Running head: ADVANTAGE OF ADVANCE DIRECTIVES
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A CASE AGAINST BILL 14: The Advantages of Advance Directives for Medical Assistance in
Dying
Jessica Grewal
Seneca College
NUR403 - Development of Self as Nurse: Nursing Ethics
Dr. Malini Persaud
March 16, 2020
ADVANTAGES OF ADVANCE DIRECTIVES
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A Case Against Bill 14: The Advantages of Advance Directives for Medical Assistance in Dying
The Royal Society of Canada’s Expert Panel on End-of-Life Decision Making defines
advanced directives as “directions given by a competent individual concerning what and/or how
and/or by whom decisions should be made in the event that, at some time in the future, the
individual becomes incompetent to make healthcare decisions” (Schüklenk et al., 2011, p. 5).
Federal Bill 14 regarding Medical Aid in Dying decrees that individuals with degenerative
disorders should not have the right to advance directives even when they are of sound mental and
cognitive state to give consent. When taking into consideration the crucial role of ethics and
morals in the medical field, it is clear that Bill 14 ultimately rids competent Canadian citizens of
their basic rights of life and liberty. I argue that due to the increase of severe mental diseases that
alter cognition at the time of diagnosis, Canadians should be permitted to prepare an advance
directive for MAID before their illness begins to affect their competency and decision making.
This essay will explore how the benefits of advance directives outweigh the drawbacks by
examining the personal, economical and societal advantages of allowing patients to give consent
to MAID before they reach a point where they are mentally incompetent to make healthcare
decisions.
I will first explain why denying patients the right to advance directives leads to negative
consequences for the individual on a personal level. The first aspect to consider is why the
person whose life is in question should not have the ability to exert control over it, especially if
he or she is already aware that their future level of mental cognition will not allow for such
decisions to be made after the fact. As Dr. Justine Dembo of the University of Toronto informs,
“judgments about suffering, irremediability, and quality of life are closely intertwined, and
capable patients rightly define these terms as they apply to their own unique situations. Because
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suffering is a personal experience, only the affected individuals can assess whether it is
intolerable” (2018, p. 453). As such, it is clear that in such a subjective situation, it would only
make sense that the final decision should be in the hands of the individual who would be most
affected, in the form of an instruction directive, or the individuals that he or she entrusts that
right to, in the form of a proxy directive. The healthcare field, especially, is one that especially
must ensure an ethical code of conduct based on the best intentions for the patient, and the best
way to do so is to allow a patient to have adequate control over their end of life care. In addition,
as Ronald Ingle (2012) highlights, the use of advance directives has major impacts on an
individual’s sense of dignity in dying. Advance directives give patients a certain level of control
that rids them of the potentially devastating impacts on self-image and dignity near the end of
their life as a result of being seen at their lowest by loved ones. When they have a plan in place
for their end of life care, both the patient and their family can feel more at ease with the situation;
the patient may not feel as if they are a burden to their family, and the family may not feel
pressure to make decisions on behalf of their suffering family member, without a clear
understanding of what he or she would have wanted. As such, it is evident that just as the use
advance directives would allow for the patient to better plan their own life and allow the patient’s
family to better accommodate their loved one.
Furthermore, the economic benefits of allowing for advance directives must be
considered. In order to examine these benefits, I will first present some startling characteristics
regarding the global elderly population, of individuals older 60 years of age. As Sahardi notes,
“According to the WHO, the proportion of the world's population older than 60 years of age will
nearly double from 962 million to 2.1 billion in 2050… Moreover, in 2050, 80% of the older
population is expected to live in low- and middle-income countries” (2019, p.1). The importance
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of these statistics to Bill 14 is backed up the majority of scholarship on the issue, including the
Royal Society of Canada Expert Panel on End-of-Life Decision-Making. The World Health
Organization (WHO) specifically call attention to the relevance of aging population and growth
in chronic diseases to end of life discussions (Schüklenk et al, 2011, p. 8). It is also imperative to
mention that the degenerative diseases being referred to in Bill 14 such as Alzheimer's disease,
Parkinson's disease, and atherosclerosis are directly related to ageing through the deterioration of
organ functions and mental competency (Sahardi, Makpol 2019, p.1). Taking into consideration
the fact that the number of individuals at risk to these diseases is gradually increasing, it is worth
discussing how this could affect the future of healthcare costs. It logically follows that more
patients in palliative care require more financial resources and thus increasing expenses within
health care as a whole. These expenses not only take away more from the taxpayers’ pockets but
might also result in funding cuts to other deserving areas of the healthcare field. Advanced
directives can take away at least a portion of these expenses by permitting the wishes of patients
who do not want to remain in palliative care for an extended period of time, thereby helping
reduce lower health care costs as a whole. As a result, the economic incentives against Bill 14
are clearly evident and given the economic benefits assist in lowering healthcare costs for the
majority, it is a moral win as well.
This leads to the final advantage of advance directives that I will discuss in this paper
which has to do with the societal and ideological impacts of Bill 14. The decisions an individual
makes in regard to their end of life care rely heavily on the Canadian Constitution’s core value of
autonomy which has historically been protected through legal rights in Canada (Schüklenk, et al,
2011, p. 8). As such, one must question why the federal government would propose such a bill
that limits the legal status of individuals and directly contradicts the principle of autonomy that is
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central to the Canadian Charter. I believe it is also necessary to examine a popular argument in
favour of Bill 14 in order to prove that it is not a justifiable criticism of advance directives. Dr.
Merril Pauls among others, informs that autonomy is tricky to situate in this situation because of
the responsibility of healthcare professionals in acknowledging that the patient’s wishes and state
of mind might differ following the time after he or she writes an advanced directive. However,
Dr. Pauls, Larkin and Schears also iterate that “in most situations, an AD matches what our
clinical judgment would support (i.e., the terminally ill patients who do not want life-sustaining
treatments) or we are able to verify the wishes with a substitute decision-maker” (2015, p. 563).
Thus, it is clear that this criticism, though valid to a certain point, rarely takes effect and speaks
more to the fact that advanced directives are more helpful than they are detrimental. On the other
hand, using this criticism as enough justification to keep Bill 14 begins to speak to the larger idea
of what we as a society stand for in terms of personal rights and liberties, and how Bill 14 rids
Canadians of these basic rights.
I have demonstrated why it is imperative that Canadians with degenerative diseases be
given back their right to prepare an advance directive for MAID for a plethora of reasons. Based
on individual, economic and ideological justifications, I have illustrated that the benefits of
advance directives are far too consequential in the moral and ethical code of the healthcare field
to be ignored. Refusing individuals their basic rights of liberty not only undervalues the patient’s
right to choose and control their own life, but it also violates the Constitutional Order that
Canada was built upon. It is clear that Bill 14 must be put to a stop.
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ADVANTAGES OF ADVANCE DIRECTIVES
References
J., Schuklenk, U., & Roggler, J. et al. (2018). “For their own good”: A response to popular
arguments against permitting medical assistance in dying (MAID) where mental illness is
the sole underlying condition. The Canadian Journal of Psychiatry, 63(7). 451-456. Doi:
10.1177/07067437118766055
Ingle, R. Dying with dignity--advance directives. (2012). SAMJ South African Medical Journal,
102(1), 10. Retrieved from Academic OneFile database.
Pauls, M., Larkin, G. L., & Schears, R. M. (2015). Advance directives and suicide attempts--ethical
considerations in light of Carter v. Canada, SCC 5. CJEM : Journal of the Canadian
Association of Emergency Physicians, 17(5), 562-564. Doi: 10.1017/cem.2015.64
Sahardi, N. F. N. M., & Makpol, S. (2019). Ginger (Zingiber officinale Roscoe) in the prevention
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End-of-life decision-making in Canada: the report by the Royal Society of Canada expert
panel on end-of-life decision-making. Bioethics, 25 Suppl 1(Suppl 1), 1–73.
https://doi.org/10.1111/j.1467-8519.2011.01939