Medical schools are grappling with difficult choices on how to change the way they teach medicine, in the wake of a landmark Supreme Court of Canada ruling legalizing physician-assisted suicide.
In a unanimous ruling released in February, the Supreme Court struck down provisions of the Criminal Code that prohibit physician-assisted suicide and voluntary euthanasia on constitutional grounds. It said these services should be available to a competent adult who clearly consents to the termination of life and who has “a grievous and irremediable medical condition” that causes intolerable suffering. The court suspended its ruling for a year to allow Parliament time to introduce new legislation.
Although medical schools already include end-of-life care in their curricula, the court’s ruling will require significant changes in the way it is taught, said Geneviève Moineau, president and chief executive of the Association of Faculties of Medicine of Canada. “Every student will need to be informed of the most recent decision by the Supreme Court,” she said. “That’s an absolutely important part of our new reality.”
Dr. Moineau said the last time faculties of medicine had to deal with such a profound change in health law was in 1998, when the Supreme Court struck down laws that prohibited abortion. “This will be similar,” she said. But medical schools must wait until the federal and provincial governments bring in new legislation – should they choose to do so – before making specific curricular changes, she added.
At the University of Toronto, undergraduate medical students receive 72 hours of training on ethics and professionalism, including end-of-life care, spread over four years, said Erika Abner, the undergraduate faculty lead on ethics and professionalism. This includes some discussion about the Supreme Court decision and its potential implications. “But we can’t go very much further because we’d be speculating on what’s going to happen, and we really don’t know how it’s going to be rolled out legislatively,” Dr. Abner said.
However, Jocelyn Downie, professor in the faculties of law and medicine at Dalhousie University and a member of the legal team for the plaintiffs in the case, said medical schools should begin preparing for the changes now. “We know that physician-assisted suicide and voluntary euthanasia will be legal in Canada as of next February,” she said. “That suggests to me that it’s not too early to be developing modules on the clinical practice side of things, how to perform it, how to provide it.”
Medical schools will also need to teach legal and ethical considerations, said Dr. Downie. “You have to teach them what is the law so they understand what they can and can’t do, what they must and must not do,” she said. She noted that a study recently published in the journal, Canadian Family Physician, found that many of the Quebec health care practitioners surveyed were confused about which end-of-life practices are already legal in the province and which ones would become legal under the proposed “medical aid in dying” law. Quebec’s National Assembly approved the legislation, which permits doctor-assisted suicide, last year. It is expected to come into effect at the end of 2015.
Faculties of medicine also need to consider who will deliver the training and in what year of study. Dr. Downie said all undergraduate medical students should be taught the legal and ethical considerations of assisted suicide while residents could learn the clinical and practical aspects. She is planning to develop teaching modules on the legal aspects of the Supreme Court’s ruling that she will make available to medical schools that request them.
Another consideration will be how to deal with students who have a conscientious objection to providing such services to their patients. All doctors must be trained to inform patients of their rights and about who can help them receive the services they want to receive, said Dr. Moineau of the AFMC, the association representing Canada’s 17 faculties of medicine. But, as is the case with abortion, they will not have to perform those services.
Once the ruling comes into effect, Canada will join several other jurisdictions that allow physician-assisted suicide including the Netherlands, Belgium, Luxembourg, Switzerland and some U.S. states. It remains an offence in most Western countries.
The issue has been a contentious one for Canadians and for the medical profession. Surveys by the Canadian Medical Association show that its membership is divided on the issue. The CMA has called on legislatures to ensure than any new laws contain safeguards to protect the rights of physicians, both those who elect to perform euthanasia and those who don’t.
Harvey Chochinov, Canada Research Chair in palliative care and psychiatry professor at the University of Manitoba, said a doctor’s personal views on assisted suicide can get in the way of what should be an objective determination of a patient’s ability to provide free and informed consent. Doctors who are the least experienced in pain management and palliative care are those who tend to be most supportive of “death hastening practices,” he said in an email. On the other hand, physicians who are politically opposed to assisted suicide are less likely to be able to determine a patient’s competence to provide consent than doctors who support it.
As far as training goes, medical schools need to do a better job of educating students about issues related to death and dying, he said. Students must understand that an expression of a wish to die indicates “abject suffering” which can occur throughout one’s life. “The medical curriculum should teach students how to respond to an expressed desire for death, the multiple antecedents that give rise to these feelings, and the ways and means of mitigating such profound anguish,” Dr. Chochinov said.
“It is inconceivable to contemplate teaching students how to euthanize patients when the basic skills and competencies needed to address those things moving patients towards a wish to die are hardly broached, let alone mastered, during the course of medical training,” he said.