Winnipeg Free Press

Winnipeg Free Press (Newspaper) - February 19, 2025, Winnipeg, Manitoba THINK TANK COMMENT EDITOR: RUSSELL WANGERSKY 204-697-7269 ● RUSSELL.WANGERSKY@WINNIPEGFREEPRESS.COM A7 WEDNESDAY FEBRUARY 19, 2025 Ideas, Issues, Insights Don’t confuse advance health directives with MAID I READ Ruth Enns’ Feb. 3 Think Tank piece in the Free Press (Medical assistance in dying and advance directives) with great interest, because these are topics that interest me. However, while it’s good to see these issues become part of a broader conversation, some clarification is required. Ms. Enns is clearly passionate about her subject matter, but I believe she is confounding advance health directives with advance requests for med- ical assistance in dying, and these are two very different tools. Advance directives (ADs) — also known as health-care directives — express the decisions you’ve made about the kind of health care you want in the future should you become incapaci- tated. In Canada, you can set out detailed wishes for yourself and name a trusted person as your substitute decision-maker in the event that you cannot communicate. For example, an AD might stipulate that if you were gravely injured in an accident and were comatose with catastrophic and irreversible brain damage, you would not wish to continue being fed through a tube. The government webpage on Manitoba health directives explains that while such ADs are bind- ing and will be honoured by the courts, “health -care professionals treating you are not obliged to search for or ask about a signed directive.” So, “It is important to be sure that family, friends, your doctor and your proxy know you have a directive and know where it can be found.” ADs are not the same as advanced requests for medical assistance in dying (MAID). The former is about a person’s wishes for care that could prolong life or allow it to ebb; the latter is a direc- tive about ending their life at a certain definitive point. While a substitute decision-maker is responsible for conveying a person’s wishes in terms of AD, they cannot request MAID on another person’s behalf. As Dalhousie University’s Health Law Institute makes clear, “It is not possible to request MAID through a provincial or territorial advance direc- tive.” Advanced directives and MAID are different things, but both involve personal choices and both also require conversations that some people find uncomfortable. As a rule, we don’t like to think of ourselves as being no longer in control or helpless to tell people what we want. Currently, Quebec is the only place in Canada where advance requests for MAID are available. People in that province have been able to make the requests under certain prescribed circum- stances as of Oct. 30, 2024. If a person is diag- nosed with a serious and incurable illness that will eventually leave them incapacitated, they can apply — while they are still able to consent — to receive MAID when they reach a point in their de- terioration that they find personally unacceptable. For example: if I lived in Quebec, was diag- nosed with Alzheimer’s disease and was still men- tally competent (a period that can last for years), I might decide that when I was no longer able to recognize my children, spouse or siblings — or even myself — that I wished to receive MAID. It’s not exactly a mechanism that allows us to “order up a beautifully scripted death like a latte- to-go,” as Ms. Enns writes of advance directives in her piece; indeed, anyone who has watched a loved one’s steady decline through dementia can tell you there is nothing beautiful or scripted about the multitude of small deaths a person ex- periences as the disease robs them of themselves. While advanced requests for MAID are still in contradiction of the Criminal Code of Canada, the federal government has said it won’t challenge what is happening in Quebec for now. On Feb. 14, the Canadian government wrapped up the online survey portion of a countrywide consultation on advanced requests for MAID. The results of its findings are expected this spring. You can find Health Canada’s comprehensive 2023 report on MAID here: bit.ly/4hsoPQA. It offers insights on exactly how MAID is ad- ministered and regulated in this country. It also outlines the rigorous conditions that have to be met before MAID is approved and the considerations taken into account by medical pro- viders. No one is being “‘helped’ into the nearest hearse,” as Ms. Enns suggests, without due care and consideration for their unique circumstances, their wishes and the law. And people can, and do, change their minds after requesting MAID. In 2023, for example, 496 people did so. Finally, to suggest that no one “has time, resources and patience for such conversations these days,” as Ms. Enns did, does a disservice to the people making difficult choices about their health and their lives only after a great deal of contemplation, as well as to the thoughtful, ethical and compassionate medical professionals who are willing to help them achieve a measure of autono- my over their own lives — and deaths. Pam Frampton is a freelance writer and editor who lives in St. John’s. pamelajframpton@gmail.com X: pam_frampton | Bluesky: @pamframpton.bsky.social Recruitment and retention: a health-care challenge MANITOBA’S government was elected in Oc- tober 2023 with a strong mandate to “fix health care.” Central to this commitment is resetting the relationship with Manitoba’s health-care workers. For nearly every sector in health care, new collective agreements have been signed over the last nine months that take a step towards reset- ting this relationship, setting the foundation for staffing up the public system. Allied health workers — specialized health professionals from paramedics to diagnostic tech- nologists to occupational therapists and beyond — remain the last sector working without a new contract. A 96 per cent strike mandate from Manitoba Association of Health Care Professionals mem- bers, the union for around 7,000 of the nearly 8,000 allied health professionals working across Manitoba, released on Jan. 29 reveals that, among this section of health care, patience is wearing extremely thin. In the face of growing health-care expendi- tures, settling a new contract with allied health workers that can prevent staff from leaving and attract others to work in the public system must remain a critical priority. The work performed by allied health profes- sionals is key to bringing down wait times and achieving health-care improvements put forward in the last election. Allied health workers are highly specialized professionals who, in most cas- es, require years of training — losing more staff now will leave Manitobans with high wait times for years to come. Deep frustration among allied health workers is due to high staff vacancies, increasing workloads, and declining morale. MAHCP surveys from May and December 2024 reported that a large majority of staff are experiencing workload increases and declining morale. Nearly half reported losing colleagues in the last year. Under the previous government, allied health workers went five years without a contract, leaving most without a wage increase through the pandemic. This story should be a familiar one by now — wage stagnation mixed with high vacancy rates have proven to be a toxic cocktail in health care, leading to burnout, early retirements, and many exiting health care altogether. New con- tracts signed by nurses, doctors and other health workers have reflected this context and offered wages geared to recruitment and retention. The same needs to be applied in allied health. Reports of high vacancy rates across allied health professions remain a persistent issue, de- spite the Manitoba government’s recent staffing updates. In January, rural paramedic vacancy rates raised alarms due to rural EMS stations in Virden and Russell running at 50 per cent vacancy. The EMS station in Shoal Lake was operating with only one of 13 positions filled. Across all rural regions, 28 per cent of paramedic positions are reportedly vacant. A recent access to information request revealed that rural ambulances were out of service due to staff shortages a record 30,000 hours per month on average in 2024. Other data disclosed a 23 per cent vacancy rate across technical/professional staff in Southern Health, represented by the Manitoba Government and General Employees’ Union. At the same time, more than 4,000 people were waiting for services provided by technical and professional staff in Southern Health. Staff vacancies have been highlighted as a key component of high wait times for diagnostic pro- cedures such as CT scans and MRIs. Data from the Canadian Institute for Health Information shows that in 2023 (the most recent interprovin- cial data) Manitoba’s median wait times for MRIs were highest among provinces, while CT scan waits were second highest. Manitoba’s median wait times for MRIs reached 27 weeks in Septem- ber 2024, a four-year peak. Long wait times for diagnostic procedures cre- ate bottlenecks in health care, making them a key to lowering wait times across the system. There is no question that recruitment and reten- tion cost money. Manitoba’s per capita health-care expenditures are beginning to climb again after years of austerity, but remain below the Canadian average. There remains a long way to go to return to pre-2016 trends in health spending. In 2015, Manitoba’s per capita health expen- diture was third-highest among provinces — in 2024, Manitoba is forecast to be second-lowest. Further, prior to 2016 Manitoba’s per capita health spending was consistently above the Canadian average — in 2024 Manitoba’s spending is starting to trend towards the Canadian bench- mark but remains far below. The audits of health authorities released on Feb. 5 reveal that health authority expenditure is increasing in large part due to salaries and supply costs. These salary expenditures are necessary to staff up the public system and reduce spending on private agencies. Rebuilding the health-care workforce and relieving pressure on existing staff needs to re- main at the core of fixing Manitoba’s health-care system. This will require significant additional spending, but the alternative is a continued loss of staff and services. Niall Harney is a senior researcher with the Canadian Centre for Policy Alternatives — Manitoba. Different kinds of thieves WHAT’S the difference between smash-and- grab raids and protection rackets? Not all that much from the legal point of view, but protection rackets have a lower level of risk and a higher rate of return. Take Rwanda, for example. President Paul Kagame is running no personal risks, but the Tutsi soldiers of the M23 rebel army, which essentially works for him, are fighting an actual war in the neighbouring Demo- cratic Republic of Congo. The current task of the M23 army is to seize control of the part of eastern DRC that borders Rwanda and steal the rich mineral reserves of that region: gold, cobalt, and above all coltan, which is essential for smartphones and almost all other sophisti- cated electronic devices. This region contains up to 60 per cent of the global reserves of coltan ore, and it’s easy to steal and market. It’s dug out by tens of thousands of small-scale operators work- ing landscapes honeycombed with shallow digs, and once it reaches Rwanda, they mix it with locally mined coltan and market it as a Rwandan product. Stolen coltan currently accounts for a secret but significant share of Rwandan government income, but it’s a typical smash- and-grab operation: lots of violence and a short-term perspective. At the moment they’re doing well: M23 seized all of North Kivu last month, and has already conquered most of South Kivu this month. Paul Kagama always sends some Rwandan soldiers along to back up the local thugs (4,000 Rwandan troops this time), but this is the third time in 30 years that Rwanda has sent its army into the eastern DRC to grab resources. Lots of people die, but it never lasts. Whereas a protection racket is a long- term relationship: “Nice little shop/country you’ve got here. You wouldn’t want to see it smashed/destroyed now, would you? Just have the cash ready every Friday and noth- ing bad will happen to you.” Or in Ukraine’s case, just have half your mineral output loaded up for shipment every Friday and you won’t be hurt. “I want the equivalent of like (US)$500 billion worth of rare earths, and they’ve essentially agreed to do that,” U.S. President Donald Trump says he told the Ukrainian government last week. The truth is that Ukrainian President Volodymyr Zelenskyy knew the mob boss would be coming round for his cut, so he offered to pay even before Trump asked. It caught Trump on the hop, so the first number out of his mouth in reply was US$500 billion. That’s almost five times the value of U.S. military and civilian aid to Ukraine since the Russian invasion three years ago (US$116 billion), but it’s far less than Trump could really screw out of a country with its back to the wall. In a couple of days, therefore, Trump upped the demand hugely — but he followed Zelenskyy’s suggestion that it should come out of Ukraine’s future mineral wealth, since Kyiv currently has no spare money at all. Trump said he now wanted 50 per cent of Ukraine’s future income from exploiting its reserves of rare metals and critical materi- als: titanium, uranium, lithium, beryllium, manganese, gallium, zirconium, graphite, apatite, fluorite and nickel. Half Ukraine’s mineral income forever could be worth as much as US$5 trillion. Zelenskyy didn’t fall for that, so now they are in a negotiation. It’s not just about the price Ukraine pays for survival, but also about what assurances Trump can give that paying off America will really guarantee Ukraine’s survival. The underlying difficulty is that the White House mob has farmed the enforcement work out to the Kremlin mob. The Russians may hate Ukraine enough to insist on de- stroying it even if Trump makes a deal with Zelenskyy — which is far from agreed. That’s the downside of protection rackets. It’s a crowded field, and there are always other rival mobs trying to spoil your play or cut you out completely. Don Corleone had to deal with problems like this in his (fictional) past, and Don Kagame has been handling them successfully most of his life. Don Trump is new to this game, and we shall see. Gwynne Dyer’s new book is Intervention Earth: Life-Saving Ideas from the World’s Climate Engineers. GWYNNE DYER NIALL HARNEY PAM FRAMPTON RUSSELL WANGERSKY / FREE PRESS Advance health directives and advance requests for MAID both involve personal choices, but that’s where the similarities end. ;