Theoretical perspective 

Theory about professional role change41 42 and the issue-attention cycle are used in this study.35 Professional role change theory includes practices and how professionals behave at work.41 43 Some studies of professional role change show that physicians may resist changing their role, which can result in a lengthy and difficult change process.44 45 The passing of new legislation may greatly change physicians’ role.42 In Canada, physicians’ role was modified to incorporate MAiD in mid-2016 (with the exception of Québec where euthanasia became legal in December 2015), which meant their role also expanded to include: consulting and supporting patients with MAiD requests, assessing patients’ eligibility for MAiD and providing ‘aftercare to bereaved relatives'.46 The issue-attention cycle35 has five stages about how newspaper attention to issues differs over time: (1) preproblem, (2) alarmed discovery and euphoric enthusiasm, (3) realising the cost of significant progress, (4) gradual decline of intense public interest and (5) postproblem. We use professional role change theory and the issue-attention cycle together, because newspaper portrayals about MAiD discuss physician role change over decades due to sustained public interest in the issue. Using these theories together helps shed light on the path and context within which physicians’ role changed when MAiD became legal in Canada. They additionally help us understand the context within which communication through newspaper stories occurs.

We conducted a qualitative textual analysis examining Canadian online and print newspapers in English and French from 1972 to 2016 (figure 1).47 48 This method was chosen as it was the ideal way to understand and thoroughly analyse each portrayal of MAiD and physicians’ role at the sentence level. All included articles were read to gain in-depth insight into the data. A quantitative approach was not used, such as content analysis, as this could have missed nuances in the qualitative data. No assumptions were made about newspaper articles or how MAiD and physicians’ role were portrayed, rather we let the data tell the story by using grounded theory for coding.

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Figure 1

Flow chart of methodology. *Nineteen per cent of each year within 2014–2016. 

Articles were included from when suicide was decriminalised—1 January 1972—to the day after Bill C-14 passed—18 June 2016—when MAiD became legal. Because two other qualitative textual analyses of tobacco and gun control found that newspaper portrayals of the issue changed after legislation passed, we decided to end our study at the legalisation of MAiD to avoid this potential bias.20 49 Additionally, most newspaper studies of attention to issues analyse these from beginning to end, often during a short time period of a few days to a few weeks.22 As discussed in the ‘Introduction’ section, our topic was portrayed in French and English newspapers for 44 years thus we examined the topic over the entire time period.

The Canadian Business and Current Affairs, Canadian Newsstream, the Canadian Broadcasting Corporation’s website and Eureka.cc were searched using the terms: ‘assisted death’, ‘assisted suicide’, ‘aide médicale à mourir’, ‘right to die’, ‘end of life’, ‘dying with dignity’, ‘euthanasia’, ‘euthanasie’, ‘Loi concernant les soins de fin de vie’, ‘mort dans la dignité', ‘suicide assisté' and ‘suicide avec assistance médicale’. Newspaper articles were downloaded into Microsoft Word and assessed by two authors using the following inclusion criteria: published in a Canadian newspaper, discussed MAiD in Canada and full-text. Articles were excluded if they exclusively discussed MAiD in other countries. Articles were also removed if they addressed withdrawal of life-sustaining treatment or passive euthanasia. Duplicate articles were removed, including articles that were in both English and French, by including the article that was chronologically published first. Disagreements about whether an article was included were resolved by discussing it with a third author and reaching consensus. A database of included MAiD newspaper articles was created in NVivo 11. The dataset was available to the research team via a private shared folder in Dropbox. The databases searched are available through most libraries and many articles are freely available on public websites. As newspaper articles are vetted by the journalist, editor(s), newspaper staff and the public, the integrity of the data was not further verified.

In health and other disciplines, the traditional approach to newspaper analysis focuses on stories that discuss a single event over a short span of time, sometimes a few days.22 27 50 51 Furthermore, there is no standard for random sampling of large newspaper article databases.52 Given this study’s scope and aim, along with a lack of similar health articles to model from, the methods of qualitative textual analyses of newspapers in fields such as nanotechnology, electromagnetic fields and hybrid electric vehicles were used. In non-health studies with 1000+ included newspaper articles, the median random sample was 18.7% (13.5%–26.3%).53–58 Thus, we used a random sample of 19% by era generated by Stattrek’s Random Number Generator.59

The context of this study was newspapers in Canada, which included French and English languages as well as national and local events. Five eras were developed based on key Canadian MAiD events connected to physician role change.36 37 In 1972, suicide was decriminalised. In 1991, the Right to Die Society was founded, and Rodriguez spoke to Parliament about legalising MAiD. In 1996,​ Dr Généreux was arrested for assisting suicide. In 2005, Member of Parliament Lalonde introduced a key private member’s MAiD Bill. In 2014, the Supreme Court of Canada (SCC) agreed to hear the appeal for Carter vs Canada and MP Fletcher introduced two private member MAiD Bills. In 2015, the SCC granted the Federal government 1 year to change the Criminal Code and on 17 June 2016, Bill C-14 passed. Because the last era contained 50% of the articles, we followed the methods of a similar large newspaper study and randomly sampled 19% for each year.57

Patient and public involvement

Patients and the public were not involved in this study.

Analysis 

The analyses were conducted by ETC and CS. To ensure that coding was consistent, each author independently coded a sample of sentences and compared the results, then one author completed the coding. Then, 10% of this coding was randomly checked and disagreements were resolved by discussion. For example, a disagreement about whether the sentence ’In Holland, euthanasia is widely practised' should be coded as Holland or practice was resolved by using both codes. All downloaded articles were imported into NVivo 11 and separated into folders by era, then language (eg, 2005–2013 English). The top 10 most frequent words (keywords) were derived in NVivo 11. English and French articles were initially analysed separately to evaluate whether they contained similar or different codes and themes. Since 2014–2016 was a very significant period leading up to the legalisation of MAiD and contained 50% of the total articles, these articles were initially analysed by year in case there were differences in codes and themes. A statistical analysis was performed using χ² and Fisher’s exact tests to identify differences between the number of articles containing a top 10 keyword between both eras and languages. A p value <0.05 was considered to be statistically significant.

Sentences containing one of the top 10 keywords ’euthanasia/euthanasie/suicide' were copied into Microsoft Word and analysed using grounded theory by open-coding within each era.60–62 This keyword was chosen as it best represented vocabulary being used to describe MAiD in all eras. For example, the previously mentioned Holland code was combined with similar codes with country names (eg, the USA, Belgium, Switzerland) under the theme Countries (other). The same process was used to coalesce all other codes into themes. The definitions of each theme are provided in the ’Results' section. Using the above process, similar codes were grouped together and preliminary themes were identified for each era.61 Constant comparison was then used to compare emerging themes in each era62 and develop the final set of themes. Data saturation was reached when no new codes or themes were found in each era.62

Euthanasia/euthanasie/suicide keyword analysis

French and English newspaper articles within the five eras were analysed, which, as outlined in the ‘Methods’ section, were defined by key Canadian events.36 37 Sample quotes from each theme and era are provided in table 4.

1972–1990—newspapers’ portrayal of public opinions about physicians’ MAiD role (preproblem stage)

Before suicide was decriminalised by the Federal government in 1972, newspapers reported a 1968 poll that showed 45% of Canadians were already receptive to MAiD; acceptance had grown to 77% by 1990. They also informed Canadians that the advocate organisation Dying with Dignity Canada was founded in 1982. Although MAiD was illegal in Canada, and only a handful of physicians were discussing it, journalists published what was occurring in other countries. This included healthcare professionals respecting patients’ ‘do not resuscitate’ (DNR) declarations. At this time, DNR was revolutionary and sometimes considered a form of MAiD. Journalists also reported that physicians euthanised patients in other countries, especially the Netherlands, and were not prosecuted. For example, newspapers published stories about Dr Jack Kevorkian, an American physician, who created a ‘suicide machine’ to help patients commit suicide. For the next two decades, Canadians read about Dr Kevorkian’s regular court appearances for his role in assisting suicide.

At the beginning of this era, journalists portrayed physicians’ MAiD role as being considered controversial and having limited public debate. By 1990, they were portraying MAiD as a social issue. The press drew attention to the taboo topic of committing suicide by featuring stories about ill patients who overdosed in desperation to die, often from stockpiling drugs, because their physician could not help them die (table 4). Journalists tended to feature favourable public opinion polls and supportive stories about MAiD. However, Christian and Catholic religious organisations and opponents voiced their discontent with newspapers for not portraying their view. To opponent’s dismay, journalists wrote that the Anglican Church mistakenly indicated that it approved of MAiD, but this was not true. However, stories such as this fed into growing public discontent about physicians not being able to provide MAiD.

Because newspapers published MAiD stories as early as 1968, this topic was considered newsworthy long before it became legal in Canada. In articles, journalists discussed MAiD as a choice and even a right that Canadians lacked. For example, newspapers featured stories about Canadians suffering and unable to die with dignity, because they could not access MAiD. Journalists also examined Canadians’ growing fears that advancing medical technology meant that physicians could keep them alive against their wishes. Journalists revealed to the public that some Canadian physicians secretly performed euthanasia (table 4). Articles also provided information about how citizens could lobby the government to change Canada’s Criminal Code (CCC) and legalise MAiD.

By 1990, news stories were discussing the nuances of active and passive MAiD. From this era forward, physicians were typically portrayed as disagreeing about whether they should perform MAiD or not, but most stories quoted physicians that opposed it. The CMA did not take a stand for or against MAiD, instead promoting palliative care. Journalists’ long-term attention to MAiD and whether physicians should provide it began in this era.

1991–1995—newspapers’ portrayal of legal aspects of physicians’ MAiD role (alarmed discovery and euphoric enthusiasm stage)

In this era, newspapers mainly discussed court cases, the first tabling of legislation and the establishment of parliamentary committees to study MAiD. Sue Rodriguez’ numerous provincial and federal court cases and appeals were well-covered by the press. Rodriguez poignantly asked Parliament in a highly publicised 1991 video statement "If I cannot give consent to my own death, whose body is this? Who owns my life?”63 The frequent articles about Rodriguez reflected positive Canadian polls about the right to decide when and how to die. In 1994, a physician illegally provided her with MAiD.

The press also described confusion about who had jurisdiction over MAiD—provinces, courts or the Federal government. Parliament and the SCC disagreed about which body could legalise MAiD. Starting in 1991, newspapers reported that three federal Members of Parliament (MP), including Robert Wenman and Chris Axworthy, tabled private members’ MAiD Bills. In 1992 and 1994, Svend Robinson, who was present at Rodriguez’ death, tabled two MAiD Bills. Although newspapers kept the public well-informed about MAiD developments in the federal legislature that would change physicians’ role, they continued to point out the lack of opposition to it. However, journalists did discuss MAiD’s illegality, indicating it could be a slippery slope for Canadian society.

Although not MAiD, newspapers discussed Robert Latimer’s widely publicised case and conviction for murdering his disabled daughter, Tracy, within the wider Canadian debate about having a choice in dying. Newspapers additionally portrayed MAiD as a choice by featuring quotes from Canadians who wanted the right to choose when they die. Letters from the public mentioned that euthanasia should be available to people because it was already an acceptable option for pets (table 4).

Journalists kept Canadians informed about MAiD developments in other countries. For instance, Washington State’s 1991 defeated this ballot question. As well, articles discussed international criticism of the Netherlands as physicians were euthanising dementia and mental illness patients, possibly against the patient’s wishes. Journalists continued to link MAiD with patient suffering and intolerable pain by featuring people who had agonising and prolonged deaths because they were denied MAiD by their physician and the government. MP Robinson, who was calling for MAiD to become legal, publicly discussed his friend who suffered terribly before dying (table 4). Newspapers additionally reported on two new contentious books about how to commit suicide, Final Exit and How to Die with Dignity, which empowered patients to take matters into their own hands if they could not change physicians’ role. Numerous stories discussed how MAiD should be defined and what it should include (eg, assisted suicide, euthanasia, etc). Although not MAiD, newspapers published numerous stories about patients who won court cases to disconnect medical equipment and/or refuse treatment/food, like Nancy B in Québec (ie, passive euthanasia). Journalists reported that palliative care continued to distance itself because MAiD conflicted with its philosophy.

In the midst of court cases, bills and growing support from the Canadian public, newspapers reported that the CMA was considering developing a position against MAiD, since it did not have one. While there were reports of illegal MAiD occurring, Canadian physicians continued to be portrayed as opponents who advocated instead for palliative care. In 1993, newspapers reported on a landmark survey which found that two-thirds of Alberta physicians did not want to make MAiD decisions and were evenly split over its morality. Some physicians who took the survey said they feared being incriminated for abuse, while others said they did not receive MAiD requests from patients. MAiD opponents were portrayed as criticising journalists for their one-sided, favourable portrayal. In letters and stories, opponents voiced their concerns about the dangers of MAiD (ie, allowing the euthanasia of humans). Opponents also warned Canadians that safeguards might not protect vulnerable people who may be discarded, rather than take up valuable bed space.

1996–2004—newspapers’ portrayal of professional aspects of physicians’ MAiD role (realising the cost of significant progress stage)

Some Canadian medical professionals began to be featured in newspapers as advocates for physicians to change their role and accommodate MAiD. In 1996,​ Dr Maurice Généreux made headlines when he was arrested, and eventually jailed, for writing HIV patients fatal barbiturate prescriptions. Shortly after, Dr Nancy Morrison made the national news for hastening the death of Paul Mills, a patient with terminal cancer. Although physicians advocated for change from within the profession and a national survey found that 20% of them would participate in MAiD, the CMA continued to oppose it. Journalists observed medicine’s growing split: palliative care providers strongly opposed MAiD and said that patients did not request it, while other physicians were either undecided or supported it.

Newspapers portrayed MAiD as an open, yet polarised, discussion that had captured Canadians’ interest. They described MAiD as an ‘act of love’, ‘good death’ and ‘based on mercy’ and as ‘cruel’ and ‘unjust’. In light of physician’s role, journalists continued to explore the differences between passive euthanasia, active euthanasia and assisted suicide. Stories about the first national survey of Canadian patients with cancer revealed they wanted MAiD. Newspapers persisted in featuring stories about incapacitated and suffering patients with untreatable pain being denied MAiD, which reflected many Canadians’ desire for it to be part of physicians’ role. In contrast, physicians continued to be portrayed as advocates for improving palliative care and pain control.

Reporters continued to publish stories about MAiD in other countries, especially the Netherlands, where physicians were not prosecuted for euthanising patients. Stories about Dr Kevorkian reported that he had assisted over 100 patients and continued to be arrested and appear in US court. Journalists also reported about Australia’s first MAiD death. All MAiD deaths in other countries occurred with the aid of physicians.

As newspapers reported that national polls showed growing public support, newspapers publicised that the Prime Minister, Jean Chrétien, promised to hold a free vote about MAiD, which did not occur. Politicians also defeated MP Robinson’s motion to review and revise the CCC to accommodate MAiD. Public calls to track and study the occurrence of MAiD, even though it was illegal, went unanswered due to physicians’ fear of being prosecuted. Physicians disputed stories about illegal MAiD deaths in Canada, which were reported from being none to hundreds annually.

2005–2013—newspapers’ portrayal of political aspects of physicians’ MAiD role (realising the cost of significant progress stage)

In 2005, MP Francine Lalonde, who died of cancer in 2014, introduced another federal private member MAiD Bill. A known MAiD supporter Steven Fletcher, Canada’s first quadriplegic MP, was publicised because he abstained from voting; possibly because his beliefs did not reflect those of disability advocates or his party. While some politicians continued to call for revisions to the CCC, others alleged that denying MAiD to Canadians infringed on the Canadian Charter of Rights and Freedoms. Gloria Taylor, who had Amyotrophic Lateral Sclerosis (ALS), received a legal exemption in 2011 for MAiD from the Supreme Court of British Columbia. Although she died in 2012 of natural causes, newspapers reported that her case went to the SCC in the next era. A 2009 poll of Québec physicians found 74% support for MAiD and 4 years later the province introduced Bill 52 An Act Respecting End-of-Life Care/Loi concernant les soins de fin de vie, which passed in the fifth era.

Newspapers again portrayed the growing awareness of patient rights and autonomy regarding the option and choice for MAiD. As patients were more actively participating in their health and access to the internet grew, these began to affect the patient-physician relationship. This was evident by the number of stories about and letters from Canadians reporting that they wanted physicians to accommodate MAiD. Additionally, a 2011 Royal Society of Canada report recommended that MAiD be legalised and monitored by a national body. Newspapers reported that the Euthanasia Prevention Coalition of Canada attempted to discredit the Royal Society of Canada report because the panel members were publicly known for being in favour of MAiD. Physicians expressed their disappointment that newspaper articles continued to discuss Canadian patients’ fears about palliative care and suffering during the dying process. Journalists revealed that Canadians were secretly accessing MAiD in other countries, such as Switzerland, if they could afford it and were well enough to travel. But they also reminded readers that participating in this process could result in jail time.

Newspapers reported that many physicians and the conservative Federal government were opposed to MAiD. For instance, a 2011 CMA poll found that only 34% of physicians supported MAiD. Some physicians said they had never had a request for MAiD. While some physicians requested clarification about what was legally permissible, many articles discussed their continued call for changes to palliative care. Stories also indicated that Canada’s conservative government opposed changes to the CCC and voted against MAiD Bills. Nevertheless, MP Lalonde continued to publicly maintain there should be guidelines for the illegal MAiD deaths that were occurring. The courts were also conflicted. Stories about rulings revealed some judges agreed with the 1993 SCC decision, while others had a different interpretation.

Newspaper reports about the growing number of unwanted hastened deaths and fears about the slippery slope in European countries did little to quell Canadian’s support. Opponents publicly voiced their fear that because hospitals made thousands of errors, the same could occur with MAiD. In letters and stories, they also questioned MAiD’s impact on vulnerable people who wanted to live, such as the elderly and disabled. Disability advocates received more attention from journalists in this era, but their arguments did not seem to be as powerful as stories about people’s horrible deaths from being denied MAiD.

Since it seemed that Canadians wanted to determine their own death, journalists began to portray MAiD as a national debate that needed to occur. They highlighted calls of discrimination against ill patients who were physically unable to take their life or travel to receive MAiD. Newspapers also explored the various interpretations of quality of life and the process of dying, and featured frameworks and processes that could be used for MAiD in Canada. Although the terms ‘euthanasia/euthanasie’ and ‘suicide’ had long been used by the press to describe MAiD, journalists began to use phrases such as ‘dying with dignity’ and ‘mort douce et sans souffrance’. Reports about Québec’s legislative debate fuelled the idea that MAiD could become legal in Canada and many newspapers took notice.

2014–2016—newspapers’ portrayal of court cases and legal aspects of physicians’ MAiD role (alarmed discovery and euphoric enthusiasm stage)

In 2014, newspapers reported on the SCC case Carter vs Canada filed by the B.C. Civil Liberties Association (BCCLA) on behalf of Taylor and Kay Carter, who had spinal stenosis. It was anticipated that the SCC would rule in the BCCLA’s favour. This same year, MP Fletcher’s two private member Bills to provide and monitor MAiD were defeated in the Federal Parliament. In February 2015, the SCC ruling on the Carter appeal gave the Federal government 1 year to change the CCC. English and French newspapers reported that Québec passed MAiD legislation 6 months before the SCC decision. Due to a federal election and party change, Bill C-14 Medical Assistance in Dying was not passed until 17 June 2016. To capture opponents’ views, newspapers published declarations and statements from religious organisations and leaders opposing MAiD.

The biggest shift in newspaper discussions in this era was from whether to legalise MAiD to what the legislation should contain, who should be included and how it could be accessed. Journalists reported that legislation would allow physicians to practice euthanasia and participate in assisted suicide. Patients would be required to consult two physicians and wait 2 weeks before receiving MAiD. Some citizens and organisations such as Dying with Dignity are still making the news today for rallying against Canada’s restriction of MAiD to physical suffering only. Although newspaper columnists and letter-writers debated whether to allow minors to access MAiD, it is only available to adults over 18 years. Journalists reported that safeguards would protect vulnerable people, but reminded Canadians that physicians felt strongly about providing additional resources to palliative care.

Until mid-2016, newspapers reported that Canadians continued to travel to other countries to end their life. When legislation was delayed for 4 months in 2016, stories revealed that some grievously ill Canadians obtained a court order to access MAiD. Some hospitals indicated that it was going to be difficult to provide both palliative care and MAiD, and palliative care staff did not want to administer MAiD. Stories about publicly funded Catholic hospitals and nursing homes indicated they would not participate, causing problems for patients in smaller centres. Journalists interviewed hospital executives and physicians about the changes needed including: staffing, compensation, location, standards, timing, assessment and criteria. As MAiD is administered provincially and some hospitals and physicians were not participating, articles discussed Canadians’ concerns about uneven or no access.

Whether to change physicians’ role became moot and newspapers focused on which changes to make. Newspapers quoted physicians who voiced discomfort about how their role would change and that they would betray patient trust. Some physicians believed that being required to refer patients for MAiD made them indirectly responsible for a patient’s death. These physicians formed groups such as Physicians Alliance for Total Refusal of Euthanasia and Collectif des médecins contre l’euthanasie. The CMA softened its opposition to MAiD, indicating physicians should follow their conscience. The SCC ruling changed physicians’ role in every province except Québec where a long debate between politicians, physicians and the public resulted in legislation being passed before the ruling was known. Newspapers reported that the paradox of teaching medical students about MAiD and healing bothered physicians, but they updated the curriculum to incorporate MAiD. Physicians expanded their role to include: referring patients, determining a patient’s eligibility and participating in MAiD.