes.)
Almost all of Canada's 110 Catholic hospitals have also indicated that they will refuse to provide assisted dying, something that will be particularly problematic in small centres with a single hospital.
Quebec law – like federal law – requires a patient to be terminally ill to be eligible for assisted death. It also requires two physicians to sign off on the request, though at the Centre hospitalier de l'Université de Montréal (CHUM), a nurse can provide the second signature. This rule change came because doctors appeared to be rejecting many legitimate requests.
In recent days, statistics have begun to trickle out. (Under the law, they must be published every six months, but in a decentralized fashion, so overall numbers are difficult to calculate precisely.)
What we know is that, since the law passed in Quebec last December, there haven't been a lot of assisted deaths – only about a dozen a month.
There have been roughly 120 requests, and about 40 were denied.
There were roughly 30 assisted deaths in the Quebec City region, 12 in the Eastern Townships and five in the Outaouais.
In Montreal, the numbers are especially low: There have been only two assisted deaths at the MUHC (one of who was transferred from palliative care), and six at the CHUM – Montreal's two super-hospitals, along with one each at the Royal Victoria and the Montreal Neurological Institute.
It's not enough to have a law saying patients have a right to assisted death. Physicians, institutions and lawmakers must ensure that right can be exercised.
If a patient's constitutional rights are to be real, not merely theoretical, self-serving obstructionism cannot be tolerated.
André Picard