How far can advance care directive go?

A bioethicist who spent decades urging Catholics to plan for their last days by naming a substitute decision maker in an advance care directive is now incensed at the idea the government will likely allow the directive to be used to invoke euthanasia.

In a quick consultation process that included a two-week online survey in January, Canada’s Justice Department has been figuring out how to extend so-called Medical Aid in Dying (MAiD) or voluntary euthanasia — possibly to people whose underlying medical condition is solely psychiatric, to teens judged competent to make their own medical choices and to cases of disability where death is not “reasonably foreseeable.” 

One of the options on the table is to allow Canadians to specify in an advance care directive that they want doctors to end their life even if — or because — they become incompetent and can no longer communicate their preference.

“Advance care directives are a bad idea for euthanasia,” said Redemptorist Fr. Mark Miller, an ethicist for the Centre for Clinical Ethics serving the Unity Health hospitals of St. Michael’s, St. Joseph’s and Providence in Toronto.

“Even with regard to treatment decisions, (advance care directives) are sometimes notoriously difficult to interpret,” Miller said.

Interpreting a person’s wishes for assisted suicide from a document will be just as ambiguous if not more so, Miller said.

“Advance directives were originally brought in to help prevent over-treatment by doctors. Then they moved to the place of expressing patient wishes about end-of-life treatment,” Miller said. “Every piece of legislation that I looked at regarding advance directives explicitly states that they could not be used for euthanasia.”

Legal documents commanding doctors to end the life of their patients has the potential to rip families apart in hospital rooms, according to Miller. Figuring out just when a dying patient would have wanted to stop treatment is already a fraught decision for designated substitute decision makers faced with family members who may never have spoken to the patient about their end-of-life decisions, he said.

"Even with treatment decisions, (advance care directives) are sometimes notoriously difficult to interpret"

- Fr. Mark Miller

“If one adds the challenges of communicating exact wishes in a document about an unknown situation, there will be huge gaps in what a substitute decision maker reads and what a person has intended,” Miller said. “Will advance care directives trump family relationships? We already have a problem with advance care directives and acceptance or refusal of treatment options when the family has not been informed.”

The most likely use of advance care directives to order up MAiD is by people who decide they would rather not live through all the stages of dementia.

“They are judging Alzheimer’s patients from their own point of view, as living a life not worth living,” Miller said. “But many of those with Alzheimer’s are quite content.”

Miller anticipates a future of advance care directives ordering doctors to kill happy and comfortable dementia patients while family are left helpless to intervene.

Expansion of Canada’s euthanasia laws has been mandated by a September Quebec Superior Court decision that struck down parts of the 2015 law which restricted MAiD to “reasonably foreseeable” natural death. 

The federal government, then in the middle of an election campaign, decided against appealing the decision, which will go into effect March 11 unless the government asks for an extension.

Canada’s Catholic bishops have deplored the speed of the revision process, but have not specifically urged the government to ask the court for an extension.

Miller believes Catholics need to better understand their Church’s opposition to euthanasia.

“We live life to the end, like our Saviour who died on the cross,” he said. 

“Not by being stoics and following a rule not to kill ourselves, but by trusting that there is a (health care) system where we will be looked after and people who genuinely care enough to help us live while dying — because we are worth it and we are not dead yet.”

Government and media have fallen for persuasive marketing of death by euthanasia societies that use the fear of dying to make choosing death seem like a heroic, even moral stand, according to Miller.

“From an ethics point of view, once it is established that it is good (see St. Thomas Aquinas on choosing the good) to kill somebody, then who has the right to limit the criteria?” he asked.