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Canadian French and English newspapers’ portrayals of physicians’ role and medical assistance in dying (MAiD) from 1972 to 2016: a qualitative textual analysis
  1. Ellen T Crumley1,
  2. Caroline Sheppard2,
  3. Chantelle Bowden3,
  4. Gregg Nelson4
  1. 1 Rowe School of Business, Faculty of Management, Dalhousie University, Halifax, Nova Scotia, Canada
  2. 2 Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  3. 3 Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
  4. 4 Departments of Oncology and Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Professor Ellen T Crumley; ecrumley{at}dal.ca

Abstract

Objective To examine how Canadian newspapers portrayed physicians’ role and medical assistance in dying (MAiD).

Design Qualitative textual analysis.

Setting Online and print articles from Canadian French and English newspapers.

Participants 813 newspaper articles published from 1972 to 2016.

Results Key Canadian events defined five eras. From 1972 to 1990, newspapers portrayed physician’s MAiD role as a social issue by reporting supportive public opinion polls and revealing it was already occurring in secret. From 1991 to 1995, newspapers discussed legal aspects of physicians’ MAiD role including Rodriguez’ Supreme Court of Canada appeal and Federal government Bills. From 1996 to 2004, journalists discussed professional aspects of physicians’ MAiD role and the growing split between palliative care and physicians who supported MAiD. They also reported on court cases against Canadian physicians, Dr Kevorkian and suffering patients who could not receive MAiD. From 2005 to 2013, newspapers described political aspects including the tabling of MAiD legislation to change physicians’ role. Lastly, from 2014 to 2016, newspapers again portrayed legal aspects of physicians’ role as the Supreme Court of Canada was anticipated to legalise MAiD and the Québec government passed its own legislation. Remarkably, newspapers kept attention to MAiD over 44 years before it became legal. Articles generally reflected Canadians’ acceptance of MAiD and physicians were typically portrayed as opposing it, but not all did.

Conclusions Newspaper portrayals of physicians’ MAiD role discussed public opinion, politicians’ activities and professional and legal aspects. Portrayals followed the issue-attention cycle through three of five stages: 1) preproblem, 2) alarmed discovery and euphoric enthusiasm and 3) realising the cost of significant progress.

  • change management
  • qualitative research
  • medical journalism

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Strengths and limitations of this study

  • This study examines a large random sample of print and online newspaper articles published in French and English.

  • Some important themes and codes may not have appeared in the random sample due to sampling bias, culture bias and the halo effect.

  • Certain publications may be under-represented depending on whether their publication is available online or in databases.

  • This study looks at online and print news media only and does not consider media from television, social media, external websites, RSS feeds, apps, etc or the general decline of print newspapers.

Introduction  

Medical Assistance in Dying (MAiD) is currently permitted on four continents—Europe, Asia, North America and South America—and being debated internationally.1 2 Depending on the jurisdiction, MAiD may include passive, active, assisted suicide and euthanasia (other relevant definitions include: active euthanasia—accelerating or intentionally causing death by means of a single act from a third party; passive euthanasia—withdrawing or withholding life-sustaining care in order to allow a patient to succumb to their medical condition and assisted suicide—providing the means or circumstances where someone is able to take their own life, which sometimes may involve a physician3). In Canada, the context of our study, the Federal Parliament passed Bill C-14 Medical Assistance in Dying in June 2016.4 MAiD is a legal option for eligible Canadian patients suffering from an incurable medical condition to end their life with the help from a physician or nurse practitioner (NP) (in the province of Québec physicians can only perform euthanasia, not assisted suicide. NPs cannot perform euthanasia in Québec). Except in the province of Québec, physicians and NP can legally provide knowledge to patients about self-administration of death and the means for a patient to take their own life (ie, write a prescription). They can also legally administer a lethal cocktail of pharmaceuticals to hasten a patient’s death (while Canadian patients can self-administer MAiD, 99.8% of 2468 Canadian patients—from June 2016 to December 2017—chose to receive MAiD from a physician/NP; only 5 patients underwent self-administered deaths.5 This may be because the preferred pharmaceuticals for MAiD self-administration were only approved in Canada in late 2017; it is unknown if more patients will choose self-administration6).3 7 8 Although some consider passive euthanasia MAiD, it was already permitted in Canada and is not included in the legislation.

Polls from 1968 onwards9 10 showed that Canadians supported MAiD, yet it was not legalised for over four decades. Healthcare budgets in Canada are tight and continually increasing.11 While implementing MAiD could reduce healthcare spending,12 Canadian newspapers consistently wrote about MAiD as a way to help decrease a patient’s prolonged suffering and give them control over the dying process (ie, autonomy).13 Despite growing public support for MAiD, physicians and the Canadian Medical Association (CMA) have long resisted changing their professional role to include it.13–15

When choosing subjects, journalists and editors have a duty to report current events and facts, and decide which issues are appealing and newsworthy. Since sensational stories capture the public’s attention, newspapers generally report on emerging issues—which may or may not have much research.16 Newspapers help inform the public and may shape their opinion, but may also prolong public misconceptions about an issue.16–22 Whether newspapers actually influence behaviour change or legislation has been debated in many disciplines.23–26 Research has found that the public relies on newspapers for health information; however, newspapers may inaccurately report medical issues27 28 and bias towards positive health coverage has been found.29 30 For example, the Australian media promoted popular opinion and specific interest groups, and ignored or misinterpreted scientific findings that did not fit into its portrayal of MAiD.31 32

Newspaper studies do not often follow long-term, decades-long issues but rather focus on shorter time periods of a few days to several years,17 18 33 34 limiting researchers to a snapshot of an entire issue. It is important that long-term issues discussed over decades are studied in their entirety, that is, from the beginning of newspaper stories being published about an issue to the end.35 A long-term analysis of Canadian newspaper stories regarding physicians’ MAiD role allows us to capture shifting portrayals as the discussion progressed. It also provides insight about events and opinions as they happened, were reflected on and resurfaced over time. As most studies focus on a few major newspapers, this could additionally overlook local and contextual factors. Thus, it is essential to collect broad data from both local and national Canadian newspapers that discussed MAiD.

To our knowledge, there is limited research about MAiD in Canada (at the 2018 MAiD conference, Dr Wiebe, a Canadian researcher and physician, presented the handful of Canadian MAiD studies that have been published to date) and only a single study of MAiD and physicians’ role in Canadian newspapers.34 Existing studies of MAiD in newspapers have several shortcomings. First, they focus on a few years of print English articles, usually centred around a significant event, such as a court case. Second, they do not examine French-language or online newspapers. Third, because researchers only analysed a few years of articles, studies overlook the gradual accumulation of key MAiD events (eg, court cases, bills and polls) that occurred over the 44 years.36 37 In this study, we attempt to address some of these shortcomings by investigating MAiD in French and English Canadian newspaper articles from 1972 to 2016. Our article does ‘not focus on the merits of the assisted suicide debate nor do we comment on the intent of the news accounts. Rather, our purpose is to discuss the portrayals the news stories help to create’.38

As MAiD in Canada is a new practice that has a small amount of published research,2 39 40 we must examine the information that is available. Given the scarcity of published medical research, Canadian newspapers are a credible data source as journalists have written many stories about MAiD and have been discussing it since 1972. Thus, newspaper articles provide important information about MAiD, such as portrayals of events, legislation, public opinion polls and physicians’ views. To our knowledge, no one has systematically studied portrayals of MAiD in Canadian newspapers since 1972. Hence, our objective is to analyse Canadian French and English online and print newspaper portrayals of physician’s MAiD role from when suicide was decriminalised in 1972 to its legalisation in 2016. Our research question is: how do Canadian French and English online and print newspapers portray physicians’ role and MAiD? Given Canadians’ intense interest in physicians’ MAiD role and its recent legalisation, our study gives unique insight into how newspapers portrayed it over time.

Methods

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.

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

Results

The database searches retrieved 22 160 articles; 591 French (the 591 French articles were published in French in Québec newspapers. An additional 37 English articles were published in a Québec English newspaper (eg, The Gazette (Montreal)) and 3479 English articles met the inclusion criteria after removing duplicates. The 19% random sample contained 813 articles, 700 English and 113 French. Table 1 describes the newspaper articles sampled.

Table 1

Characteristics of random sample English and French newspaper articles by era

The top 10 keywords were derived to check for differences between French and English articles (table 2A). Because few of the top 10 keywords differed based on language, all articles were analysed together. There was a statistically significant decline in the number of French articles in 2005-2013 and 2014-2016 that had the keyword ’euthanasia/euthanasie/suicide', but this may be due to a sampling error in previous eras or that ’mort dans la dignité' was being used instead. The articles from 2014, 2015 and 2016 also had similar top 10 keywords, and therefore were analysed together (table 2B).

Table 2A

Percentage (%) of articles with top 10 keywords in the random sample of French (F) and English (E) newspaper articles by era

Table 2B

Percentage (%) of articles with top 10 keywords in the random sample of French (F) and English (E) newspaper articles by year from era 2014 to 2016

Due to the topic being studied, MAiD, the top 10 keyword group ‘euthanasia, euthanasie or suicide’ was focused on. Sentences (n=1315) (figure 2) containing ‘euthanasia, euthanasie or suicide’ were analysed for themes in both languages (table 3). With the exception of the theme Countries (other) that was not included in era 1972–1990, the themes were similar across the other eras.

Figure 2

Number of sentences analysed for ‘euthanasia/euthanasie/suicide’ by era (n=1315)

Table 3

Themes from ‘euthanasia/euthanasie/suicide’ keyword analysis

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.

Table 4

Newspaper quotes about physician role change and MAiD by theme and era

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.

Discussion and conclusion

Our qualitative content analysis of Canadian French and English newspaper articles over four decades found that different aspects of physicians’ MAiD role were portrayed in each era. Although table 3 may be interpreted as: 1) the discourse has not changed significantly or 2) the discourse within the themes has changed, our qualitative analysis of themes indicates that newspapers’ attention focused on different aspects of MAiD over time. The long debate about MAiD over time was crucial: newspapers kept Canadians current about developments by regularly publishing articles about polls, legislation, court cases and public perceptions about suffering and dying. Additionally, the press continuously reported the disconnect between physician opposition, Canadians’ growing support and politicians’ attempts to legalise MAiD. Although religious groups and many physicians opposed MAiD, newspapers primarily focused on portraying MAiD developments positively.

Our findings were consistent with other Canadian MAiD studies7 33 34 40 and our study enabled us to examine the issue from beginning to end in both languages. Like other studies of MAiD,33 34 we found that newspapers reflected popular opinions about it. Similar to newspaper studies about health issues,18 20 22 27 28 33 34 40 the themes we identified may not fully represent how the public, politicians and physicians perceived MAiD. As well, one Canadian study40 described how proponents pushed for MAiD’s legalisation by highlighting suffering patients, palliative care’s shortcomings and public dissatisfaction with medicine’s focus on prolonging life. We add another perspective: newspapers regularly paid attention to polls, the public, court cases, appeals and Bills that could change physicians’ role. While most newspaper studies focus on short-term issues,18 20 22 27 28 33 34 40 64 ours examined professional role change over decades. Our findings may be relevant to other contexts, because opportunities for physician role change can arise both outside and inside of the profession.

A physician’s role has been characterised by The Royal College of Physicians and Surgeons of Canada in the CanMEDS framework into seven areas: medical expert, communicator, collaborator, leader, health advocate, scholar and professional,65 and encompasses responsibilities, practices and tasks. The roles that could change with the legalisation of MAiD include collaborator (ie, shared decision-making), leader (ie, patient safety), health advocate (ie, partnership) and professional (ie, commitment to saving or prolonging life for patient, ethical judgement, personal well-being).66 Other themes we found, such as supporting and committing, were intertwined with physician role change. Supporting patients’ choice is connected with the partnership, educator, and shared decision-making role of physicians, while committing could be connected to physicians’ role to uphold ethical and legal decision-making.

We reveal a rich story about how MAiD portrayals shifted as the issue unfolded, going through the issue-attention cycle’s stages 1, 2 and 3, then back to stage 2 when MAiD was going to become legal.35 For physicians’ MAiD role portrayals, the first three of the five stages were observed before legalisation: 1) public opinion (‘preproblem’, 1972–1990), 2) legal aspects (‘alarmed discovery and euphoric enthusiasm stage’, 1991–1995 and 2014–2016) and 3) professional and political aspects (‘realising the cost of significant progress stage’, 1996–2004 and 2005–2013). Interestingly, even though Québec legalised MAiD in 2015, newspaper articles in the 2014–2016 era did not move to ‘gradual decline of intense public interest’ (stage 4). This may be because MAiD was still not legal across the rest of Canada. To summarise, the portrayal of physicians’ role in MAiD evolved from: stage 1) a descriptive look at physician actions (ie, number of physicians secretly performing MAiD) and public opinion of whether they believe MAiD should be legalised; to stage 2) a passionate ethical debate of defining what a physician’s role is in end-of-life care and the legal ramifications of changing their role; to stage 3) addressing the physician’s role in policy change and professional obligation to relieve patient suffering and respect patient choice and dignity and then back to stage 2) the portrayal of the physicians as conservative/resistant to adopting MAiD, but legally required to define and educate role change in order to provide service.

Understanding newspapers’ portrayal of physicians’ role in MAiD may provide important insights for professionals, policymakers and legislators. Four continents have legalised MAiD and more are currently examining it.1 For over four decades, Canadian newspapers played a part in keeping attention on MAiD, but physicians did not change their professional role until they were legislated to do so. Based on stories about physicians favouring palliative care and opposing MAiD, Canadian patients and politicians may have perceived that physicians would not support their end-of-life wishes, and thus were reluctant to change.14 15 67 Health policymakers could examine the issues newspapers are paying more attention to and devote more time to understanding what might need to be changed to resolve an issue. Although not appropriate for every issue or in every context, our study reveals that legislation might be a path to achieve change in professional roles.

This study’s strengths are that it thematically captures MAiD’s portrayal of the public, politicians, physicians and key events in Canadian newspapers for the issue’s entire duration. Our article sample may be biased because it is based on newspapers that allow their publications to be entered into searchable online databases, which helps explain why some provinces and territories are not well represented in the random sample. The random sample may not represent the full sample, signifying sampling bias68 and meaning that some themes may not be present. Articles written before MAiD was legal may be predisposed to culture bias and the halo effect (ie, the tendency for an impression created in one area to influence opinion in another area).68 To surmount confirmation and sampling bias,34 53–58 each era was randomly sampled and the last era was oversampled. Analysing the full database instead of a random sample could yield additional insights.

We observed that women who fought MAiD court cases and tabled Bills were prominently featured in newspapers, but more male physicians and politicians were quoted. Additionally, Health Canada reports that 2% more women than men received MAiD up to June 2017.5 These suggest that gender bias may be present. Exploring gender and MAiD may yield additional insights into gender differences in healthcare use and access.69 As well, future researchers will want to pay careful attention to patient empowerment and its connection to MAiD as it is under-represented in our sample. This may be because newspapers did not explicitly connect these two topics or that the random sample is biased.

Although two-thirds of Canadians identify as Roman Catholic and/or Christian, journalists paid less attention to religion in the random sample. This also warrants further investigation, because religious physicians, politicians, hospitals and citizens helped defeat Bills, stall MAiD legislation after the SCC ruling and voiced their discontent in letters and news stories. There is also little known about the relationship between religion, opposing MAiD and religion’s decline in Canada. The lack of attention to palliative care, advocated by physicians and MAiD opponents, should be investigated as it appears to be an important topic for physicians.

Future research could also examine newspaper article tone to understand whether Canadian newspapers used a balanced approach when portraying MAiD.70 Based on our reading of all the articles in the random sample, it appears that many had a positive tone towards MAiD. However, this may be a reflection of Canadians’ general support for MAiD. It also anecdotally seems that newspapers negatively portray physicians’ and their resistance to MAiD.

Other qualitative research such as interviewing physicians involved in MAiD legalisation may reveal whether newspaper portrayals of MAiD helped them change their perspectives. Investigating articles published in both Canadian medical journals and newspapers after legalisation could also expand our understanding about MAiD portrayals and changes in physicians’ role.

We note the growing importance of social media, websites, RSS feeds, apps, etc and the general decline of newspapers, which may affect the results of future newspaper studies. It would be prudent for future researchers to consider how different generations access news about MAiD (eg, seniors are more likely to watch television and millennials are more likely to use an app or social media).

As well, it is also important to note that further research about the portrayal of MAiD and physicians’ role in Canadian French-language newspapers and in the French language is needed. Because MAiD legalisation occurred differently in Québec (ie, public debate, then legislation) than the rest of Canada (ie, SCC ruling, then legislation), the different pathways to legalisation should be explored. Because Canada is officially bilingual, future researchers should be attentive to this issue.

Acknowledgments

The authors are grateful for the research assistance of Jina Lee and the administrative support of the Rowe School of Business.

References

  1. 1.
  2. 2.
  3. 3.
  4. 4.
  5. 5.
  6. 6.
  7. 7.
  8. 8.
  9. 9.
  10. 10.
  11. 11.
  12. 12.
  13. 13.
  14. 14.
  15. 15.
  16. 16.
  17. 17.
  18. 18.
  19. 19.
  20. 20.
  21. 21.
  22. 22.
  23. 23.
  24. 24.
  25. 25.
  26. 26.
  27. 27.
  28. 28.
  29. 29.
  30. 30.
  31. 31.
  32. 32.
  33. 33.
  34. 34.
  35. 35.
  36. 36.
  37. 37.
  38. 38.
  39. 39.
  40. 40.
  41. 41.
  42. 42.
  43. 43.
  44. 44.
  45. 45.
  46. 46.
  47. 47.
  48. 48.
  49. 49.
  50. 50.
  51. 51.
  52. 52.
  53. 53.
  54. 54.
  55. 55.
  56. 56.
  57. 57.
  58. 58.
  59. 59.
  60. 60.
  61. 61.
  62. 62.
  63. 63.
  64. 64.
  65. 65.
  66. 66.
  67. 67.
  68. 68.
  69. 69.
  70. 70.
View Abstract

Footnotes

  • Contributors ETC, CS, GN and CB contributed to conception and design. ETC and CS analysed the data. GN participated in discussions about the data and analysis. ETC and CS wrote the first draft. GN and CB edited the manuscript. All the authors approved the final version submitted for publication.

  • Funding Private Donation, Division of Gynecologic Oncology, Tom Baker Cancer Centre, Alberta Health Services, Canada. Rowe School of Business, Dalhousie University, Canada provided in-kind administrative support.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The dataset could be rebuilt using the search terms and fee-based subscription databases detailed in the methods.

  • Patient consent for publication Not required.

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