Objection de conscience et aide médicale à mourir : une étude qualitative auprès de médecins québécois Conscientious Objection to Medical Assistance in Dying: A Qualitative Study with Quebec Physicians

Patients in Quebec can legally obtain medical assistance in dying (MAID) if they are able to give informed consent, have a serious and incurable illness, are at the end of their lives and are in a situation of unbearable suffering. Since the Supreme Court of Canada’s 2015 Carter decision, access to MAID, under certain conditions, has become a constitutional right. Quebec physicians are now likely to receive requests for MAID


Introduction
Quebec legalized "medical assistance in dying" (MAID) with the adoption in 2014 of the Act Respecting End-of-Life Care [1].Unable to amend the Criminal Code, which is a federal jurisdiction, Quebec has chosen to include MAID in the continuum of care provided to people at the end of their lives.To be eligible for MAID, persons must be 1) insured within the meaning of the Health Insurance Act; 2) the age of majority and able to consent to care; 3) at the end of their lives; 4) suffering from a serious and incurable illness; 5) in a medical situation characterized by an advanced and irreversible decline in their abilities; and 6) in a state of physical suffering that cannot be alleviated under conditions they consider tolerable.
Following the Supreme Court of Canada's Carter decision in 2015, access to MAID became a constitutional right across Canada.Reversing the 1993 Rodriguez decision, the Supreme Court ruled that patients with "serious and irreparable health problems" causing them persistent and intolerable suffering must now be able to obtain assistance to end their lives, administered or supervised by health professionals [2].This right to autonomy regarding end-of-life choices derives, according to the highest court in the country, from the right to life, liberty and security of the person guaranteed by section 7 of the Canadian Charter of Rights and Freedoms [3,4].According to the Court, the prohibition of MAID forces some people to commit suicide while they are still able to do so, thus taking their lives earlier than desired and unduly restricting their autonomy with regard to decisions relating to their physical integrity and end of life.As has been affirmed by many philosophers and palliative care scholars, the process of dying is part of life [5].For most of us, a personal reflection on what constitutes a good life, one that is meaningful, includes a reflection on the end of life we wish for ourselves.What characterizes pluralistic societies is the fact that conceptions of the "good life", and by extension of "good death", vary [6].
The Government of Canada passed the Act to Amend the Criminal Code and Make Related Amendments to Other Acts (Medical Assistance in Dying) [7] in 2016 to comply with the Supreme Court's decision.The law creates an exemption in the Criminal Code to exclude medical assistance in dying from the category of "culpable homicide offences".The main difference between the Quebec and Canadian laws in terms of eligibility for MAID concerns the stage of a serious and incurable illness of which a person is suffering.The federal law states that the person's "natural death" must have "become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining" [7].
Physicians caring for people at the end of their lives or who are suffering from incurable degenerative diseases must now respond to patients who wish to avail themselves of this new right or obtain information about it.Since death is an issue that raises both metaphysical and ethical questions about the character and value of human lifequestions to which several reasonable answers are possibleit is normal that many people, including health professionals, continue to believe that no human intervention intentionally causing death is ever morally justifiable.
The current legislative framework explicitly provides for the right of conscientious objection of health professionals.No physician should be required to administer a lethal injection or assess a patient's eligibility if this contravenes his or her conscience.While there is a commitment to "respect the personal beliefs of health care providers" in the preamble to the federal law, the Quebec law states that "a physician may refuse to administer medical assistance in dying because of personal beliefs and [that] a health professional may refuse to participate in its administration for the same reason."[1] However, this right is contested.In both the medical ethics literature and in societal debates, some question the legitimacy of statutory accommodation [8][9][10][11].Others argue that the right to conscientious objection is currently being used to justify the decisions of physicians who do not wish to participate in the MAID process for reasons that are not philosophical, moral or religious [12].
The study we conducted offers a different perspective.It does not in any way refute the thesis that some physicians abuse or instrumentalize the right to conscientious objection, but it does suggest that the refusal of many physicians to participate in the MAID process stems from an authentic moral deliberation about the relationship between their values (professional and personal) and the act of intentionally causing a patient's death.The legalization of MAID has forced many physicians to reflect on the meaning of medicine and their practice, the relationship between their personal beliefs and professional ethics, and the ethical and social consequences of creating a right to MAID.
After presenting the study, we will discuss the role of religious and secular reasons presented by participants and then analyze the secular reasons for opposition or ambivalence with regard to MAID.The participants' responses were grouped into four sets of secular reasons.In the last part of the text, we reflect on the meaning and implications of some of the concerns expressed by participants, as well as on the contribution of this study to the continuation of the public debate on MAID.

Objectives of the study and presentation of the qualitative component
The overall objective of this study is to advance ethical reflection on physician requests for exemption from medical assistance in dying (MAID).To this end, the specific objectives are to: 1) clarify the ethical issues inherent in physicians' requests for exemption and 2) present elements for a clear and rigorous position on the conflict between patients' and physicians' rights.The study has two components: a qualitative and a normative component.The qualitative and descriptive component has a third specific objective: 3) to better understand and describe, on the basis of physicians' discourse, the reasons (religious and secular) justifying the opposition or reservations of the latter with regard to MAID.A normative argument concerning the rights and duties of physicians and the harmonization of the rights of physicians and patients will be presented in a subsequent article.

Methodology Sampling and recruitment
The qualitative component of this study focused on physicians who, in their practice, receive requests for medical assistance in dying and who oppose or have serious reservations about MAID.Twenty physicians were recruited from November 2017 to May 2018.Based on other comparable studies [12,13], it can be concluded that this number permitted a reasonable level of data saturation and an analysis that would be considered reliable.Given the exploratory and non-confirmatory nature of this qualitative and descriptive research, it does not claim to be statistically representative.The interest of this approach lies mainly in the richness of the points of view obtained.A network sampling method (snowball) was preferred.To do this, the information about this study was first sent to a few physicians corresponding to the desired profile who, in turn, forwarded the same information to other physicians with a similar profile.
The criteria for selecting participants were as follows: • be a member of the Quebec Collège des Médecins; • be called upon, in their practice, to receive MAID requests; • have exercised or plan to exercise the right to conscientious objection This study was approved by the research ethics boards of UQÀM (1520_e_2017) and Université Laval (116964).Participants' written consent was obtained and the study was conducted in accordance with the principles set out in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans [14].

Data collection method and analysis
The data collection method used was semi-structured individual interviews.These interviews were approximately one hour long and were conducted entirely by one of the two researchers in charge of this study.The interview guide included an openended question and follow-up questions related to the research objectives.The original guide was first developed in congruence with the theoretical framework of this research, which focused on the meaning and extension of freedom of conscience [15].This then enabled the emergence of new themes throughout the interview process.
Data analysis was carried out based on the complete transcription of the material collected from physicians according to the procedures associated with continuous thematic analysis as described by Paillé and Mucchielli [16].This mixed analysis (based on the conceptual framework but open to the inclusion of codes that also take into account unexpected or new information) was carried out by the two researchers who conducted the study.This type of analysis made it possible to identify the main themes associated with the reasons and motivations for physicians' opposition to or reservations regarding medical assistance in dying.Reading the transcripts first led to the identification of the attitudes and beliefs of the participants that emerged most frequently and forcefully.The data were then grouped into four main themes: 1) the ends of medicine and professional identity, 2) the philosophy and practice of palliative medicine and resources allocation in palliative care, 3) benevolent paternalism, "good death" and interests of future selves, 4) the risk of a slippery slope and the protection of vulnerable people.The identification and description of these themes made it possible to lay the foundations, in complementarity with the normative aspect, for a clearer and more rigorous position on the normative question at the heart of this study.

Description of the participants' characteristics
The age of participants at the time of the interview ranged from 25 to 75 years of age.The sample consisted of 20 physicians.The majority had expertise in palliative care or were family physicians.The other participants practiced in a variety of specialty areas: internal medicine, thoracic surgery, public and community health, anesthesiology and critical care, endocrinology and geriatrics.Just over half of the sample had between 21 and 40 years of practice and came from Montreal and surrounding areas.A few physicians from Quebec City, Lévis and other regions also participated in the study.These characteristics are summarized in Table 1.

Opposition to the concept of "medical assistance in dying"
All participants deplored the use of the notion of "medical assistance in dying" to describe the medical act of administering a lethal injection to a patient in order to cause his or her death.Almost all participants (19/20) considered that MAID was in fact a form of euthanasia9 and that it would be more honest to admit it: "it is euthanasia, it would be less hypocritical to say so" (Pierre).On this point, it seems clear to us that MAID is, in Canada, a form of "voluntary euthanasia".Euthanasia is "voluntary" when a cognitively competent person requests that an action that will result in his or her death be taken, usually by a health professional.While it is conceptually possible to argue that the notion of "medical assistance in dying" adequately describes the medical procedure in question and is consistent with the Quebec legislative approach that integrates MAID into a continuum of end-of-life care, this does not make it a separate act from voluntary euthanasia [17,18].It is likely, as some of the participants stated, that the proliferation of concepts contributes to increased confusion about end-of-life care (palliative care, continuous palliative sedation, medical assistance in dying, euthanasia, assisted suicide, etc.)According to one participant: I think it's a term that looks better than what it actually is.Hum...I wish we call it differently because it sounds nice to the public...I don't think the term is accurate.Someday I feel it's almost like we invented it to justify what we do as a society.I don't like the term... (Timothy)10 Others mentioned that: The term, I think it's a euphemism, personally.In fact, everywhere in the world, where there is euthanasia, it is called that.We are innovating here.I don't know if it's an innovation or if there's a purpose behind it.I think there's a purpose behind it.It's to soften it.To make it less serious.(Debbie) ...most people believe that medical assistance in dying is about providing quality palliative care.Then when I explain a little bit to them what it is, they say, "Oh yes! Oh, well noted..." (Maria) It shocks me that we call it a treatment [MAID].You know, I might get emotional.For me, it's not a treatment.At least not one like the others.(Suzanne)

Sources of opposition or ambivalence to the MAID
Five participants said that their religious identity was an integral part of their personal identity and that their religious beliefs partly explained their opposition to MAID.It should be noted, however, that among all participants who reported having religious beliefs, opposition to MAID was also justified on secular or public grounds.As one participant stated: "It's interesting, because any good secular argument that I may give I would say comes from my religious beliefs."(Timothy) These participants seem to spontaneously accept the criterion of political legitimacy [19] according to which public norms must be based, in societies marked by reasonable pluralism of conceptions of good life, on reasons that all can in principle accept.In other words, common public norms must not be justified solely by reasons derived from a comprehensive conception of what constitutes a good and meaningful life.For John Rawls (2016), "public reasons" are derived from a "political conception of justice".A conception of justice is "political" for Rawls when those who adhere to a reasonable conception of the good life can potentially accept it [19]11.
These participants saw their identity as unified or integrated rather than segmented.Religious and secular values and beliefs are conceived of and lived as consistent with each other rather than being in tension: "and that, I cannot accept that...as a doctor.As a citizen first of all, as a doctor second, and finally as a Catholic" (Justin).Another participant said, "I am a believer.I am a Catholic.It must be part of it.I couldn't tell you what percentage.I am a person... that's one of the factors that influences me." (Line) Five other participants stated that their faith or religious education shaped, in some cases "perhaps unconsciously", their judgment on MAID and their refusal to integrate it into their practice.That being said, secular reasons were very much predominant among these participants.For example, one participant stated that she remains somewhat a believer, that she practices little her religion, but that it is possible that her spiritual trajectory may influence her more or less consciously.However, the reasons that were decisive for her were all secular.Another said, "Yes, the religious dimension is present in me, but let's say it would be the last one invoked."(Pascale) Just over a third of participants (7/20) stated that they were atheists or that religion did not influence their positioning with regard to MAID, and three others did not explicitly answer questions about their relationship to religion.The reasons mentioned by these ten participants were exclusively secular.In the words of our participants: I'm not religious.I was born a Catholic, but it's been 50 years or more since I went to church, it's not an issue.(Pierre) I know people who are conscientious objectors who are very Catholic, and then I know people who are atheist conscientious objectors.I'm in the atheist category.I am... very very very atheist (laughs).(Julie) Our study thus raises doubts about the perception that the majority of conscientious objections in Quebec are motivated by strong religious beliefs, essentially Catholic.Deploring the social representation of conscientious objectors, one of our participants said: I have a friend who is very opposed to this [MAID].But he is a palliative care specialist.He is a "being of light" but he has been called all the names: "You, catho", but he is not Catholic at all, he is an atheist, as much as I am.That's why it felt somehow good to come to see you... He's getting attacked, it doesn't make sense.(Julie)

From objection to ambivalence
Participants' attitudes and beliefs towards MAID lie on a continuum that ranges from principal and categorical opposition to deep and agonizing ambivalence.Three general attitudes about MAID can be discerned in participants' responses: 1) a principled and categorical opposition; 2) a more contextual, contingent opposition and an evolving personal view; and 3) a willingness not to participate in the process while accepting the legitimacy of the collective choice allowing MAID.Positions (2) and (3) reflect, to different degrees, moral ambivalence with respect to MAID.
Those within the first group believe that any act intentionally causing death is morally reprehensible.Almost half of the participants (9/20) can be classified in this category.For some, "euthanasia is murder".Another told us, "I am against it in all situations."(Line) The second group -6 of our participantsspontaneously admitted that this was a difficult ethical issue for them and that, while they were initially rather opposed to the legalization of MAID and did not wish to integrate it into their practice at this time, their views were in motion.Their discussions with patients and colleagues influenced their thinking.It is not impossible that some of them may one day agree to evaluate patients or administer MAID to a patient they have been following for a long time.As one participant put it: "My perspective has changed since the law was passed and colleagues have conducted medical assistance in dying.It is possible that I would one day agree to do so if a patient I have been with for a long time asks me to do so."(Lucie) Finally, the last group are not morally opposed to MAID, but they do not feel able to administer it themselves and, like the second group, they consider that it would have been preferable to wait until there was better access to quality end-of-life care before allowing MAID.Five of our participants were part of this group.In their own words: I...finally, I think I'm preaching more that patients have a right to access both palliative care and medical assistance in dying...I don't want to do medical assistance in dying.I am grateful.I am grateful for the 11 "Unreasonable" conceptions are those that argue that public norms and institutions should favour citizens who adhere to a particular conception of the good life and, by extension, disadvantage citizens who adhere to other conceptions.In other words, reasonableness is embodied in the a cceptance of criteria of reciprocity and equity in the distribution of the benefits and burdens of social cooperation [19].
doctors who are willing to do it because I am not ready to do it.But these patients, they have the right to euthanasia.So there must be doctors to do it.(Talia)

Opposition or ambivalence to MAID: four categories of reasons
Secular beliefs and values thus emerged as clearly predominant in our study.As mentioned above, since these are the kinds of reasons that should underpin laws and public policies in pluralistic societies where secularism of the state prevails [15], we have chosen to make them the central focus of our analysis.We have grouped them into four main classes: 1) the ends of medicine and professional identity, 2) the philosophy of palliative medicine and resource allocation in palliative care, 3) benevolent paternalism, the "good death" and the interests of future selves, 4) the slippery slope argument and the protection of vulnerable people.The considerations and arguments classified in one or other of these categories can obviously overlap and reinforce each one another.

1) The ends of medicine and professional identity
Most participants saw a strong incompatibility or tension between the act of intentionally causing death and the principles and purposes guiding the practice of medicine.Medicine is primarily seen as a struggle against illness and death.Then, when confronted with the limits of curative medicine, participants believed that their role was to accompany the patient to the end by offering them care that allows the best possible quality of life.As one of the participants said: "At first, I wanted to save my patients.Now I am wiser, I know that my role is above all to accompany them."(Kim) If they are great promoters of palliative medicine, critics of aggressive therapy and defenders of patients' right to refuse treatment, they consider that medicine must in some way be a space entirely devoted to the protection of life, its quality and the reduction of suffering.Death is seen as part of the normal course of life, but the physician has an ethical obligation not to provoke or deliberately precipitate death.They therefore see an ethically significant difference between killing and letting die.Their conception of the ethical norms inherent in the practice of medicine (role morality) leaves no room for an act deliberately causing death: "that one can cause death, that is beyond my understanding as a doctor."(Pierre) For a participant, stopping treatment and controlling pain means stopping "delaying the disease", which is different from "causing death" (Debbie).These participants internalized the requirement contained in the Hippocratic Oath that: "I will do everything to relieve suffering.I will not unduly prolong the agonies.I will never deliberately cause death."[20] As one participant made clear: I believed in what was taught to us at that time, the first thing is "first, do no harm", then we help and support...I did not study medicine to kill people.I don't think you need to be a doctor to kill people... I was a member for years of Amnesty International, I was completely opposed to having doctors in torture chambers, to having doctors who apply the death penalty.A doctor is there to help people, give them hope and work until the end of their lives to make life the best it can be.That's my conception of medicine.(Julie) For others: The practice of scientific medicine consists in administering, performing an act whose benefit is greater than the risk.All medicine is based on this, has always been based on this.Even before it was scientific, doctors tried not to aggravate the disease... it was always primum non nocere.First, do no harm.(Pascale) To make that gesture... To end someone's life.Honestly... (Lola) It's as if I'm becoming a hired killer, that's how I see it.(Eloise) One participant expressed in a vivid way the incompatibility between the aims of medicine and MAID: You know, in football, you have both, you have got each one end of the field, but if I go to a line, my profession is to go to that.Then if euthanasia is legal, it means I do a 180 degree and then I go to the other line.That's how I see it.(Timothy) In general, medical teams have the prerogative to determine what is "appropriate care" for patients.The integration of MAID into the range of services offered to patients at the end of life requires a partial redefinition of the professional identity of physicians and their prerogatives and responsibilities.Since the adoption of the Act to Amend the Criminal Code and Make Related Amendments to Other Acts (Medical Assistance in Dying) [7], a patient who meets the criteria established in the legislation has a constitutional right to obtain MAID, which necessarily limits the professional autonomy of physicians.As participants noted: And then, in some ways, my judgment is taken away from me, because I am not the one who judges.It's the law that sets the criteria...So it's not really, by definition, a medical act.As a doctor, I have to do what is medically required.(Kim) It's collusion with the College of Physicians, but basically it was imposed by the Government of Quebec.It's not medicine.It is not up to them to define what medicine is.It's not for the Supreme Court of Canada to define what medicine is.(Line)

2) The philosophy and practice of palliative medicine and resource allocation in palliative care
Considering that a quarter of the participants practice palliative medicine and that all the others have done so in the past or are advocates of this approach, the question of the relationship between MAID and palliative care was one of the themes that emerged most strongly from the interviews.For some, the very philosophy of palliative medicine is incompatible with MAID.According to this view, palliative care must be entirely devoted to the management of the physical symptoms causing pain and to the psychosocial and, when desired, spiritual care of patients.If palliative medicine is strongly opposed to aggressive medical treatments [21], its rehabilitation of the dying process as an integral part of life would put it in tension with MAID.
In addition, from a clinical perspective, some participants felt that palliative medicine has fairly effective means of providing an acceptable quality of life for patients with incurable diseases.Clinical knowhow and increased scientific knowledge on the effects of opioid and non-opioid analgesics would in almost all cases allow palliative care specialists to control patients' pain [5].In the case of refractory pain at the end of life, palliative sedation (continuous or not) can provide relief to the patient, if practiced properly, without causing or precipitating death [22].
According to two participants: Unbearable suffering, I'm not sure that's really common.Are there many who really have suffering that is not treatable?I think it must be extremely rare and too rare to create the need for euthanasia.(Timothy) I think that when, as a palliative care physician, I follow someone, well, my tools are powerful enough.(Kim) A doctor with forty years of practice said, "I have never faced unbearable suffering that I could not control."(Justin) And if the suffering felt by a patient is refractory and unbearable, palliative sedation is then necessary: "So, if we have refractory pain in an incredible way, I think continuous palliative sedation is called for."12(Debbie) One participant also said that: The advantage of palliative sedation is that it is not the doctor who decides when the patient will die.He dies when he dies.We watch him, we stay by him, we hold his hand, then at some point he leaves.And I like that it's not the doctor who decides." (Julie) In this regard, some participants pointed out that there was no equivalence between continuous palliative sedation and MAID: Sedation doesn't cause death if you do it right.If we've tried everything to relieve the patient.We give him a sedation so that he is not conscious, so that it is temporary, so that it is until the end.Of course, if you're talking about a patient who is not on the verge of death, you give him long-term sedation and you don't give him food or water, that's killing the patient.If he is at the end of his life, when we cannot anyhow give him food or drink, we give him a sedation to relieve him in the last days, that's another thing.13(Line) For the vast majority of participants, the legalization of the MAID, and in particular its integration into a "continuum of end-oflife care" in Quebec, can only increase the current lack of knowledge and understanding about palliative care.Some people already fear palliative care because they believe that patients are euthanized without their consent or that the administration of large and repeated doses of morphine precipitates death.These myths will be reinforced, according to participants, if MAID is practiced in palliative care units or hospices.One participant noted that fears about palliative medicine, particularly with respect to morphine, remain widespread: So when I say to that person, "Listen, the morphine I give you, I calculate it in a way that is not dangerous for you.I will not kill you.And I'm careful.I am very careful."And so, that's something that's important to me.That the patient I'm treating feels safe, that there is trust.But there is a fear of morphine right now.(Kim) Some participants feared that the integration of the MAID would be to the detriment of palliative care, whose status was already precarious in Quebec and elsewhere in Canada [23,24].This participant clearly summarized the concerns expressed by several others: The other reason, and it's probably the main reason, is that I think we can do extraordinary things in palliative care.I think it is a very complex and evolving discipline that must be encouraged.There is a lot of science being done in there....I think it's going to be a dichotomy: medical assistance in dying and palliative care, and I'm afraid there are patients who have not been offered the palliative care interventions package, I see that we still have a lot of progress to make as a society in terms of understanding of death....So people are not aware of palliative care, they still think palliative care is really just in the field of death, just at the last minute, they don't know that it can extend over long periods of time, that we can increase the quality of life a lot, that people can be relieved.And then I'm afraid it [MAID] will become the easy option... (Julie) In addition, since palliative care embraces a holistic view of patient wellnessa view according to which the physical, psychosocial and spiritual dimensions of wellness must be considered together [25] participants emphasized that the environment provided by palliative care hospices or units can foster a serene and satisfying end of life.When resources are sufficient, palliative care provides a soothing physical environment, as well as medical, psychosocial and spiritual support that allows patients to be surrounded by their loved ones and to address issues that concern them or that they wish to discuss with professionals and volunteers.
Noting that patients' suffering is often of an "existential" nature and regretting the lack of resources to hire social workers and psychologists, one participant said, "Is it acceptable to say: We will end your life because I don't have the necessary resources to help you?I find that unacceptable.I think it's horrible."(Talia) Participants stated that what they perceive as the underfunding of palliative care makes it morally unacceptable, at least in the current context, to legalize MAID.As mentioned above, MAID is part of a broader end-of-life care strategy in Quebec.One of the conditions of acceptability of MAID set out by the Select Committee on Dying with Dignity was that Quebec patients at the end of their lives must have access to quality palliative care and that, consequently, the legalization of MAID must be accompanied by the allocation of additional resources for palliative care [26].However, since the Act Respecting End-of-Life Care [1] was adopted at the same time as the budgetary restraint measures put forward by the Government of Quebec, participants were almost unanimous in their opinion that the acceptability condition had not yet been met: If this [MAID] responds to a resource gap, well, I say to myself that it is completely ethically unacceptable.That's why I think as long as I have that feeling, I don't think I can get involved in processes like that.(Debbie) So, at some point, when we talk about dignity, we should ask ourselves: is it really the disease that makes us undignified or the health system in which we are in?(Debbie) There is a pain clinic.They're fantastic, but it takes two years to see them.It doesn't make sense.So we say: "ok, we can kill you next week or we can fix your pain in two years".(Line) Because we are not organized in our area [urban area] to have volunteers to spend the night with patients...and say: "I did this because I didn't have access to resources", I would be very angry.(Helen)

3) Benevolent paternalism, the "good death" and the interests of future selves
It appeared to us that one of the categories of reasons explaining the positioning of our participants with regard to MAID is a form of "benevolent paternalism".In ethical theory, paternalism refers to the position that it is sometimes legitimate to ignore a person's will on the basis that he or she is not always in the best position to determine the nature of his or her own good or interests [27].We propose viewing paternalism as "benevolent" when it is anchored in an authentic concern for the well-being of the people concerned.Paternalism takes a "political" form when it is considered that the state can legitimately use its power to prescribe or prohibit behaviour in the name of the rightly understood self-interests of citizens [27].Policies put forward in the name of public health, such as the requirement to wear seat belts when travelling by car, generally fall into the category of benevolent political paternalism.
There is a wealth of literature in medical ethics on medical paternalism [28].In the context of our study, the positions we call paternalistic are those that argue that people are not well equipped to understand how they will experience the progression of the disease or that emotions such as the fear of suffering, being a burden to loved ones or living in undignified living conditions are disproportionately important in assessing the value of their lives with advanced disease.An underlying idea expressed repeatedly is that it is very difficult for the "present self" to anticipate what the reality of the "future self" will be and the nature of its interests once it reaches the end of life stage.Experienced doctors have reported following patients who, after moments of discouragement when they wanted to end it, have regained a certain quality of life and had meaningful experiences.
The possibility that the patient will "adapt" to their illness and change their mind about the value of the life that remains to be lived, especially if they have access to quality care, is one of the most important considerations in many of the participants' deliberations.
For participants: People, they change their minds.Suddenly, one day, they wake up depressed.Then the next day, there is something that has changed in their lives and gives it back meaning.How do I know that in a week's time this patient wouldn't want to live?And I would have taken that life.I don't find that acceptable.Because there is this risk that I will take away a life that could still have been of a certain quality.Maybe it is not someone who is able to run a marathon, but someone who will live his days peacefully, comfortably and who will find meaning in his life.The great-granddaughter is pregnant.All of a sudden, there is a desire, a desire to live one more day, one more week, one more month.So there's that.There is this uncertainty.(Talia) Listening to patients, seeing changes in a patient who was scared to death when he learned of his illness and telling you, "I might as well die right now."And then a few months later, he gets attached, maybe there's a hope, a new protocol... There's the moment when you get a ton of bricks on your head, you know, and it's too heavy for you, and then that's when you really have to go quietly, and say good we'll cross the bridge when we get to the river, and then we'll look at how we can improve, what can we do right now,... Then I saw patients' view of their disease evolves.(Julie) I often have the impression that some people are probably more in denial of their condition when they decide to seek medical assistance in dying.Then I have the impression that with the passage of time, they would probably accept the situation more.Then, it would probably allow them to experience some moments that are still beneficial for them.(Jérôme) Not surprisingly, several participants expressed strong opposition to the possibility that "advanced medical directive" tools could be used to allow people to apply for MAID in advance in the event that they have a neurodegenerative disease such as Alzheimer's.In the Netherlands, persons diagnosed with a serious and irreversible disease that will eventually render them incapable of free and informed consent may express their wish to be euthanized at some point in the course of the disease in an advanced medical directive [29][30][31].For one participant, advanced MAID requests are "a total aberration".(Kim) Some pointed out that the application of advanced MAID requests would pose major difficulties: Did they consider that, even if we write it in our advanced medical directives, when will we decide that it is too much for the patient?Because right now, as long as he recognizes you, is that okay?At some point, it's when he's incontinent that it's no longer correct?Is that when he stops eating?Is it when he gets agitated?I say to myself: who's going to put themselves on a panel to decide that?I don't even understand how they're going to decide at what stage... the demented person, they won't know.She won't understand.I say to myself, "Did you realize that they're probably going to have to be tied up?"Because it's not like we're going to say, "Okay, don't move.Look at the bird over there."Then we go ahead..., that doesn't make any sense.(Debbie) In connection with the difficulty for the patient to project herself accurately into the future, some participants justify their refusal to participate in the MAID process on the basis of an implicit or explicit conception of the "good death".Whether it is what we discover about ourselves in illness or reconnecting with family and friends, giving ourselves the chance to live the end of life to the fullest offers the opportunity to grow and close the last chapter of our lives.Paternalism becomes a form of perfectionism here.Many participants added that "suffering is part of life" and, in some cases, that it must be accepted and faced "with courage": "a life without suffering does not exist.You have to face suffering with courage" (Justin), said one of the participants.These excerpts clearly show that a certain amount of (benevolent) paternalism and perfectionism remains in the opposition or ambivalence of several participants with regard to MAID: Death is part of life... it's included.We can't have control over everything.I think that the narcissistic evolution of Westerners, to think strictly of themselves and then of each individual, which has brought positive things, but here I think it is a path that shows the negative sides of individualism.(Pierre) So many people also told me: "The last months of my life were the most beautiful months of my life".We can say that they are rationalizing, I'm not sure about that, I think they were no longer telling themselves stories when they told me that.I think they spoke the truth, they had nothing more to lose, they had no image to preserve.I say to myself, well..., maybe we should also listen to this from those patients who have learned about death and then decided to live.I accompanied one of my friends with AIDS a very long time ago, 20 years ago, and we had a kind of ethics of the present moment, to try to make every moment as perfect as possible.I learned that from him.(Julie) But, let's say the patient [in palliative care] is comfortable.Every day is a gift of life.Because people are going to start saying the real stuff.A real legacy.A lot of things are happening.Grief is completely different.Then, this allows us to gain some control over our own death depending on what we see.Right now, if the number of medical assistance in dying increases, that's how we're going to see death.She put on her beautiful dress the way she wanted.That's how we want to represent the end of life.Well, it's a societal choice, but... (Debbie) I'm going to tell the patient: "I, you see, I'm a palliative care doctor.I'll explain my business to you.I am in no way against medical assistance in dying.I'll tell you right away."Then I explain my business.Then I say, "I have a complete closure from you.Even with an aggressiveness, an anger that I feel.Because I'm trying to make you think about other things."(Debbie) MAID's interruption of the dying process deprives not only the dying person of a significant experience, but also the relatives who accompany the person.One participant said that this cannot justify conscientious objection, but that it is nevertheless part of the ethical cost inherent in MAID: Then I also think of the consequences for the relatives, say, of someone who would die by medical assistance in dying.For me, accompanying a dying person means learning to live, learning precious things.In some way, what the person is telling us.And then I think the person minimizes his or her value at that time.Their value and the social role they play.I take the opportunity of a conversation to talk about the role they have to play with their loved ones who come to visit them.That no, it's not a burden and then there's some good that comes out of it.Then the people who come to visit a dying person, they make a gesture of solidarity, they make a gesture of generosity.But it's not for me to judge whether the person thinks it's valuable or not.I don't have to object on the basis of that, but it's part of my thinking.(Kim)

4) The risk of a slippery and protection of vulnerable persons
The slippery slope argument affirms that a particular action or decision is not desirable because it would inevitably lead to other decisions that are ethically unacceptable.In Canada, only adult persons capable of giving informed consent, living with a serious and irreversible disease, whose death is reasonably foreseeable and whose suffering they deem unbearable, are eligible for the MAID.While the Government of Quebec maintains that it has proceeded cautiously by legalizing voluntary euthanasia for adults at the end of their lives, the study participants saw it as more or less inevitable that the eligibility criteria for MAID would be broadened, in line with citizens' claims [31,33]14.At the time of the interviews, most were aware that the Quebec Ministry of Health had set up a group of experts working on the issue of incapacity to provide informed consent in the case of neurodegenerative diseases.They were also aware that the federal government had mandated the Council of Canadian Academies to create working committees on "mature minors", mental health and advanced requests [31][32][33].
Compared to adults at the end of their lives and who are capable of consent, the categories of people who could potentially have access to MAID are seen as more "vulnerable".
One participant recalled that, in addition to autonomy, the principle of beneficence is one of the cardinal principles of bioethics [34]: "When autonomy has been stated as a bioethical principle with the other three.Even these people didn't say it's supreme.Beneficence, for example.There are many areas in life in which our autonomy is limited."(Line) The danger of the slippery slope was explicitly mentioned by one of the participants: When we open a door to one thing that in our society is maybe not the best, we open the door to more and more and more.You talked about rights a few minutes ago, I mean, it's funny their right to die, this just opened the door.I expect that as years go on because of the arguments of rights of people, that it will be expended more and more and more and that is even more scary to me.I just think as a society, do you want to start saying that life is no longer valuable?You know it's a very slippery slope.(Timothy) According to others: ...and now it's not just the elderly anymore...A law, it's always like that, it broadens... it's now eugenics.Anyone who doesn't look the way we want, they'll be flushed.(Maria) I think it could drift.That I think is the ultimate danger.As a society, we don't want to get rid of people we think are useless, even though some people think they are burdensome.(Patrick) Some fear the impact of expanding MAID to other groups in society, such as people living with disabilities or suicidal thoughts: There's a guy who works with us who's in a wheelchair, a guy in his forties.He was against euthanasia because he felt targeted by it.He says: "There are people on the street I don't know who tell me I'd rather be dead than like you".So there is a whole group of people with disabilities who are very afraid of this law because they feel targeted.They say [life is not worth living] if you can't go to the bathroom alone anymore.He said, "I couldn't go to the bathroom alone all my life.I think my life is as valuable as the neighbour's."(Sacha) It's kind of the same reason I'm here, I'm against the death penalty.It's that there are always mistakes.The death penalty is sometimes a death sentence for innocent people.Well, in euthanasia, we are going to euthanize people in conditions that are not quite clear, or we have not really asked them for their opinion, or we have put pressure on them.(Gérard) It is because medical assistance in dying is a law, that we must let people who commit suicide die.And several cases of people who have attempted suicide, who have been brought to the hospital, who have been told "well they want to die, let them die".This is the first blunder, if I can say so about this law.(Pascale) The scarcity of resources in the health system has also been identified as one of the sources of potential abuses: The excesses for me are so likely... maybe I'm the one who's narrow-minded, but, an 800-bed hospital, you need two beds, you kill two in the two in the afternoon, from Monday to Friday, you don't even have a nurse on weekends.You don't have anyone there on weekends, you settle 10 situations.You have a palliative care unit, 10 beds, you have care all day long, occupational therapy, physiotherapy, inhalation therapy, all kinds of services, it is expensive.So placing an administrator who looks at two beds, who deals with 10 situations per week, which costs 10 times less than the other 10 beds... that's accounting there.And to say "ah, we're still going to encourage palliative care" when you have that option, that won't happen, in my opinion.(Pierre) The pressure that could be put on patients by members of their entourage was also mentioned: All of these are family conflicts.One thing I do is assess the cognitive competence of older people with cognitive disabilities.sometimes I am called to testify in court for families who are in conflict."Is he fit, is he unfit?"And often it's about money.The one who wants the parent to be unfit is the one who is emptying the bank account.Sometimes it's just money, sometimes it's emotions and they can't agree.The patient says yes to this one day.He says yes to the other one the other day because he doesn't want to hurt anyone.It's very, very complex.(Line) Slippery slope arguments are rarely considered convincing in ethics [33,35].Any freedom or opportunity offered to people can lead to excesses or morally disturbing applications.The answer to the fear of a slippery slope is to reflect on the desirable limits of the right guaranteed to citizens and to build institutional capacity to enforce established rules.For example, while it is true that freedom of expression may allow hate or defamatory speech, the answer to this real problem is to prohibit hate and defamatory speech, not to suppress freedom of expression.That being said, as social demands for greater accessibility to MAID increase, participants' fears about the fate of people living with vulnerabilities are serious and deserve to be heard.

Discussion and Conclusion
The recognition of physicians' right to conscientious objection logically raises the question of the residual obligations of the conscientious objector, including the difficult question of referral.What should be the responsibilities of a physician who does not wish to practice MAID to the patient who submits such a request?Can they simply tell their patient that they are exercising their right to be exempted?Should they refer their patient to another physician or administrator?There are divergent positions on this issue.The Act Respecting End-of-Life Care [1] provides that the conscientious objector must ensure the "continuity of care provided to the person" and notify the relevant administrative authority [s.31].
In a previous article, we argued that the "double effect" doctrine can be invoked to argue that the obligation to refer does not constitute an excessive restriction of physicians' freedom of conscience [36].We will not repeat this argument here.We will simply point out that 14 of our participants said that the issue of referral did not cause them any particular moral discomfort.These participants usually refer their patients to their Professional Services Directorate (PSA) or to the Interdisciplinary Support Group for MAID (ISU) to which they have access.It should be noted, however, that 4 of the participants who were most strongly opposed to MAID did not want to refer.Two of them do not interpret the referral of patients to an administrative authority or other care unit as a true medical referral.For one of these participants, "it is complicity to refer [a patient] to someone else."15 (Julie) Our study suggests that referring to an impersonal organizational body rather than a colleague reduces the moral cost inherent in the obligation to refer, while possibly proving more effective for patients since the responsibility for ensuring that their rights are respected is transferred to an accountable organizational structure rather than carried by a busy physician.
In terms of the study's limitations, the exploratory and qualitative nature of this research does not allow us to determine to what extent the physicians who participated are representative of all Quebec physicians who do not wish to practice medical assistance in dying on the basis of moral considerations.It is also likely that the type of sampling chosen (snowball) resulted in a certain homogeneity among our participants.Participants sometimes referred us to colleagues in their practice environment or with whom they are used to discussing MAID issues.Finally, in order to obtain a more general picture of the attitudes of Quebec physicians regarding the relationship between medical assistance in dying and their conception of the ends of medicine and the values inherent in their professional role, conducting a comparable study with physicians who have Page 134 agreed to integrate MAID into their practice would be desirable.Their discourse would help to better understand the diversity of views on the values and ends of medicine within the medical community.
In conclusion, the results of this study show that serious and profound secular reasons, situated in the ambit of freedom of conscience, motivate the decision of a subset of Quebec physicians who do not wish to integrate MAID into their medical practice.The five physicians who declared having religious beliefs that were difficult to reconcile with MAID also based their decisions on secular reasons similar to those mobilized by participants who reported that they were not influenced by religious faith.Whether or not one agrees with their positions, the opposition to or ambivalence towards MAID derives from authentic moral deliberations.In addition to providing arguments to those who argue that the decision of Quebec and Canadian legislators to provide for a right of conscientious objection in end-of-life care legislation was wise, this study reveals that the voice of physicians who oppose or have reservations about MAID is one of the conditions for a robust democratic debate including varied and minority views on the right to MAID and its limits.Indeed, even those who argue that the legalization of MAID is justified and based on sound ethical principles such as human dignity, moral autonomy and respect for physical integrity must recognize that reflection on the effects of MAID is complex and valuable.On these issues, we believe that the views of our participants must be heard.In a subsequent text, we will use the results of this qualitative study to defend specific normative positions on the rights and duties of physicians and on the conciliation of the rights of physicians and patients in the context of MAID.