Hawryluck Laura
Health Law Can. 2017 May;37(4):86-95.
At the heart of high stakes end of life (EOL) decisions such as withdrawal of life-sustaining treatments (WLST) or medical assistance in dying (MAiD), are concerns that vulnerable people in our society need to be legally protected from prematurely ending their own lives or from having their lives inappropriately ended by healthcare teams predisposed to negatively assess their quality of life. Recently, two Supreme Court of Canada rulings in Rasouli and Carter (MAiD) have clearly emphasized the role of consent in providing legal protections to people at the end of life. The role of the medical standard of care is less clear: though the Supreme Court in Rasouli was careful to state there had been no ruling on the medical standard of care with respect to WLST, the Court did state that standard of care considerations would be important in such decisions. In contrast to Rasouli, the result of the Carter ruling was that consent alone is insufficient protection for physician assisted death without a medical standard of care. Subsequently, in its new legislation, the Canadian Government restricted access to MAiD on the grounds that some people - those who lose capacity, with mental illnesses and mature minors - are so vulnerable that this potential choice at the EOL must be denied. In simple terms, for some, consent and the medical standard of care are insufficient protections. Such claims and their consequences are a sign of an emerging and significant problem: the reduction of medicine to a mere contractual relationship while disregarding its fiduciary nature simply because the courts have, in the words of Chief Justice McLachlin, "never reviewed physicians' good faith treatment decisions on the basis of fiduciary duty". The goals of this article are to explore issues of vulnerability and equality, the existing protections in both medicine and law and the emerging need for courts to evaluate physicians' fiduciary duties in high stakes EOL decisions in order to resolve conflicts with respect to WLST, to ensure access to MAiD and to promote the future aualitv of EOL care for all Canadians.
在诸如撤除维持生命治疗（WLST）或医疗协助死亡（MAiD）等高风险的临终（EOL）决策核心，存在着这样的担忧，即我们社会中的弱势群体需要得到法律保护，以免过早结束自己的生命，或避免被倾向于负面评估其生活质量的医疗团队不适当地结束生命。最近，加拿大最高法院在拉苏利案和卡特案（MAiD）中的两项裁决明确强调了同意在为临终者提供法律保护方面的作用。医疗护理标准的作用则不太明确：尽管最高法院在拉苏利案中谨慎地指出，尚未就WLST的医疗护理标准作出裁决，但法院确实表示，护理标准考量在这类决策中很重要。与拉苏利案不同的是，卡特案裁决的结果是，在没有医疗护理标准的情况下，仅靠同意不足以保护医生协助的死亡行为。随后，加拿大政府在其新立法中限制了MAiD的获取，理由是一些人——那些失去行为能力的人、患有精神疾病的人和成熟的未成年人——非常脆弱，必须剥夺他们在临终时的这种潜在选择。简单来说，对一些人而言，同意和医疗护理标准提供的保护并不充分。此类主张及其后果表明出现了一个重大问题：将医疗行为简化为纯粹的契约关系，而忽视其信托性质，仅仅是因为正如首席大法官麦克拉克林所说，法院“从未基于信托责任审查医生出于善意做出的治疗决定”。本文的目的是探讨脆弱性和平等问题、医学和法律中现有的保护措施，以及法院在高风险的临终决策中评估医生信托责任的新需求，以便解决与WLST相关的冲突、确保MAiD的可及性，并促进所有加拿大人未来临终护理的质量。
