Kanada - Max-Planck-Institut für ausländisches und internationales

Transcription

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Kanada
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Regine Heemann
Staatsanwältin in Stuttgart, ehemalige Mitarbeiterin am Max-PlanckInstitut für ausländisches und internationales Strafrecht, Freiburg i.Br.
unter Mitarbeit von
Gerhard Werner
Rechtsreferendar, ehemaliger Mitarbeiter am Max-Planck-Institut für
ausländisches und internationales Strafrecht, Freiburg i.Br.
Übersicht
Die Terminologie in der Diskussion um die Sterbehilfe ist nicht einheitlich.
So findet man für die aktive Sterbehilfe, also das Verabreichen von Mitteln
mit dem Ziel, den Tod herbeizuführen, die Begriffe "active", "direct" oder
auch "negative" euthanasia. Dem wird die passive Sterbehilfe, d.h. der Verzicht auf lebensverlängernde Maßnahmen gegenübergestellt, die als "allowing to die", "passive", "indirect" oder "positive" euthanasia bezeichnet wird.
Außerdem wird zwischen "voluntary" und "unvoluntary" euthanasia unterschieden. Als "voluntary" wird die Sterbehilfe dann betrachtet, wenn der
Patient selbst die Entscheidung über den Abbruch der Behandlung trifft. Des
weiteren stehen auch die Fälle zur Diskussion, in denen schmerzstillende
Medikamente verabreicht wurden, die gleichzeitig lebensverkürzende Wirkung haben (pain-killing medical treatment shortening life, reducing the life
expectancy of the patient).
1.
Gesetzliche Regelung der Sterbehilfe
Das kanadische Strafgesetzbuch (Criminal Code von 1953/54) enthält keine
speziellen Vorschriften über die aktive und passive Sterbehilfe bzw. das Verabreichen lebensverkürzender Mittel. Für die rechtliche Beurteilung der Sterbehilfe sind daher die allgemeinen Tötungstatbestände maßgebend.
1.1
Aktive Sterbehilfe
Danach ist jemand, der den Tod eines anderen Menschen mit Tötungsvorsatz
verursacht, wegen Mordes (murder) strafbar (s. 212 CC, siehe Dokument
1.1), der mit lebenslanger Freiheitsstrafe sanktioniert wird. Da das Tatmotiv
kein notwendiges Element der schuldhaften Tötung bildet, ist es für die Tatbestandserfüllung irrelevant, ob der Täter aus Mitleid handelt. Diese Tatsache
kann jedoch Bedeutung für die Strafzumessung haben.1
Ausdrücklich geregelt ist in s. 14 CC (Dokument 1.1), daß eine Einwilligung
in die Tötung den Täter nicht entlastet.
Es wird jedoch darauf hingewiesen, daß der Nachweis, der Tod des Patienten
sei durch ärztliches Handeln herbeigeführt worden und nicht schon als Folge
1
Keyserlingk, ZStW 97 (1985), S. 185.
412
Kanada
des Gesundheitszustandes des Todkranken eingetreten, in der Praxis nur
schwer zu führen ist.2
In den Fällen, in denen - unter den Umständen angemessene - Mittel zur
Schmerzlinderung des Patienten verabreicht werden, die aber gleichzeitig den
Todeseintritt beschleunigen, wird der Tötungsvorsatz verneint.3 Außerdem
sei die Beschleunigung des Todes eine unvermeidliche Nebenwirkung von
ärztlich indiziertem Handeln, also Folge des Gesundheitszustandes, so daß
auch die Kausalität zwischen dem Handeln und dem Tod zu verneinen sei.4
1.2
Passive Sterbehilfe
Grundsätzlich hat jedermann das Recht, über seinen Körper zu bestimmen, so
daß ein Arzt an den eindeutig geäußerten Willen eines volljährigen und geistig normalen Patienten gebunden ist.5
Dieses Recht wird allerdings in den Fällen eingeschränkt, in denen der Patient zunächst ausdrücklich eine Behandlung ablehnt, dann aber in einen Zustand gerät, in dem er keinen Willen mehr äußern kann: Hier wird der medizinische Eingriff über die strafbefreiende Common-Law-Einrede der "necessity to save human life", die über s. 7 (3) CC anwendbar ist, bzw. bei operativen Eingriffen über s. 45 CC (nur im Rahmen der reasonable care) gerechtfertigt (vgl. Dokument 1.1).6 Ärztliches Handeln trotz vorheriger Ablehnung
wird also nur in den Fällen sanktioniert, in denen die Behandlung über den
Rahmen der reasonable care hinausginge.
Die Fälle der Nichtbehandlung bzw. des Sterbenlassens können unter folgenden Voraussetzungen zur Strafbarkeit wegen Tötung durch Unterlassen
führen:
-
Der Patient hat keinen Willen geäußert oder eine Behandlung ausdrücklich gewünscht.
2
3
4
5
Keyserlingk, ZStW 97 (1985), S. 185; LRC Canada, Working Paper 28, S. 21.
Keyserlingk, ZStW 97 (1985), S. 187.
Keyserlingk, ZStW 97 (1985), S. 186 f.
LRC Canada, Working Paper 26, S. 70 f.; Dickens, McGill Law Journal 26 (1981),
S. S. 847 ff.
Dickens, McGill Law Journal 26 (1981), S. 853, 855, 862; ders., The Canadian Bar Review 62 (1984), S. 206.
6
Übersicht
-
-
413
Die erforderliche Behandlung muß absichtlich vorenthalten worden sein
(murder, ss. 205, 212 CC), oder das Unterlassen muß die Folge von grober Fahrlässigkeit sein (manslaughter, ss. 205, 217 CC) (Dokument 1.1).
Die Unterlassung muß den Tod verursacht haben.
Es muß eine Pflicht zum Handeln bestehen.
Der Criminal Code enthält einige Vorschriften, die Handlungspflichten normieren und gleichzeitig eigene Unterlassungstatbestände darstellen. Solch
eine Pflicht besteht zunächst gemäß s. 197 (Dokument 1.1) für Eltern; sie
wurde von den kanadischen Gerichten auch für Angehörige von medizinischen Berufen anerkannt (Hôpital Notre-Dame v. Patry (1972) C.A. 579).7
Danach besteht die Pflicht, Maßnahmen zu treffen, die zum Schutz und zur
Erhaltung des Lebens des jeweiligen Schutzbefohlenen notwendig sind.
S. 198 CC (Dokument 1.1) begründet für alle Personen, die mit medizinischer Betreuung befaßt sind, die Pflicht, diejenige Sorgfalt anzuwenden, die
vernünftigerweise gefordert werden kann.
S. 199 CC (Dokument 1.1) verlangt, daß eine einmal begonnene Handlung
fortzuführen ist, wenn ein Unterlassen eine Lebensgefahr mit sich bringen
würde.
Bei ärztlichem Handeln muß dabei aber der Verhaltensstandard, der in
s. 45 CC enthalten ist, mitberücksichtigt werden: So macht sich jemand nicht
strafbar, wenn er unter Berücksichtigung der konkreten Umstände eine vernünftige Entscheidung trifft - die auch dahin gehen kann, bei einem Todkranken keine lebenserhaltenden Maßnahmen mehr einzuleiten.8
Wenn der Patient selbst keinen Willen mehr äußern kann oder wegen Alters,
Bewußtlosigkeit oder Geisteskrankheit nicht einwilligungsfähig ist, so ergibt
sich keine Pflicht zur Lebenserhaltung um jeden Preis. Gemäß ss. 198, 199,
45 CC muß der Arzt nur so lange eine Behandlung einleiten oder fortsetzen,
als sie der "reasonable care" entspricht. Wenn der Patient geäußert hat, daß er
auch im Zustand der Bewußtlosigkeit eine weitergehende Behandlung wünsche, so sind die Ärzte nur im Rahmen der reasonable bzw. ordinary care
dazu verpflichtet. Einen Anspruch auf nicht mehr der reasonable care entsprechende, also außergewöhnliche Behandlung, hat der Patient nicht.9
7
8
9
Vgl. ausführlicher LRC Canada, Working Paper 26, S. 22, 23 mit weiteren Nachweisen.
LRC Canada, Working Paper 28, S. 17.
Dickens, McGill Law Journal 26 (1981), S. 862.
414
1.3
Kanada
Todeszeitpunkt
Eine gesetzliche Regelung bezüglich der Bestimmung des Todeszeitpunkts
existiert im kanadischen Recht bislang nur in der Provinz Manitoba. Sie wurde durch einen 1974 von der Law Reform Commission Manitoba veröffentlichten Bericht angeregt; hiernach gilt ein Mensch als tot, wenn seine
Gehirnfunktionen endgültig erloschen sind (irreversible cessation of all brain
functions) (Dokument 1.3). Die Reichweite dieser Bestimmung für die Bundesgesetze, insbesondere das Strafrecht, konnte nicht geklärt werden.
1.4
Suizid/Beihilfe
Der Suizidversuch ist seit 1972 nicht mehr strafbar. Trotzdem macht sich
derjenige, der aktiv einem (potentiellen) Suizidenten durch Rat, Anstiftung
oder Hilfe beisteht, nach s. 224 CC (Dokument 1.1) strafbar, unabhängig davon, ob der Suizid zur Ausführung gelangt.
2.
Rechtsprechung
Zu den Problemen der aktiven oder passiven Sterbehilfe haben die Gerichte
bisher kaum Stellung genommen.10
Im Fall Astaforoff - Attorney General of British Columbia, Stevenson and
Merat v. Astaforoff and Attorney General of Canada (1983) 35 C.R. (3d) 69
(B.C.S.C.) - (Dokument 2.1) entschied der Supreme Court British Columbia
über das Gewährenlassen eines Suizidenten. Es ging um die Frage, ob eine
Strafgefangene, die in Hungerstreik trat, künstlich ernährt werden mußte
bzw. durfte.
Das Gericht führt aus, daß sich gemäß s. 224 CC zwar nicht strafbar macht,
wer einen Suizidenten lediglich gewähren läßt, daß aber andererseits jeder im
Rahmen von s. 197 CC (legal duty to provide necessaries of life) verpflichtet
ist, Maßnahmen zur Verhinderung des Suizids zu ergreifen, wenn ihm dies
zumutbar ist. Besonderes Gewicht legte das Gericht auf den Umstand, ob der
Suizident - noch - frei entscheiden kann. Wenn der Suizident bewußtlos wird
oder "unable to make a free choice" ist, wird offenbar eine Handlungspflicht
bejaht.
10
Zur Erklärung der Diskrepanz zwischen Strafbarkeit einerseits und Nichtverfolgung
andererseits siehe LRC Canada, Working Paper 28, S. 20 f.
Übersicht
415
Bezüglich der Frage der Nichtbehandlung von schwerkranken Kindern erging
1983 eine Entscheidung ebenfalls des Supreme Court British Columbia im
Falle des siebenjährigen Stephen Dawson - Re Superintendent of Family and
Child Service and Dawson et al. (1983) 145 D.L.R. (3d) 610 sub. nom. Re S.
Dawson [1983] 3 W.W.R. 618, 42 B.C.L.R. 173 (B.C.S.C.) - (Dokument
2.2).11 In diesem Fall hatte die Jugendwohlfahrtsbehörde eine gerichtliche
Genehmigung für eine Operation beantragt, durch die ein Shunt (eine Art
Abflußleitung) genäht werden sollte, um dem Gehirn von Stephen Flüssigkeit
zu entziehen. Die Eltern hatten die Einwilligung in die Operation verweigert,
da sie die Operation als lebenserhaltend ansahen und angesichts der Zukunftsaussichten ihres schwer behinderten Sohnes einen würdigen Tod vorzogen. Der Supreme Court entschied gegen die Eltern und genehmigte die
Operation. Gestützt wurde die Entscheidung auf die - im Gegensatz zu der
Einschätzung der Eltern stehende - günstige Zukunftsprognose des Kindes, so
daß es sich nicht um das Recht eines unheilbar Kranken auf den Tod, sondern
vielmehr um das Recht des Kindes auf normale medizinische Betreuung handele.
Das Gericht griff die im amerikanischen Quinlan-Fall entwickelte Unterscheidung zwischen "ordinary" und "extraordinary" care auf: Die Behandlungspflicht des Arztes besteht nur insoweit, als es sich um normale medizinische Behandlung ("ordinary medical care") handelt. Handelt es sich hingegen um "extraordinary care", so darf sie nur mit Einwilligung des Betroffenen bzw. bei Kindern mit der der Eltern vorgenommen werden.
Mit der Frage der Nichtbehandlung von schwerkranken Kindern befaßt sich
auch die Couture-Jacquet-Entscheidung des Appeal Court of Quebec (Couture-Jacquet v. Montreal Children's Hospital (1986), [1986] R.J.Q. 1221
(C.A.)).12
11
12
Eine Besprechung dieser Entscheidung siehe Dickens, Canadian Bar Review 62 (1984),
S. 196 ff.
Die Entscheidung ist besprochen von Keyserlingk, McGill Law Journal 32 (1987),
S. 413 ff.
416
Kanada
Der Appeal Court hob darin eine Entscheidung des Superior Court auf, die
das Montreal Children's Hospital dazu ermächtigt hatte, entgegen der Zustimmungsverweigerung einer Mutter, deren schwer an Krebs erkrankte
zweijährige Tochter einer weiteren Chemotherapie zu unterziehen. Entscheidender Ansatzpunkt für die Entscheidung war s. 42 Public Health Protection Act (Quebec),13 wonach die elterliche Verweigerung der Zustimmung
zu einer Behandlung dann unbeachtlich ist, wenn sie sich nicht im Interesse
des Kindes ("in the child's best interest") rechtfertigen läßt.
Im zu entscheidenden Fall hielt der Appeal Court die Zustimmungsverweigerung für gerechtfertigt, insbesondere im Hinblick auf die schädigenden
Nebenwirkungen weiterer Chemotherapie und deren geschätzte, aber nicht
gesicherte Erfolgsquote von nur 10-20 %.
Die Zulässigkeit der Verweigerung medizinischer Behandlung durch den
Patienten selbst hat der Superior Court of Quebec in zwei Fällen verneint:
Im Fall Dion (Institut Philippe Pinel de Montréal c. Dion (1983) 2 D.L.R.
(4th) 234, [1983] C.S. 438 (Que. S.C.)).14 war ein Untersuchungshäftling
(Dion) betroffen, der an paranoider Schizophrenie litt und die zur Verhinderung einer Verschlechterung seines Zustandes erforderliche Medikamententherapie ablehnte.
Das Gericht hielt diese Ablehnung für unbeachtlich, weil Dion aufgrund seiner Krankheit "incapacitated" sei und daher bei ihm die für die Entscheidung
erforderliche Einsichtsfähigkeit nicht vorliege.
Im Fall Niemiec (Procureur Général du Canada c. Hôpital Notre-Dame et un
autre (défendeurs) et Jan Niemiec (mis en cause) [1984] C.S. 426 (Que.
S.C.))15 hatte der sich in Abschiebehaft befindende Niemiec ein Stück Draht
verschluckt und, obwohl ernste Komplikationen zu befürchten waren, jegliche medizinische Behandlung mit der Erklärung abgelehnt, er wolle lieber
sterben, als in sein Heimtland zurückgewiesen zu werden.
Das Gericht überging seine Verweigerung einer Behandlung mit der Begründung, das Prinzip der Unverletzlichkeit einer Person ("inviolability of the
13
14
15
R.S.Q. c. P-35.
Die Entscheidung ist besprochen von Somerville, The Canadian Bar Review 63 (1985),
S. 59 ff.
Auch diese Entscheidung ist Gegenstand der Besprechung von Somerville (Anm. 14).
Übersicht
417
person") sei nicht absolut. Es bestehe lediglich mit dem Ziel, es einer Person
zu ermöglichen, ihre körperliche Integrität und ihr Leben zu erhalten. Das
Prinzip dürfe nicht dazu beansprucht werden, genau das gegenteilige Ergebnis (hier: den Tod) zu erreichen. Zudem sei der Respekt vor dem Leben höherrangig als der Respekt vor der Entscheidungsfreiheit. Vielmehr bestehe
eine Jedermanns-Pflicht, das Leben und die Sicherheit anderer zu schützen.
Entsprechend autorisierte das Gericht, im Rahmen seiner sogenannten "parens patriae power", die Klinik zur Vornahme der erforderlichen Operation.
3.
Literaturstimmen
Die Tatsache, daß weder gesetztes Recht noch eindeutige Präzedenzfälle auf
die Frage antworten, in welchem Umfang eine lebenserhaltende Behandlung
vorzunehmen ist, führte dazu, daß von vielen Seiten versucht wurde, konkretere Gesichtspunkte zu entwickeln.
So wurde der Versuch unternommen, die Formel, daß eine Pflicht zu lebenserhaltender Behandlung im Rahmen von "ordinary care" besteht, faßbarer zu machen. Ob ordinary oder extraordinary care vorliegt, soll jeweils anhand der besonderen Umstände, insbesondere der Krankengeschichte und der
Zukunftsaussichten entschieden werden. Bei gegebener Überlebenschance
bzw. positiver Prognose handele es sich regelmäßig um gewöhnliche, also
erforderliche Behandlung.16
Es wird auch darauf abgestellt, ob die Behandlung therapeutisch sinnvoll ist
(dann, wenn sie das Leiden heilt oder lindert)17 bzw. ob durch Unterlassen
die eigenen Interessen des Patienten18 gefördert werden.
Die Legitimation eines Rechts von Todkranken zur Verweigerung weiterer
medizinischer Behandlung wird neuerdings auch unter Einbeziehung der Canadian Charter of Rights and Freedoms19 (Dokument 1.2) diskutiert.20
16
17
18
19
20
Vgl. Keyserlingk, ZStW 97 (1985), S. 189; Dickens, McGill Law Journal 26 (1981),
S. 861.
In diesem Sinn LRC Canada, Working Paper 28, S. 35 f., obwohl sie diese Unterscheidung für wenig gewinnbringend hält; vgl. auch Keyserlingk, ZStW 97 (1985),
S. 120.
Vgl. Dickens, The Canadian Bar Review 62 (1984), S. 196 ff.; Keyserlingk, Sanctity of
life, S. 107 ff.; ders., ZStW 97 (1985), S. 192.
Part I of the Constitution Act (1982).
Carnerie, McGill Law Journal 32 (1987), S. 299 ff. Daß dieser Gesichtspunkt erst jetzt
an Bedeutung gewinnt, liegt wohl daran, daß die Canadian Charter of Rights and Free-
418
Kanada
Nach Carnerie sind zur Begründung eines "Right to Die" folgende Sections
der Charter zu erwägen:21
-
Section 7: Life, Liberty and Security of the Person;22
Section 2 (a): Freedom of Conscience and Religion;
Section 12: Cruel and Unusual Treatment.
Allerdings habe ein darauf gestütztes Recht zur Behandlungsverweigerung
keinesfalls absolute Wirkung. Einschränkungen seien im Rahmen von s. 1
der Charter zulässig.23
Soweit strafrechliche Bestimmungen, namentlich ss. 241 (b), 197 (2) (b),
198, 14 CC, das Recht zur Behandlungsverweigerung beschränken, wird jedoch die Einhaltung der Voraussetzungen von s. 1 der Charter ("reasonable
limits", "demonstrably justified in a free and democratic society") bezweifelt.24
4.
Richtlinien
4.1
Grenzen der Behandlungspflicht
Richtlinien, die rechtlich verbindlich wären, bestehen nicht. Vielmehr wurden
allgemeine Verhaltensregeln von verschiedenen medizinischen Institutionen
aufgestellt, um Ärzten und anderem medizinischem Personal Entscheidungshilfen bei der Behandlung unheilbar Kranker an die Hand zu geben.
Ihnen allen liegt das gemeinsame Prinzip zugrunde, daß der einsichtsfähige
unheilbar Kranke (competent terminally ill) ein Recht hat, lebenserhaltende
Maßnahmen abzulehnen und dies in einem Patiententestament (living will)
festzulegen. Manche Krankenhäuser haben - offenbar zu Dokumentationszwecken - eigene Muster für Patientenverfügungen entwickelt, die im Bedarfsfall dem Patienten zur Unterschrift vorgelegt werden.
21
22
23
24
doms erst seit dem 17.4.1982 Teil der kanadischen Verfassung ist, die bis dahin geltende Canadian Bill of Rights aber lediglich den Rang eines einfachen Bundesgesetzes
hat.
Carnerie, McGill Law Journal 32 (1987), S. 312-330.
Unter "Life" wird auf den Qualitätsaspekt des Lebens und unter "Liberty" auf die Entscheidungsfreiheit abgestellt. Carnerie, McGill Law Journal 32 (1987) S. 322 f.
Carnerie, McGill Law Journal 32 (1987), S. 330.
Carnerie, McGill Law Journal 32 (1987), S. 333, 335.
Übersicht
419
Da die Entscheidung, ob ein Patient "competent" und ob er "terminally ill"
ist, beim Arzt liegt, werden Kriterien entwickelt, die ihm diese Beurteilung
erleichtern sollen. Zudem wollen sie verhindern, daß ein Fall von verschiedenen Ärzten unterschiedlich beurteilt wird.
Ebenso wird für den Fall, daß der Patient "incompetent" ist, festgelegt, an
welche Kriterien die Weiterbehandlung geknüpft werden und welche Person
die Entscheidung treffen soll.
Solche Richtlinien wurden von mehreren Krankenhäusern (Ottawa Civic
Hospital; Hôpital Notre-Dame in Hearst, Ontario; Royal Victoria Hospital in
Montreal, Quebec; Chedoke McMaster-Hospital in Hamilton, Ontario - Dokumente 3.1) als auch als "Joint Statement on Terminal Illness" (Dokument
3.2) von einem gemeinsamen Gremium der Canadian Nurses Association, der
Canadian Medical Association und der Canadian Hospital Association erstellt. Schon 1982 wurde von der Canadian Medical Association ein "Statement on Terminal Illness" erarbeitet (Dokument 3.3).25
So wurde in einigen Krankenhäusern eingeführt, bereits vor dem Eintritt kritischer Situationen festzulegen, ob Wiederbelebungsversuche unternommen
werden sollen, so daß sogenannte DNR-Orders ("Do Not Resuscitate") in die
Patientenkartei aufgenommen werden können.
Eine Umfrage im McMaster University Medical Centre, Hamilton, das ebenfalls das Verfahren der DNR-Order empfohlen hatte, ergab, daß diese Möglichkeit von dem medizinischen Personal als weitgehend hilfreich und positiv
beurteilt wurde.26
4.2
Bestimmung des Todeszeitpunkts
Die Canadian Medical Association veröffentlichte 1968 Kriterien zur Bestimmung des Todeszeitpunkts, die auf die Gehirnfunktionen abstellen und
die 1974 vom Canadian Medical Association General Council bestätigt wurden.27
25
26
27
Abgedruckt in Ontario Medical Review, May 1983, S. 240 f.
Veröffentlicht in Canadian Medical Association Journal 125 (1981), S. 830 ff.
Siehe "The Canadian Medical Association Statement on Death, November 1968", Canadian Medical Association Journal 99 (1968), S. 1266.
420
Kanada
5.
Reformbestrebungen
5.1
Sterbehilfe
Die Law Reform Commission (LRC) von Kanada beklagt in ihrem Bericht
"Euthanasia, Aiding Suicide and Cessation of Treatment" (Working Paper 28,
1982; Report 20, 1983) eine große Rechtsunsicherheit, konnte sich aber nicht
dazu durchringen, wesentliche Reformen vorzuschlagen. So wird empfohlen,
die aktive Sterbehilfe weiterhin als Tötungsdelikt zu bestrafen. Die Regelung
hinsichtlich der Nichtbehandlung durch einen Arzt solle gesetzlich klargestellt werden (Dokument 4.1). Außerdem schlug die LRC in ihrem Working
Paper 26 von 1980 u.a. vor, ein dem § 323c StGB vergleichbares Delikt einzuführen (Dokument 4.2).
Ein Gesetzentwurf "An Act to amend the Narcotic Control Act to allow heroin to be used for terminally ill patients and those in intractable pain" wurde
1984 von einem Parlamentsmitglied eingebracht. Er sah vor, die Verwendung
von Heroin zu medizinischen Zwecken zu legalisieren. Eine entsprechende
Gesetzesänderung wurde jedoch bislang nicht vorgenommen.
In der Provinz Ontario wurde im März 1977 beim Gesetzgeber von einem
Parlamentsmitglied ein Gesetzesvorschlag ("An Act respecting the Withholding or Withdrawal of Treatment where Death is Inevitable" - Dokument
4.6) eingebracht, der auf die Erfahrung mit dem kalifornischen Natural Death
Act zurückzuführen war. Wegen Neuwahlen wurde der zunächst positiv aufgenommene Vorschlag dann aber nicht mehr weiterverfolgt.
5.2
Todeszeitpunkt
Die LRC von Kanada entwarf im Anschluß an Überlegungen im Working
Paper 23 ("Criteria for the determination of death") von 1979 (Dokument 4.3)
1981 in ihrem Report 15 "Criteria for the determination of death" eine Vorschrift über die Bestimmung des Todeszeitpunkts (Dokument 4.4). In der
Provinz Saskatchewan wurde von der dortigen LRC 1980 ebenfalls ein Entwurf für eine solche Bestimmung erarbeitet: "Tentative Proposals for a Definition of Death Act" (Dokument 4.5). Soweit ersichtlich, wurden diese Reformvorschläge vom Gesetzgeber bisher noch nicht umgesetzt.
5.3
Suizid/Beihilfe
Die LRC von Kanada empfiehlt in Working Paper 28 und Report 20, die Suizidbeteiligung weiterhin strafrechtlich zu sanktionieren (Dokument 4.1).
421
Dokumentation
Dokumentation
Seite
1.
2.
3.
Gesetzliche Bestimmungen ........................................................................ 422
1.1
Criminal Code (Auszug) .................................................................. 422
1.2
Canadian Charter of Rights and Freedoms (Auszug) ...................... 424
1.3
Manitoba: Vital Statistics Act (1970/75) (Auszug) ......................... 425
Gerichtsentscheidungen (Auszüge) ........................................................... 425
2.1
Attorney General of British Columbia, Stevenson and
Merat v. Astaforoff and Attorney General of Canada ..................... 425
2.2
Re Superintendent of Family and Child Service and
Dawson et al.; Re Russel et al. and Superintendent
of Family & Child Service et al. ...................................................... 425
Richtlinien ................................................................................................. 427
3.1
4.
Richtlinien verschiedener Krankenhäuser für die
Behandlung unheilbar Kranker ........................................................ 427
3.1.1
Ottawa Civic Hospital - Do Not Resuscitate Policy,
November 1984 ................................................................... 427
3.1.2
Notre-Dame Hospital, Hearst/Ontario,
January 1984 ....................................................................... 429
3.1.3
Royal Victoria Hospital Montreal, Quebec ......................... 431
3.1.4
Chedoke-McMaster Hospital, May 1982 ............................ 433
3.2
Canadian Nurses Association, Canadian Medical Association,
Canadian Hospital Association: Joint Statement on Terminal
Illness (1984) ................................................................................... 436
3.3
Canadian Medical Association: Statement on Terminal Illness
(1982) - Auszug ............................................................................... 438
Reformvorschläge ...................................................................................... 439
4.1
LRC Canada: Euthanasia, Aiding Suicide and Cessation
of Treatment (1983) - Auszug ......................................................... 439
4.2
LRC Canada: Medical Treatment and Criminal Law (1980) Auszug ............................................................................................. 441
4.3
LRC Canada: Criteria for the Determination of Death (1979) Auszug ............................................................................................. 441
4.4
LRC Canada: Criteria for the Determination of Death
(1981) - Auszug ............................................................................... 442
422
5.
Kanada
4.5
LRC Saskatchewan: Tentative Proposals for a
Definition of Death Act (1980) - Auszug ........................................ 442
4.6
Ontario: Proposed Natural Death Act (1977) .................................. 443
Literatur ..................................................................................................... 446
Abkürzungsverzeichnis ........................................................................................ 450
1.
Gesetzliche Bestimmungen
1.1
Canadian Criminal Code 1953-1954 (Auszug)28
7. (...)
(3) Common law principles continued. Every rule and principle of the common
law that renders any circumstance a justification or excuse for an act or a defence to
a charge continues in force and applies in respect of proceedings for an offence under this Act or any other Act of the Parliament of Canada, except in so far as they
are altered by or are inconsistent with this Act or any other Act of the Parliament of
Canada.
14. Consent to death. No person is entitled to consent to have death inflicted upon
him, and such consent does not affect the criminal responsibility of any person by
whom death may be inflicted upon the person by whom consent is given.
21. (1) Parties to offence. Every one is a party to an offence who
(a) actually commits it,
(b) does or omits to do anything for the purpose of aiding any person to commit it,
or
(c) abets any person in committing it.
(2) Common intention. Where two or more persons form an intention in common
to carry out an unlawful purpose and to assist each other therein and any one of
them, in carrying out the common purpose, commits an offence, each of them who
knew or ought to have known that the commission of the offence would be a probable consequence of carrying out the common purpose is a party to that offence.
45. Surgical operations. Every one is protected from criminal responsibility for
performing a surgical operation upon any person for the benefit of that person if
(a) the operation is performed with reasonable care and skill, and
(b) it is reasonable to perform the operation, having regard to the state of health of
the person at the time the operation is performed and to all the circumstances of
the case.
197. Duty of persons to provide necessaries. (1) Every one is under a legal duty
(a) as a parent, foster parent, guardian or head of a family, to provide necessaries
of life for a child under the age of sixteen years;
(b) as a married person, to provide necessaries of life to his spouse; and
28
R.S.C. 1970, Chap. C-34.
Dokumentation/Gesetzliche Bestimmungen
423
(c) to provide necessaries of life to a person under his charge if that person
(i) is unable, by reason of detention, age, illness, insanity or other cause, to
withdraw himself from that charge, and
(ii) is unable to provide himself with necessaries of life.
(2) Every one commits an offence who, being under a legal duty within the meaning
of subsection (1), fails without lawful excuse, the proof of which lies upon him, to
perform that duty, if
(a) with respect to a duty imposed by paragraph (1) (a) or (b),
(i) the person to whom the duty is owed in destitute or necessitous circumstances, or
(ii) the failure to perform the duty endangers the life of the person to whom
the duty is owed, or causes or is likely to cause the health of that person to
be endangered permanently; or
(b) with respect to a duty imposed by paragraph (1) (c), the failure to perform the
duty endangers the life of the person to whom the duty is owed or causes or is
likely to cause the health of that person to be injured permanently.
(3) Every one who commits an offence under subsection (2) is guilty of
(a) an indictable offence and is liable to imprisonment for two years; or
(b) an offence punishable on summary conviction.
(4) For the purpose of proceedings under this section,
(a) evidence that a person has cohabited with a person of the opposite sex or has in
any way recognized that person as being his spouse is, in the absence of any
evidence to the contrary, proof that they are lawfully married;
(b) evidence that a person has in any way recognized a child as being his child is,
in the absence of any evidence to the contrary, proof that the child is his child;
(c) evidence that a person has left his spouse and has failed, for a period of any one
month subsequent to the time of his so leaving, to make provision for the
maintenance of his spouse or for the maintenance of any child of his under the
age of sixteen years is, in the absence of any evidence to the contrary, proof
that he has failed without lawful excuse to provide necessaries of life for them;
and
(d) the fact that a spouse or child is receiving or has received necessaries of life
from another person who is not under a legal duty to provide them is not a defence.
198. Duty of persons undertaking acts dangerous to life. Every one who undertakes to administer surgical or medical treatment to another person or to do any
other lawful act that may endanger the life of another person is, except in cases of
necessity, under a legal duty to have and to use reasonable knowledge, skill and care
in so doing.
199. Duty of persons undertaking acts. Every one who undertakes to do an act is
under a legal duty to do it if an omission to do the act is or may be dangerous to life.
205. (1) Homicide. A person commits homicide when, directly or indirectly, by any
means, he causes the death of a human being.
(2) Kinds of homicide. Homicide is culpable or not culpable.
(3) Non culpable homicide. Homicide that is not culpable is not an offence.
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(4) Culpable homicide. Culpable homicide is murder or manslaughter or infanticide.
(5) Idem. A person commits culpable homicide when he causes the death of a human being,
(a) by means of an unlawful act,
(b) by criminal negligence,
(c) by causing that human being, by threats or fear of violence or by deception, to
do anything that causes his death, or
(d) by wilfully frightening that human being, in the case of a child or sick person.
(...)
212. Murder. Culpable homicide is murder
(a) where the person who causes the death of a human being
(i) means to cause his death, or
(ii) means to cause him bodily harm that he knows is likely to cause his death,
and is reckless whether death ensues or not;
(b) where a person, meaning to cause death to a human being or meaning to cause
him bodily harm that he knows is likely to cause his death, and being reckless
whether death ensues or not, by accident or mistake causes death to another
human being, notwithstanding that he does not mean to cause death or bodily
harm to that human being; or
(c) where a person, for an unlawful object, does anything that he knows or ought to
know is likely to cause death, and thereby causes death to a human being, notwithstanding that he desires to effect his object without causing death or bodily
harm to any human being.
217. Manslaughter. Culpable homicide that is not murder or infanticide is manslaughter.
224. Counselling or aiding suicide. Every one who
(a) counsels or procures a person to commit suicide, or
(b) aids or abets a person to commit suicide, whether suicide ensues or not, is
guilty of an indictable offence and is liable to imprisonment for fourteen years.
1.2
Canadian Charter of Rights and Freedoms (Auszug)29
1. Rights and Freedoms in Canada. The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable
limits prescribed by law as can be demonstrably justified in a free and democratic
society.
2. Fundamental freedoms. Everyone has the following fundamental freedoms:
(a) freedom of conscience and religion;
(...)
29
R.S.C. 1985, Appendix II, No. 44.
Dokumentation/Gerichtsentscheidungen
425
7. Life, liberty and security of person. Everyone has the right to life, liberty and
security of the person and the right not to be deprived thereof except in accordance
with the principles of fundamental justice.
12. Treatment or punishment. Everyone has the right not to be subjected to any
cruel and unusual treatment or punishment.
1.3
Manitoba - The Vital Statistics Act (Auszug)30
2.1 For all purposes within the legislative competence of the Legislature of Manitoba the death of a person takes place at the time at which irreversible cessation of
all that person's brain function occurs.
2.
Gerichtsentscheidungen (Auszüge)
2.1
Attorney General of British Columbia, Stevenson and Merat
v. Astaforoff and Attorney General of Canada31
What Mary Astaforoff is trying to do is commit suicide. (...) But idly standing by
without encouraging a person to commit suicide is no crime. A mere spectator to a
suicide cannot be convicted of any criminal offence.
Nonetheless, it is the duty of every person to use reasonable care in preventing a
person from committing suicide. What is reasonable depends upon the facts. (...)
Given these facts, I cannot find that it is reasonable that the Attorney General for
British Columbia and the prison authorities under his direction should force-feed her
in order to prevent her suicide.
If she becomes unconscious or incapable of making a rational decision, that is another matter. Then she will be unable to make a free choice. But while she is lucid
no law compels the provincial officers to apply force to her against her will. (S. 74)
2.2
Re Superintendent of Family & Child Service and Dawson et al.;
Re Russell et al. and Superintendent of Family & Child Service et al.32
Dr. Patrick Murray is the neuro-surgeon who was originally scheduled to perform
the surgery until the consents were withdrawn. (...) He thought it was a "reasoned
decision". On medical grounds he thinks the surgery should be done but on the second level, taking in the moral and the ethical considerations raised by the parents'
attitude, he thinks that surgery would be "an extraordinary surgical intervention". He
30
31
32
R.S.M. 1970, c. V-60, as amended by S.M. 1975, c. 5, s. 1.
(1983) 35 C.R. (3d) 69 (B.C.S.C.).
(1983) 145 D.L.R. (3d) 610 (B.C.S.C.).
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thinks there is no hope for improvement after surgery - that is, he will live but will
remain in his pre-operative state. (S. 615)
In considering the application of the parens patriae jurisdiction I recognize that the
central concern is to discover what is in S.'s best interest. This is not a "right to die"
situation where the courts are concerned with people who are terminally ill from
incurable conditions. Rather it is a question of whether S. has the right to receive
appropriate medical and surgical care of a relatively simple kind which will assure to
him the continuation of his life, such as it is. (...)
I do not think that it lies within the prerogative of any parent or of this court to look
down upon a disadvantaged person and judge the quality of that person's life to be so
low as not to be deserving of continuance. (...)
It is not appropriate for an external decision maker to apply his standards of what
constitutes a liveable life and exercise the right to impose death if that standard is
not met in his estimation. The decision can only be made in the context of the disabled person viewing the worthwhileness or otherwise of his life in its own context
as a disabled person - and in that context he would not compare his life with that of a
person enjoying normal advantages. He would know nothing of a normal person's
life, having never experienced it. (...) (S. 620)
I cannot accept their view that S. would be better off dead. If it is to be decided that
"it is in the best interests of S.D. that his existence cease", then it must be decided
that, for him, non-existence is the better alternative. This would mean regarding the
life of a handicapped child as not only less valuable than the life of a normal child,
but so much less valuable that it is not worth preserving. I tremble at contemplating
the consequences if the lives of disabled persons are dependent upon such judgments.
To refer back to the words of Templeman L.J., I cannot in conscience find that this
is a case of severed proved damage "where the future is so certain and where the life
of the child is so bound to be full of pain and suffering that the court might be driven
to a different conclusion". I am not satisfied that "the life of this child is demonstrably going to be so awful that in effect the child must be condemned to die". Rather I
believe that "the life of this child is still so imponderable that it would be wrong for
her to be condemned to die".
There is not a simple choice here of allowing the child to live or die according to
whether the shunt is implanted or not. There looms the awful possibility that without
the shunt the child will endure in a state of progressing disability and pain. It is too
simplistic to say that the child should be allowed to die in peace. (...) (S. 633)
Dokumentation/Richtlinien
427
3.
Richtlinien
3.1
Richtlinien verschiedener Krankenhäuser für die Behandlung
unheilbar Kranker
3.1.1
Ottawa Civic Hospital - Do Not Resuscitate Policy, November 1984
A. Policy
The decision not to resuscitate shall be recorded in the physician's order sheet.
Without proper procedures and documentation, resuscitation WILL be initiated.
Background
While caring for the dying patient, it is the attending physician's professional responsibility to make medical judgment whether to resuscitate the patient in the event
of a cardiopulmonary arrest. In doing so, the physician also recognizes the decision
not to resuscitate the patient in no way implies that the physician has abandoned the
patient - active medical care continues. In cases of serious doubt as to the appropriateness of resuscitation, the presumption is to favour life.
B. Procedure:
NOTE:
All steps of the procedures shall be documented in the clinical record.
I. To begin the procedure of a non-resuscitative order, the attending physician shall
first assess the patient and establish the following clinical facts:
(a) the patient has a terminal irreversible condition
(b) the length of time that it is expected the patient will live, with or without intervention, as death is imminent; and
(c) resuscitative measures would merely prolong death rather than extend life
when there is no possibility of providing a satisfactory quality of life.
II. Having established the clinical facts, the attending physician in consultation with
the nursing staff, shall determine the competency of the patient and the appropriateness of the Do No Resuscitate Order.
If the attending physician or family have any doubts about the clinical decision, a
second opinion from another physician may be sought. Any consultation shall be
documented in the clinical record as a consultation note.
If the Patient is Mentally Competent
When the patient is competent, the do not resuscitate decision will be reached consensually by the patient and physician. If the patient so wishes, family members may
be consulted.
MENTALLY COMPETENT means the ability to understand the subject matter in respect
of which consent is requested and the ability to appreciate the consequences of giving or withholding consent.
.01 (a)
The attending physician shall discuss the clinical facts and possible alternatives with the patient to determine the direction of treatment following a
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cardiopulmonary arrest. A detailed account of this step shall be documented in the Progress Notes:
(i)
If the patient does not wish to be resuscitated a Do Not Resuscitate
order at the request of the patient shall be written by the attending
physician.
(ii) If the patient wishes to be resuscitated, this is recorded by the attending physician.
.02
The Do Not Resuscitate order shall be reassessed at reasonable intervals by
the attending physician who shall confirm with the patient his previous decision.
.03
A decision by the patient to rescind the order shall become effective immediately.
.04
If a physician or nurse determines that the clinical facts have changed, the
Do Not Resuscitate order may be rescinded until such time that the attending physician can discuss the clinical facts with the patient.
.05
If a competent patient consents to a Do Not Resuscitate order, this decision
cannot be overridden by the family members without a court order.
If the Patient is Mentally Incompetent
When the patient is incompetent, the do not resuscitate decision will be reached
consensually by the next of kin and the physician. Next of kin consent refers to those
acting on behalf and in the best interests of a patient lacking the capacity of make an
informed decision.
MENTALLY INCOMPETENT shall include patients who are unconscious or otherwise
not mentally competent.
.01 (a)
The name of the next of kin shall be established and documented in the
Progress Notes.
(b) The attending physician shall discuss with the next of kin, the patient's
clinical facts and the possible alternatives to determine the direction of the
treatment following a cardiopulmonary arrest. A detailed account of this
step shall be documented on the Progress Notes.
(c) If the next of kin does not wish for the patient to be resuscitated a "Do Not
Resuscitate at the request of the next of kin" order shall be written by the
attending physician.
(d) If the next of kin wishes for the patient to be resuscitated, this shall be recorded by the attending physician.
.02
The Do Not Resuscitate order shall be reassessed at reasonable intervals by
the attending physician who shall confirm with the next of kin that the previous decision has not changed.
.03
A decision by the next of kin to rescind the order shall be documented by
the attending physician or nurse and become effective immediately.
.04
If the physician or nurse determines that the clinical facts have changed,
the Do Not Resuscitate order may be rescinded until such time that the attending physician can discuss the clinical facts with the next of kin.
429
III. While A Do Not Resuscitate order is in effect, current active treatment shall be
continued and additional therapy initiated as required. All palliative measures to
assure the mental and physical comfort of the dying patient should be ensured.
Definition of next of kin
(a) His/Her spouse of any age; or
(b) If none, or if spouse is not readily available, the children who have attained the
age of majority; or
(c) If none, or if none are readily available, his/her parents; or
(d) If none, or if neither are readily available, his brothers and sisters who have
attained the age of majority; or
(e) If none, or if none are readily available, any other of his/her next of kin who
have attained the age of majority; or
(f) For children treated at the Ottawa Civic Hospital, consent shall be attained
from the parents or legal guardian.
NOTE:
If the opinion of the attending physician there appears to be conflict among
the next of kin, it is advised that the policy not be initiated.
3.1.2
Notre-Dame Hospital, Hearst/Ontario, January 1984
Preamble:
It is the general policy of Notre-Dame Hospital to maintain a maximum degree of
health and well-being of all patients.
On the other hand, the hospital also respects the fact that the patient has a natural
right to refuse or interrupt treatments which only protract the death process instead
of lengthen life.
When death is imminent, it is possible to end therapeutic and stabilizing measures,
but the treatments of comfort as well as the social and spiritual help must be prolonged so as to allow the patient to die with dignity.
Policies and procedures are therefore clearly established in order to provide for the
making of the decision not to resuscitate should the occasion arise. The wishes of the
competent patient or of the appropriate family member of an incompetent patient
and the "no resuscitation order" written by the family doctor are the essential points
in the decision.
When the patient's condition seems to be such that a decision should be made as to
whether a "no resuscitation" order should be written, that condition should be assessed according to the following points:
1. Clinical criteria:
-
death is imminent and inevitable and/or damage caused to the patients are irreversible and irreparable.
the length of time the patient will live with or without intervention.
the consequences of the "no resuscitation" order, i.e. that it may lead to the
death of the patient before the time the physician has estimated.
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2. Procedures:
When the clinical evaluation of the patient's condition justifies the "no resuscitation"
order, the following procedures of no resuscitation are recommended:
2.1 The family doctor evaluates the patient's competency. If the patient is competent, he has the right to refuse a treatment and he must be consulted. Generally, a
member of the family should also be consulted unless the patient expressly objects.
a) The family doctor informs the patient of his condition and of the fact that the
treatments offer no hope of recovery. Then the patient decides if he wants or
not to prolong his life and sufferings.
b) If the patient expresses the desire that no measures of resuscitation be started or
that certain treatments be stopped, a "no resuscitation" order and/or a discontinuation of treatment order must be written on the chart on the physician's order sheet by the attending physician.
c) The outcome of discussions with the patient and/or the family and with hospital
staff should be recorded on the patient's chart.
d) A second opinion must be obtained from another physician if there is any doubt
or disagreement about the decision. The consulting physician must make his
written recommendations on the patient's chart.
e) The attending physician should review the "no resuscitation" order at appropriate intervals.
f) If the clinical criteria appear to have changed or become invalid, a nurse or
another physician may rescind the order until the situation can be reassessed.
g) A request by the patient and/or by a family member to rescind the order, should
immediately be implemented.
h) The reasonable mental and physical comfort of the patient shall be ensured at
all times.
2.2 The incompetent patients must not be deprived of that choice. The interruption
or the non-utilization of the treatments offering no chance of success constitutes a
good decision for them too.
a) If a person has expressed his desires concerning the treatments before becoming incompetent, his desires should be respected and the physician should
act the same as if his patient was conscious and capable. (form attached).
b) If the incompetent person has not expressed and will never be able to express
his desire about the treatment, the decision must be taken in consultation with
the family or one of his representatives. Order to follow for consultation:
spouse
children (18 years old and up)
father or mother
brother or sister (18 years old and up)
guardian or other representative.
431
Form that has to be filled in by the patient:
DECISION ABOUT THE TERMINAL ILLNESS
Because of my beliefs in the dignity of the human being, I demand that in the case I
would be terminally ill, I be fully informed so that I be able to prepare myself emotionally and spiritually to die.
I consider that I have the right to take my own decisions concerning the treatments
which could unduly prolong the death process. Should I become incompetent to take
my own decisions and should I have no chance of recovery, I then ask that no extra
medical means be utilized to prolong my life, but that what is necessary to relieve
my sufferings if they become intolerable be given to me. (By "extra medical means",
I mean treatments which do not offer sufficient hope for me or which cannot be dispensed without excessive expenses, sufferings or other serious consequences). No
means however, must be taken to shorten my life.
Signed: .................................................
.....................................................................
(Witness)
Date: .....................................................
3.1.3
Royal Victoria Hospital Montreal, Quebec
Guidelines for Cardiopulmonary Resuscitation, CPR, and Do Not Resuscitate,
DNR, Orders
I. General Principles
The aims of medicine as practised in the Montreal General Hospital are the promotion of life and health and the reduction of suffering. Treatment is offered to patients with such aims in mind. Cardiopulmonary resuscitation as a specific type of
treatment would therefore be considered for all patients who require it. When a patient is competent he or she has a right to choose whether to have a forego and given
treatment, including CPR. When a patient is incompetent, treatment decisions must
be taken on the patient's behalf.
II. Competent Patients (1)
a) Those with illnesses which are either terminal or progressive and carry a likely
probability of cardiac or pulmonary arrest are to be asked as soon after admission as
is medically acceptable whether they wish or do not wish to be resuscitated if such
an event occurred. (2)
A number of individuals will decline CPR after the potential benefits and/or disadvantages have been carefully and sympathetically explained to them by the treating physician. If the patient comprehends fully the significance of this decision and
the physician believes this to be his/her real intention then this must be recorded in
the progress notes and an order not to resuscitate (DNR) written. If there is any
doubt as to the competence or understanding by the patient of the consequences of
his or her decision, at least one additional physician and another health professional
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should see the patient and assess both the patient's competence and understanding
and note in the record their findings. A DNR order cannot be written until and unless
the patient has given his or her informed consent to this course of action.
The patient's decision should only be discussed with the family with the patient's
consent, as without this there is a breach of confidentiality and an invasion of the
patient's right to privacy, both of which are protected by law.
b) Those with illnesses which are not terminal or progressive but carry a likely
probability of cardiac or pulmonary arrest such as an acute myocardial infarction,
should also be asked for consent to CPR. However, if seeking consent is considered
of potential immediate harm to the patient then consent need not be requested and
the specific reasons for this exception noted in the chart. (3)
III. Incompetent Patients (4)
a) Those with illnesses which are not terminal or progressive will be given CPR,
because there is the presumption that a person if able to choose would decide in
favour of life.
b) In the case of an incompetent patient where a consideration of CPR and DNR
orders is indicated, (that is, the patient has an illness which is either terminal or progressive and carries a likely probability of cardiac or pulmonary arrest), the physician must discuss the issue with the nearest relatives, when available, and with other
members of the health care team including the appropriate member of the attending
staff. Resuscitation will be carried out unless it is felt that the disadvantages to the
patient exceed any benefit from the temporary prolongation of life. If a DNR order is
indicated the agreement of the nearest relative, if available, is desirable. If a consensus cannot be reached, a DNR order should not be written and further advice should
be obtained.
IV. Record and Review Procedures
a) To activate a DNR order it must be written in the patient's orders. In addition a
note in the patient's record should indicate the date, the reasons for the order, who
participated in the decision, the relatives' viewpoint in the case of the incompetent
patient and the signature of the appropriate staff member.
b) All DNR orders must be reviewed and a progress note written on the record at
least every month or more often if appropriate. In particular, any DNR order must be
reviewed and a note recorded if the patient's condition changes in any significant
respect.
Addendum
The above guidelines have been written to provide a succinct statement of hospital
policy. They are consistent with current medical, ethical, and legal thinking. Clinical
staff will appreciate, however, that "real life" is never as clear cut as guidelines seem
to suggest.
Several areas are particularly prone to difficulty and ambiguity:
1. Deciding when, and how to ask patients* whether they wish or do not wish resuscitation.
2. Deciding whether patients* really intend to accept or decline resuscitation.
433
3.
Deciding whether patients* adequately comprehend consequences of a decision
to accept or decline resuscitation.
4. Deciding whether patients are or are not competent to make a decision regarding treatment.
Care needs to be taken in relation to these decisions in order to promote true communication, and with it the therapeutic alliance between patient and physician.
Moreover, such decisions may give rise to negative influences which are less than
beneficial for optimal patient care. For example, treatment personnel may feel an
awkwardness, or lack of competence in discussing life and death issues with patients
and families. They may, consequently, put off such discussions until it is too late. Or
they may too readily accept patients' and families' decisions, made in periods of
depression, or in phases of treatment in which critical and judgmental faculties are
less than adequate. They may make snap judgements concerning patients' competence or incompetence, ignoring that patients may be competent to make decisions
concerning a specific treatment modality while they may be incompetent in some
other aspects of their lives. In the case of incompetent patients, staff may too quickly
impose their own definitions of quality of life as criteria for resuscitation and inappropriately assess the value to the patient of his or her actual level of functioning.
(An incompetent, chronically ill patient, may in his own way, enjoy a life in hospital
which seems devoid of meaning to busy, and often over-worked treatment staff.)
As in all health care, optimal decision-making in this area demands reflection, study
and consultation with other appropriate resource persons.
(1) A competent patient is someone who understands the nature and consequences
of giving or refusing consent to a CPR or DNR order.
(2) A staff physician who has followed the patient prior to admission may already
be in possession of the necessary information regarding the patient`s wishes
and this should be documented in the chart. This could include a previous decision by the patient such as a "living will", a general refusal of all further intervention or the informed waiver of the right to make treatment decisions.
(3) When the disclosure of information could of itself physically or mentally harm
the patient, then consent need not be obtained.
(4) An incompetent patient is someone who does not understand the nature and
consequence of giving or refusing consent to a CPR or DNR order.
*
Or closest relatives in the case of incompetent patients.
3.1.4
Chedoke-McMaster Hospital, May 1982
Procedure to be followed in cases involving a "No Cardiopulmonary Resuscitation Order"
WHEREAS it is the general policy of this hospital to act affirmatively to preserve the
life of all patients;
AND WHEREAS this hospital also respects the competent patient's informed acceptance or rejection of treatment, and recognizes that in certain cases, the unwanted
use of heroic measures on a patient irreversibly and irreparably terminally ill, whose
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death is imminent might be both medically unsound, and so contrary to the patient's
wishes or expectations is not to be justified;
AND WHEREAS there is a growing tendency amongst physicians and patients to allow death to occur with dignity and comfort when there is irreversible and irreparable damage and death appears to be imminent;
AND WHEREAS it is essential that a policy and procedure be clearly articulated in
order to provide for the making of the decision not to resuscitate so that the treatment of such patient remains consistent and in accordance with the informed wishes
of the competent patient or the appropriate family member of an incompetent patient
and in accordance with the documented ultimate decision of the responsible physician;
THEREFORE the Board of Trustees of Chedoke-McMaster Hospitals resolves as follows:
Under conditions where, in the opinion of the attending physician the relevant facts
(1) are such that the patient's condition is irreversible and death is imminent, the
following procedures shall be carried out:
1. If the patient is competent:
(a) The relevant facts (1) shall be discussed with the patient to determine the general direction treatment should take and, specifically, whether he/she wants to
pursue prolongation of life or to accept a more imminent death and be cared
for. The specific implementation of this choice is the responsibility of the doctor. If the patient does not wish resuscitation in the event of cardiac arrest, then
a "No Cardiopulmonary Resuscitation Order" shall be written (2) on the physician's order sheet by the attending physician and signed by a second physician,
if necessary (5).
(b) The No Cardiopulmonary Resuscitation order shall be reassessed at reasonable
intervals (6) by the attending physician who shall confirm with the patient
his/her previous decision to ensure that he/she has not changed his/her mind.
(c) The patient may, at any time, request that the order be removed without question and such request shall be implemented forthwith.
(d) If the relevant facts (1) are shown to be invalid or changed, a temporary removal of the No Cardiopulmonary Resuscitation order shall be made by a nurse
or a physician until such time as the relevant facts (1) can be discussed with the
patient and documented (2) and any new decision of the patient shall become
effective.
(e) While a No Cardiopulmonary Resuscitation order is in effect, the reasonable
mental and physical comfort of the patient shall be ensured at all times.
2. If the patient is incompetent (3):
(a) The relevant facts (1) shall be discussed with the appropriate family member
(4) of the incompetent (3) patient by the attending physician. If the appropriate
family member (4), having been completely informed, decides that no unusual
treatment should be used and has so requested that physician, then a No Cardiopulmonary Resuscitation Order shall be written (2) on the physician's order
sheet by the attending physician and signed by a second physician, if necessary
(5).
435
(b) The No Cardiopulmonary Resuscitation order shall be reassessed at reasonable
intervals (6) by the attending physician who shall confirm with the appropriate
family member (4) his/her previous decision to ensure that he/she has not
changed his/her mind.
(c) The appropriate family member (4) may, at any time, request that the order be
removed without question and such request shall be implemented forthwith.
(d) If the relevant facts (1) are shown to be invalid or changed, a temporary removal of the No Cardiopulmonary Resuscitation order shall be made by a nurse
or a physician until such time as the relevant facts (1) can be discussed with the
appropriate family member (4) and documented (2) and any new decision of
the appropriate family member (4) shall become effective.
3. In all cases, the relevant facts (1) shall be documented (2) and reviewed by the
physician with the patient if competent or with the patient's appropriate family
member (4) if the patient is incompetent (3).
References
1. Relevant Facts
The relevant facts are the best reasonable estimates made by the attending physician
and a second staff physician about the following:
(a) The irreversibility of the patient's condition and/or the irreparability of the
damage it has done.
(b) The length of time that it can be expected that patient will live with intervention or without intervention.
(c) The consequences of the No Cardiopulmonary Resuscitation order, i.e. that it
may lead to the death of the patient before the time the physician has estimated.
2. Written Documentation
All No Cardiopulmonary Resuscitation orders must be written on the physician's
order sheet and signed by the attending physician and one other staff physician, (if
required), and all the relevant facts must be noted on the progress notes in the patient's medical record. The relevant facts should be reviewed by the attending physician at reasonable intervals and this noted and signed on the progress notes on the
patient`s chart. Incompetent Patient
3. Appropriate Family Member
Appropriate family member of an incompetent patient shall be in order of appropriateness as follows:
(a) His/her spouse of any age, or
(b) If none, of if his/her spouse is not readily available, the children of the patient
who have attained the age of 18 years, or
(c) If none, or none is readily available, the parents of the patient or either of them,
or
(d) If none, or if neither is readily available, brothers and sisters of the patient who
have attained the age of 18 years, or
(e) If none, or if none is readily available, any other next of kin of the patient who
has attained the age of 18 years.
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4. Incompetent Patient
Incompetent patient shall include patients who are mentally ill, unconscious, not
competent to make a rational judgment in the opinion of the attending physician and
one other staff physician, and patients under the age of 18 years unless married.
5. Consultation - Second Signature
A consultation and subsequent second signature of another physician shall be needed
when:
(a) The attending physician is in doubt as to the interpretation of the relevant data,
or
(b) The patient (or family) requests a second opinion. The availability of a second
opinion should be made known to the patient or family by the attending physician.
6. Reasonable intervals shall be such intervals as determined by the physician having regard to the patient's condition.
3.2
Canadian Nurses Association, Canadian Medical Association, Canadian Hospital Association: Joint Statement on Terminal Illness,
April 1984
A protocol for health professionals regarding resuscitative intervention for the
terminally ill.
This joint statement of the Canadian Nurses Association, the Canadian Medical Association and the Canadian Hospital Association has been developed by a working
party of the three associations, in cooperation with the Canadian Bar Association,
with the advice of representatives from the Catholic Health Association of Canada
and the Law Reform Commission of Canada, and is based on the Statement on Terminal Illness of the Canadian Medical Association. It is intended as a basic, national
guideline for use by all those involved in the care of the terminally ill. Individual
institutions may wish to develop their own guidelines as an adjunct to the national
statement.
Advances in medical technology are providing health care workers with increasingly
sophisticated methods of resuscitation. Although interventions with these devices
are often lifesaving, health care professionals often feel uncertain when deciding to
resuscitate a patient for whom such an intervention would not appear to be beneficial, in that it would prolong the dying process rather than extend life.
It is recognized that there are conditions of ill health and inevitable death for which
an instruction on the order sheet signed by the attending physician that there should
be "no resuscitation" is appropriate and ethically acceptable. It is also recognized
that it is the patient's right to accept or refuse treatment.
Therefore, in the process of caring for a dying patient it may become necessary to
consider whether to resuscitate this patient, and the following protocol should be
implemented.
437
1. Clinical criteria
1.1 When the patient's condition is such that a decision should be made as to
whether a "no resuscitation" order should be written, that condition should be
assessed according to certain clinical criteria.
1.2 Those criteria are the best reasonable estimates made by the responsible physician, and a second staff physician where appropriate, about the following:
1.2.1 the irreversibility of the patient's condition and/or the irreparability of the
damage it has done;
1.2.2 the length of time that it can be expected that the patient will live with
intervention or without intervention.
1.2.3 the consequences of the "no resuscitation" order, i.e. that it may lead to
the death of the patient before the time the physician has estimated.
2. Procedural guidelines
When the clinical assessment justifies the writing of a "no resuscitation" order, the
following procedural guidelines are recommended:
2.1 Decision
2.1.1 the attending physician should assess the patient's competency; unless
incompetency is obvious, a second opinion should be sought.
Competent patients have the right to make decisions about their treatment. If
the patient so wishes, family members may also be consulted
When the patient is incompetent, the appropriate member(s) of the patient's
family should normally be closely involved in the decision making process.
2.1.2 The opinion of nursing staff caring for the patient should be sought, the
opinion of other health care professionals involved may be sought, where practical.
2.1.3 If the attending physician has doubts about the clinical decision, a second
opinion should be obtained from another physician. (There may be circumstances in which a lack of time or unavailability of another physician precludes obtaining a second opinion).
2.1.4 A "no resuscitation" order shall be duly recorded on the patient's record.
2.2 Implementation
2.2.1 The outcome of discussions with the patient and the family, and with the
hospital staff, should be recorded in the chart along with their views. The physician consultants should record their opinion as a consultant's note.
2.2.2 The health care personnel involved in the care of the patient should be
informed of the decision taken and of the rationale for that decision.
2.2.3 The attending physician and the nursing staff should review a "no resuscitation" order at appropriate intervals.
2.2.4 A request by the patient to rescind a "no resuscitation" order should be
implemented immediately.
2.2.5 If there are unexpected changes in the patient's condition, a nurse or another physician may rescind a "no resuscitation" order until the patient's condition can be reassessed by the attending physician.
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3. Care of the patient
Palliative care to alleviate the mental and physical discomfort of the patient should
be provided at all times.
3.3
Canadian Medical Association: Statement on Terminal Illness, 1982
(Auszug)33
Advances in medical technology are providing health care workers with increasingly
sophisticated methods of resuscitation. Although interventions with these devices
are often lifesaving, physicians and allied health workers often feel uncertain when
deciding to resuscitate a patient for whom such an intervention would not appear to
the beneficial, in that it would prolong the death process rather than extend life. The
current Canadian Medical Association policy on terminal illness states that:
The C.M.A. recognizes that there are conditions of ill health and inevitable death
where an order on the order sheet by the attending doctor of "no resuscitation" is
appropriate and ethically acceptable. When caring for a dying patient, physicians
should anticipate that it may become necessary to decide whether to resuscitate this
patient if cardiorespiratory arrest occurs, and should implement the following protocol, which provides clinical criteria and procedural guidelines on which to base such
a decision.
Clinical Criteria
When the attending physician judges that a patient's condition is such that a decision
should be made as to whether a "no resuscitation" order should be written, that condition should be assessed according to certain clinical criteria.
Those criteria are the best reasonable estimates made by the responsible physician
where appropriate, about the following:
the irreversibility of the patient's condition and/or the irreparability of the damage it has done;
the length of time that it can be expected the patient will live with intervention
or without intervention;
the consequences of the "no resuscitation" order, i.e. that it may lead to the
death of the patient before the time the physician has estimated.
Procedural guidelines
When the clinical assessment justifies the writing of a "no resuscitation" order, the
following procedural guidelines are recommended:
The attending physician should assess the patient's competency. Competent
patients have a right to refuse treatment, and therefore should be consulted. The
family should, in general, also be consulted, unless the patient expressly objects. When the patient is incompetent, the appropriate member of the patient's
family or a guardian should be consulted. As well, the opinion of a second staff
physician may be sought where practical.
33
Ontario Medical Review, May 1983, S. 240 f.
Dokumentation/Reformvorschläge
-
-
439
Other health care personnel involved in the care of the patient should be informed of the decision taken and the rationale for that decision, when appropriate.
The outcome of discussions with the patient and/or family and with hospital
staff, should be recorded in the chart along with their views.
A second opinion should be obtained from another physician if there is doubt
or disagreement about the decision. Such consultants should record their opinion as a consultant's note. (There may be circumstances in which a lack of time
or unavailability of another physician precludes obtaining a second opinion).
The attending physician should review the "no resuscitation" order at appropriate intervals.
If the clinical criteria appear to have changed or become invalid, a nurse or
another physician may rescind the order until the situation can be reassessed.
All palliative measures to assure the mental and physical comfort of the dying
patient should be ensured.
A request by the patient or family member to rescind the order should be implemented immediately.
Recommendation XVI
That the Canadian Medical Association approve the "Statement on Terminal Illness"
and encourage physicians faced with the decision of writing a "DNR or No Resuscitation" Order to consider the clinical criteria and follow the procedural guidelines
outlined in this protocol.
Recommendation XVII
That the Canadian Medical Association ask the Canadian Hospital Association to
encourage its constituent provincial members to establish a policy for writing
"No-Resuscitation" Orders based on the clinical criteria and procedural guidelines
contained in the C.M.A. protocol.
4.
Reformvorschläge
4.1
Law Reform Commission of Canada, Report No. 20: Euthanasia,
Aiding Suicide and Cessation of Treatment, S. 31 ff.
I. Euthanasia
The Commission does not favour the legalization of euthanasia in any form. That is
the view expressed in the following two recommendations, both discussed earlier in
the Report:
The Commission recommends against legalizing or decriminalizing voluntary
active euthanasia in any form and is in favour of continuing to treat it as culpable homicide.
The Commission recommends that mercy killing not be made an offence separate from homicide and that there be no formal provision for special modes of
sentencing for this type of homicide other than what is already provided for
homicide.
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II. Aiding Suicide
The Commission does not favour decriminalizing the offence of aiding or counselling suicide. In Working Paper No. 28 it tentatively recommended that, "(n)o
person shall be prosecuted for an offence under the present section without the personal written authorization of the Attorney General". However, in this Report, for
reasons explained earlier, the Commission has omitted that particular recommendation. On the subject of aiding or counselling suicide, the following recommendation expresses the Commission's final position:
The Commission recommends that aiding suicide not be decriminalized, and
that section 224 of the Criminal Code be retained in its present form.
III. Cessation and Refusal of Treatment
The Commission recommends the following amendments to the Criminal Code:
199.1. Nothing in sections 14, 45, 198 199 and 229 shall be interpreted as requiring a physician
(a) to continue to administer or to undertake medical treatment against the
expressed wishes of the person for whom such treatment is intended;
(b)to continue to administer or undertake medical treatment, when such treatment has become therapeutically useless in the circumstances and is not in the
best interests of the person for whom it is intended.
199.2. Nothing in sections 14, 45, 198, 199 and 229 shall be interpreted as preventing a physician from undertaking or obliging him to cease administering
appropriate palliative care intended to eliminate or to relieve the suffering of a
person, for the sole reason that such care or measures are likely to shorten the
life expectancy of this person.
At his stage, it may be useful to summarize the tentative conclusions which the
Commission has reached to date. These conclusions are as follows:
(1) the law should recognize the competent patient's wishes and respect them
as regards the cessation or non-initiation of treatment;
(2) the law should clearly state that a physician acts legally when he decides to
terminate or not to initiate treatment which is useless or which no longer
offers reasonable hope, unless the patient has expressed his wishes to the
contrary;
(3) the law should recognize that the prolonging of life is not an absolute
value in itself and that therefore a physician does not act illegally when he
fails to take measures to achieve this end, if these measures are unless or
contrary to the patient's wishes or interests;
(4) the law should recognize that a physician continues to treat a patient
against his wishes is subject to the provisions of the Criminal Code;
(5) the law should recognize that the incapacity of a person to express his
wishes is not sufficient a reason to oblige a physician to administer useless
treatment for the purpose of prolonging his life;
(6) the law should recognize that in the case of an unconscious or incompetent patient, a physician incurs no criminal responsibility by terminating
treatment which has become useless.
4.2
441
Law Reform Commission of Canada, Working Paper No. 26: Medical Treatment and Criminal Law, S. 97 f.
Section 199.1. Duty of Persons in an Emergency. Every one is under a legal duty
to render assistance to another in an emergency, when life or health is seriously
threatened and the circumstances are such that there exists knowledge of the emergency and that the assistance can be immediately provided without undue hardship,
justification or lawful excuse.
4.3
Law Reform Commission of Canada, Working Paper No. 23: Criteria for the Determination of Death, S. 51 ff.
Part Three: The Proposed Solution
I. The Necessary Objectives
(1) The proposed legislation must avoid arbitrariness and give greater guidance to
doctors, lawyers and the public, while remaining flexible enough to adapt to medical
changes.
(2) The proposed legislation must not attempt to solve all the problems created by
death, but only the problem of establishing criteria for its determination.
(3) The one proposed piece of legislation must apply equally in all circumstances
where a determination of death is at issue.
(4) The proposed legislation must recognize only the standards and criteria of death;
it must not define the medical procedure to be used, nor the instruments or procedures by which death is to be determined.
(5) The proposed legislation must recognize standards and criteria generally accepted by the Canadian public.
(6) To remain faithful to the popular concept, the proposed legislation must recognize that death is the death of an individual person, not of an organ or cells.
(7) The proposed legislation must not in practice lead to wrong or unacceptable
situations.
(8) The proposed legislation must not determine the criteria of death by reference
only or mainly to the practice of organ transplantation.
II. The Proposed Reform
(...) The Commission makes the following recommendations:
(1) That the Parliament of Canada adopt the following text:
A person is dead when an irreversible cessation of all that person's brain functions has occurred.
The cessation of brain functions can be determined by the prolonged absence of
spontaneous cardiac and respiratory functions.
When the determination of the absence of cardiac and respiratory functions is
made impossible by the use of artificial means of support, the cessation of the
brain functions may be determined by any means recognized by the ordinary
standards of current medical practice.
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Kanada
(2) That the Government of Canada enter into agreements with the Provincial Governments to insure the adoption of this text or a similar one throughout the country
for all legal purposes in order to achieve suitable uniformity.
4.4
Law Reform Commission of Canada, Report No. 15: Criteria for the
Determination of Death, S. 12
The Commission recommends that:
(2) the Parliament of Canada adopt the following amendment to the Interpretation
Act, R.S.C. 1970, c. I-23.
For all purposes within the jurisdiction of the Parliament of Canada,
(1) a person is dead when an irreversible cessation of all that person's brain
functions has occurred.
(2) the irreversible cessation of brain functions can be determined by the prolonged absence of spontaneous circulatory and respiratory functions.
(3) when the determination of the prolonged absence of spontaneous circulatory and respiratory functions is made impossible by the use of artificial means
of support, the irreversible cessation of brain functions can be determined by
any means recognized by the ordinary standards of current medical practice.
4.5
Law Reform Commission of Saskatchewan: Tentative Proposals for
a Definition of Death Act, S. 43
The Commission is of the opinion that the legislation must reflect the current state of
the art in medicine and should not hamper medical advancements. It should be simple and straightforward, and therefore not subject to misinterpretation. It should not
set out the criteria by which death is determined.
Therefore the Commission proposes enactment of the following legislation:
An Act respecting the Definition of Death
HER MAJESTY, by and with the advice and consent of the Legislative Assembly of
Saskatchewan, enacts as follows:
1. Short title. This Act may be cited as The Definition of Death Act, 19.. .
2. Definition. Death is the total and irreversible cessation of brain function.
3. Determination of Death
(1) Death may be determined by the irreversible cessation of spontaneous circulation and respiration or by any other means recognized by the ordinary standards of
current medical practice.
(2) Where mechanical support or respiration and/or circulation is being used, the
determination of death by the attending physician shall be independently confirmed
by another physician.
443
Note: In the event this legislation is enacted, the words "in accordance with accepted
medical practice" where they appear in Section 8 (1) of The Human Tissue Gift Act,
R.S.S. 1978, c. H-15 should be deleted.
4.6
Ontario: Proposed Natural Death Act34
Explanatory Note
The purpose of this Bill is to provide a means whereby an individual may limit the
effect of a general or implied consent to medical treatment to prevent the use of lifesustaining procedures while in a terminal condition.
The Bill is designed to achieve this purpose by permitting an individual to execute a
direction limiting his consent. Once a physician or hospital employee has notice of
this direction, there is no defence of consent as a basis to avoid civil liability if the
patient is treated with life-sustaining procedures during a period of terminal condition.
An Act respecting the Withholding or Withdrawal of Treatment where Death is
Inevitable
1. In this Act,
(a) "attending physician" means physician selected by or assigned to a patient and
who has responsibility for the treatment and care of the patient;
(b) "life-sustaining procedure" means a medical procedure or intervention that utilizes mechanical or artificial means to sustain, restore or supplant a vital function to
postpone the moment of death, but does not include a medical procedure or intervention for the purpose of alleviating pain;
(c) "physician" means a person licensed under Part III of The Health Disciplines
Act, 1974;
(d) "terminal condition" means an incurable condition caused by injury or disease
by reason of which, in reasonable medical opinion, death is imminent and only postponed without improvement of the condition during the application of life-sustaining
procedures.
2. (1) Direction limiting consent. Any person who has attained the age of majority,
is mentally competent to consent, is able to make a free and informed decision and
has, or is deemed to have, consented to medical treatment may, in writing in Form 1
signed by him, direct that the consent does not extend to the application of lifesustaining procedures during a terminal condition.
(2) Witnesses of direction. A direction under subsection 1 is not valid unless the
signature is witnessed by two persons neither of whom is a relative or an attending
physician or other person engaged in the health care of the person giving the direction.
(3) Beneficiary of estate as witness. No person who witnesses a direction under
subsection 2 is entitled to any benefit from the estate of the person who gives the
direction, except charges or directions for payments of debts.
34
Zit. nach Dickens, McGill Law Journal 26 (1981), S. 876 ff.
444
Kanada
(4) Duration. A direction is valid for five years from the date of its signing unless
revoked under section 3.
3. (1) When direction effective. A direction under section 2 does not take effect
unless it is given to the attending physician of the person giving the direction or,
where the person is a patient in a health facility, is given to the attending physician
or a person on the medical staff of or employed by the health facility.
(2) Direction included in medical records. Upon a direction being given to one of
the persons mentioned in subsection 1, the direction or a copy of it shall be included
in the medical records of the person giving the direction.
(3) Revocation. Where the person signing a direction in any manner and without
regard to mental competency indicates to one of the persons mentioned in subsection
1 an intention to revoke the direction or is pregnant, the direction is revoked and
shall be removed immediately from the medical records and destroyed.
(4) Direction deemed valid. Notwithstanding subsection 1, a direction given thereunder by a person who had not attained the age of majority, was not mentally competent to consent, or was not able to make a free and informed decision, is valid for
the purposes of this Act if the person who acted upon it had no reason to believe that
the person who gave it had not attained the age of majority, was not mentally competent to consent, or was not able to make a free and informed decision, as the case
may be.
4. Terminal condition. Where doubt exists as to whether or not a terminal condition
exists for the purpose of a direction,
(a) a terminal condition shall be deemed to exist where in the opinion of two physicians, each of whom has made a separate diagnosis in respect of the person
giving the direction and neither of whom has any medical responsibility for that
person, the terminal condition exists; and
(b) a terminal condition shall be deemed not to exist where in the opinion of one
physician whose opinion is sought for the purposes of clause (a) a terminal
condition does not exist.
5. Civil liability. No action or other proceeding for damages lies against any person
for any act or omission made in good faith and without negligence in the observance
or intended observance of a direction purporting to be given under this Act.
6. Other obligations not affected. Nothing in this Act shall be construed to impose
an obligation to provide or perform a life-sustaining procedure where the obligation
does not otherwise exist at law.
7. (1) Insurance. A death that occurs subsequent to the withholding or withdrawal
of life-sustaining procedures pursuant to a direction signed under this Act shall not
be deemed to be a suicide or self-induced death under any policy of insurance.
(2) Idem. A requirement that a person sign a direction as a condition for being insured for or receiving health care services is void.
8. Offence. Subject to subsection 3 of section 3, every person who wilfully conceals,
cancels, defaces or destroys the direction of another without that person's consent is
445
guilty of an offence and on summary conviction is liable to a fine of not more than $
1,000 or to imprisonment for not more than thirty days, or to both.
9. Commencement. This act comes into force on the day it receives Royal Assent.
10. Short title. This Act may be cited as The Natural Death Act, 19.. .
Form 1
DIRECTION TO ATTENDING PHYSICIAN AND MEDICAL STAFF
I, .................. being of sound mind, wilfully and voluntarily, direct that all life-sustaining procedures be withheld or withdrawn if at any time I should be in a terminal
condition and where the application of life-sustaining procedures would serve only
to artificially prolong the moment of death.
It is my intention that this direction be honoured by my family, physicians and
medical staff as the final expression of my legal right to refuse medical or surgical
treatment and to die naturally.
Made this ................. day of ........................ (month, year) ...............................................
......................................
(signature)
The person signing this directive is personally known to me and I believe him/her to
be of sound mind.
......................................
(Witness)
......................................
(Witness)
446
5.
Kanada
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450
Kanada
Abkürzungsverzeichnis
B.C.
B.C.L.R.
B.C.S.C.
c.
C.A.
CC
Chap.
C.M.A.
C.R.
CRP
C.S.
D.L.R.
Dept.
DNR
Dr.
et al.
L.J.
LRC
No.
OHA
Que. S.C.
R.J.Q.
R.S.C.
R.S.M.
R.S.Q.
S.M.
s. ss.
sub. nom.
v.
Vol.
W.W.R.
ZStW
British Columbia
British Columbia Law Reports
British Columbia Supreme Court
chapter, contre
Court of Appeal; Recueils de jurisprudence, Cour
d'appel (Québec)
Criminal Code
Chapter
Canadian Medical Association
Criminal Reports
Cardiopulmonary Resuscitation
Recueils de jurisprudence, Cour supérieure (Québec)
Dominion Law Reports
Department
Do Not Resuscitate
Doctor
et alii
Lord Justice
Law Reform Commission
Number
Ontario Hospital Association
Quebec Superior Court
Recueils de jurisprudence de Québec
Revised Statutes of Canada
Revised Statutes of Manitoba
Revised Statutes of Quebec
Statutes of Manitoba
section, sections
sub nomine
versus
Volume
Western Weekly Reports
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