Should intractable mental illness make you eligible for euthanasia?

This article was published by Bioedge on March 28, 2023.

Michael Cook

By Michael Cook

Canada is in the middle of a vigorous debate about whether incurable mental illness is grounds for Medical Assistance in Dying. This has been approved by Parliament, but public reaction forced the government to delay implementation until 2024.

In a sensitive and eloquent essay in the online magazine Psyche, a Belgian psychiatrist, Marie Nicolini argues that “it is difficult to see how we can ethically justify ending the lives of people with mental illness”. Amongst her concerns are the following.

The definition of “incurable” or “intractable” is fuzzy and ambiguous. “In a comprehensive review of scientific research on the curability of depression, my colleagues and I found that there is no objective standard of incurability for clinicians to hold on to. The commonly used term ‘treatment-resistant depression’ typically means that a patient has had two unsuccessful trials with antidepressants; it is not a synonym for ‘incurable’.”

She points out that a long history of symptoms does not necessarily mean that a patient cannot recover: “prediction accuracy is, at best, at chance level – like flipping a coin.”

There is a serious social justice issue – the gender gap in euthanasia. There is a “consistent finding that among people receiving euthanasia for mental disorders, 69 to 77 per cent are women. In my team’s study of Dutch psychiatric euthanasia cases, 36 per cent had a history of severe sexual or other kinds of abuse. Gender-based violence is a major public health issue that affects one in three women worldwide, and for which mental healthcare and prevention are lagging. When there is evidence that a policy, particularly one that involves ending lives, may reflect or deepen pre-existing inequities, that should give us pause.”

Clinicians’ biases pose a risk to patients. “For example, euthanasia guidelines direct clinicians to assess how ‘palpable’ they find their patients’ unbearable and hopeless suffering. In the Dutch cases we studied, clinicians used the label ‘palpable suffering’ almost exclusively with regard to patients with personality disorders. This is troubling because it is well known that clinicians often view people with personality disorders negatively, as ‘difficult’ or ‘hopeless’ individuals.”

Court case launched to declare assisted suicide unlawful and unconstitutional in the US.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

This is my first analysis of the court case that was launched on April 25, 2023 to have the California assisted suicide law declared unlawful and unconstitutional. Future articles will further explain the case. EPC –USA supports this initiative.

The United Spinal Association, Not Dead Yet, Institute for Patients’ Rights, Communities Actively Living Independent and Free, Lonnie VanHook, and Ingrid Tischer have launched a lawsuit in California to strike down the California assisted suicide law with the goal of the case going to the United States Supreme Court to strike down assisted laws throughout the US. (Link to the complaint).

The Plaintiffs are all organizations with members who have disabilities, individual persons with disabilities, and/or organizations that advocate for persons with disabilities.

The case asserts that the assisted suicide act is a discriminatory scheme, which creates a two-tiered medical system in which people who are suicidal receive radically different treatment responses by their physicians and protections from the State depending on whether the person has what the physician deems to be a “terminal disease”—which, by definition, is a disability under the Americans with Disabilities Act.

The case states that assisted suicide laws are situated within a long history of American state laws and practices directly harming and discriminating against people with disabilities on the grounds that those peoples’ lives are not as worthy of protecting as others. It also states that California’s assisted suicide law steers vulnerable people to their deaths instead of providing care and supportive services.

Plaintiff United Spinal’s members with spinal cord injuries at times experience depression and suicidal thoughts as they must adjust to living with their disability after injury. Most people with life-threatening conditions who say that they want to die are actually asking for assistance in living—that is, for help in dealing with the symptoms and practical necessities common to living with a terminal disability: depression, anxiety about the future, grief, inadequate care options, dependence, lack of control, fear about physical suffering, and spiritual despair.

The case states that laws that discriminate against people with terminal disabilities by depriving them of protections afforded other persons under California law in violation of the Americans with Disabilities Act (“ADA”) and Section 504 of the Rehabilitation Act of 1973 (“Section 504”). The State’s suicide prevention programs are designed to ensure that a person’s expression of suicidal ideation is sufficient in itself to trigger mental health care, irrespective of whether they want treatment. Assisted suicide deprives Plaintiffs and their members access to these life-preserving interventions because of their disabilities.

The case states that the assisted suicide law violates the Due Process Clause of the Fourteenth Amendment by failing to include sufficient safeguards to ensure that a judgment-impaired or unduly influenced person does not receive and/or ingest lethal physician-assisted suicide drugs without adequate due process in waiving their fundamental right to live. The Act’s failure to require an exhaustive or at least evidence of an informed rejection, of less restrictive alternatives to assisted suicide––including suicide prevention services, palliative care, hospice care, and other personal support services currently provided by the State––also violates the Due Process Clause of the Fourteenth Amendment.

The case is asking the court to declare the California assisted suicide act as unlawful and unconstitutional.

Pontifical Academy for Life President must resign. Italy's assisted suicide bill must be defeated.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In the past I have stayed out of Church politics but this situation requires a response.

I am very concerned with the recent comments by Archbishop Vincenzo Paglia, President of the Pontifical Academy for Life, relating to the 2019 Italian assisted suicide Constitutional Court decision and the proposed Italian assisted suicide legislation.

In September 2019, the Italian Constitutional Court opened the door to assisted suicide in the assisted suicide case of Fabiano Antoniani, known as DJ Fabo, a music producer and motocross driver who became disabled in a 2014 traffic accident. In February 2017, Marco Cappato, a leader with the Luca Coscioni Assisted Suicide Association brought Antoniani to Switzerland where he died at an assisted suicide clinic.

The 2019 Italian Constitutional Court decision, which concerned the Antoniani death, appeared to limit assisted suicide to people being kept alive on life-support but further reading indicated that the decision was much wider. An article published in the Guardian on September 25, 2019 stated:

The court said that a patient’s condition must be “causing physical and psychological suffering that he or she considers intolerable”.

The language “causing physical and psychological suffering that he or she considers intolerable” is based on subjective criteria and allows assisted suicide to a wide group of people. I have commented on the language of the decision and expressed concern that the decision devalued the lives of people with disabilities. 

Further to that, in November 2021 an ethics committee in the central Italian region of Marche Italy approved the first assisted suicide death, a man with quadriplegia known as Mario. At that time I stated that I was concerned that the Italian assisted suicide court decisions all focused on people with disabilities.

On April 19, 2023; Archbishop Paglia, in speaking at the Perugia Journalist Festival on the theme: The Last Journey (towards the end of Life) stated:

…it cannot be excluded that in our society a legal mediation is feasible which allows assisted suicide in the conditions specified by the Constitutional Court's Judgment 242/2019: the person must be "kept alive by life support treatments and affected from an irreversible pathology, a source of physical or psychological suffering that she deems intolerable, but fully capable of making free and informed decisions". The bill approved by the Chamber of Deputies (but not by the Senate) basically went along this line. Personally I would not practice assisted suicide, but I understand that legal mediation can constitute the greatest common good that is concretely possible in the conditions in which we find ourselves.

Paglia explained in his intervention that the Catholic Church opposes assisted suicide but the language of the court decision and the assisted suicide bill, that has already passed in the Chamber of Deputies, but not in the Italian Senate, might work as a legal answer.

In response to Paglia, I ask that questions, what is assisted suicide and can there ever be a law permitting assisted suicide that is considered morally permissible?

The answer to this lies in the fundamental issue of what assisted suicide is.

Assisted suicide is an act whereby one or more persons, usually medical practitioners, directly assist in the death of another person by intentionally providing the means to cause death. In other words, where assisted suicide is legal, the medical practitioner is directly involved with causing the death of another person. It is not accidental and it is not based on a "double effect."

Assisted suicide is not acceptable under any circumstance based on the commandment, thou shall not kill. Based on the act, assisted suicide can never be considered morally permissible.

On April 24, the Vatican published a clarification concerning the comments by Archbishop Paglia. The clarification states:

In his address last week, Archbishop Paglia explained that it is important that assisted suicide remain a crime in Italian law, which the Constitutional Court sentence recognizes. However, because the Court has asked Parliament to legislate concerning the issue, the Archbishop gave his opinion that a “legislative initiative” along the lines proposed by the Senate – maintaining medically-assisted suicide as a crime while de-penalizing it in certain circumstances – might be a possible solution to the legal question.

The statement from the PAV insists that any legal compromise would in no way involve a change in the moral stance towards assisted suicide.

The clarification misses the point. Archbishop Paglia created confusion when he suggested that the 2019 Italian Constitutional Court decision and the Chamber of Deputies legislation may be an acceptable legal solution. These comments suggest that some assisted suicide deaths may be acceptable.

Archbishop Paglia does make several excellent remarks in his intervention. He spoke about the interdependence of the human person, the cultural pressure that may be felt by a dying person, the expansion of euthanasia in other jurisdictions, the abuse of euthanasia, and the need for people to be with others as they are dying. Nonetheless, the confusion Archbishop Paglia has sown is greater than the good that he expressed.

I am also concerned because the 2019 Italian Constitutional court decision and the language of the Chamber of Deputies bill infer that assisting the suicide of a disabled person can be acceptable. The 2019 court decision was based on the assisted suicide death of a disabled man and the language of the decision is discriminatory towards people with disabilities.

Further to that, the legislation states that assisted suicide can be approved when the person’s condition is “causing physical and psychological suffering that he or she considers intolerable.” These are subjective criteria that are based on a person's claim that their suffering is intolerable. No one can confirm or deny such a claim.

Paglia acknowledged that the law would allow assisted suicide for people with physical or psychological suffering, but he doesn't seem to recognize that in all jurisdictions that have legalized assisted suicide based on physical or psychological suffering this subjective criteria has led to the massive expansions of the law.

Based on his comments and the weak clarification attempt, I and those who agree to attach their name to this statement, call on Archbishop Vincenzo Paglia to resign as the President of the Pontifical Academy for Life.

Assisted suicide is the direct and intentional assisting in a suicide death. It is fundamental that the Pontifical Academy for Life effectively expresses its opposition to killing people.

To add your name to this statement, email Alex Schadenberg at: alex@epcc.ca with your full name, address and position.

Great News: Connecticut assisted suicide bill dies again.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Cathy Ludlum - Second Thoughts Connecticut

I have great news. The Connecticut assisted suicide bill has died again. This year represents 11 straight years for Connecticut to debate and defeat an assisted suicide bill.

Article from 2022: Connecticut assisted suicide bill defeated again (Link).

A news article by Hugh McQuaid for the CTNewsJunkie on April 19 reported:

A legislative panel on Wednesday tabled a proposal to allow terminally ill adults in Connecticut to end their own lives with medication, effectively ending the bill’s progress in the Judiciary Committee for the third consecutive year.

Sen. Gary Winfield, a New Haven Democrat who co-chairs the committee, announced that the proposal did not have enough support to pass as he raised it for a discussion during a midday meeting after hours of negotiations.

The assisted suicide bill sponsors, in 2023, intentionally added tighter guidelines in order to get it passed. The opponents of the bill explained that the intention was to get the bill passed, and then similar to other states, to expand the assisted suicide law in future years. McQuaid stated:

Supporters hoped those guard rails would help to win over skeptical members of the Judiciary Committee. It wasn’t enough. During a brief interview Wednesday, Winfield said earlier discussions indicated there was not even close to enough support among the committee members to pass the bill.

McQuaid reported on statements from the Judiciary committee:

“I do not want to put another thing in a lap of someone that is facing life’s difficulties and saying, ‘You also have the option to kill yourself’,” Sen. John Kissel, R-Enfield, said. “I don’t want anyone to have that option, legally, because I think that is a small step from going down the road to now you’re going to be encouraged, if not overtly, implicitly.”

There were concerns about the proposal on both sides of the aisle.

Rep. Steve Stafstrom, a Bridgeport Democrat who co-chairs the committee, spoke of his own father’s terminal cancer diagnosis and the difficult decisions it has brought. He pushed back on characterizations that opposition to the bill stemmed largely from the religious affiliation of legislators.

Instead, Stafstrom said his concerns about the proposal grew throughout this session due to court battles in other states, where lawsuits have sought to scrap safeguards similar to those contemplated under the bill.

“There are still some outstanding issues and we are right to be cautious on it,” Stafstrom said.

Connecticut is the best example of a bipartisan opposition to assisted suicide. Thank you to the disability group, Second Thoughts Connecticut, and to the many people who worked so hard to defeat the bill for eleven consecutive years.

Portugal's President vetoes fourth euthanasia bill

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

President Marcelo Rebello de Sousa

Portugal's President, Marcelo Rebello de Sousa, vetoed the euthanasia bill today. Natasha Donn reported for the Portugal Resident on April 20.

President Marcelo has returned the 4th draft of the bill decriminalising assisted dying to parliament, admitting that his reservations are his own and will not require another sending of the text to the Constitutional Court. ...Marcelo’s doubts came in the form of who “defines the patient’s physical incapacity to self-administer lethal drugs, as well as who should ensure medical supervision during the act of medically assisted death.”

President de Sousa's veto will only slow down the legalization of euthanasia / assisted suicide in Portugal. 

The Portugal Resident reported on March 31 that Portugal's Parliament passed a fourth euthanasia bill. Two of the previous bills were declared unconstitutional by Portugal's Constitutional Court and a third bill was vetoed by President de Sousa.

On January 31, 2023 Portugal's Constitutional Court rejected the third euthanasia bill. At that time the Portugal News reported:

The Constitutional Court considered that “an intolerable lack of definition as to the exact scope of application” of the decree on medically assisted death had been created, noting that the parliament went “further”, changing “in essential aspects” the previous bill.

This was the third decree approved by parliament to decriminalise medically assisted death in a period of about two years.

The first was also declared unconstitutional by the TC, in March 2021, following a request for preventive inspection by the President of the Republic, due to insufficient normative densification.

In November of the same year, Marcelo Rebelo de Sousa used the political veto in relation to the second parliamentary decree on this matter, as it contained contradictory expressions.

The previous bill passed on December 9. Similar to the other previous bills, the bill used vague language. As the Constitutional Court stated, the bill had "an intolerable lack of definition as to the exact scope of the application."

Euthanasia directly and intentionally causes the death of a person by lethal injection. Portugal needs to commit to a culture that cares for its citizens in need, not kills.

Cambridge Union Debate - Against assisted suicide

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Yuan Yi Zhu

There have been many fantastic Cambridge Union debates. On April 19, 2023 - The Critic published an excellent speech by Yuan Yi Zhu entitled: Against assisted suicide.

Zhu outlines what the pro-assisted suicide speeches will state:

They will ask you to believe, firstly, that killing someone is a form of medical care. That there are some people whose lives are so wretched that they are quite literally better off dead than alive. That, in other words, there are people whose lives are not worth living. Of course, they won’t put it so bluntly. They may even resent the matter being described so bluntly — but that is the reality of their position.

They will not tell you about the ugly, grubby origins of the pro-euthanasia movement, which are to be found in the cruel social Darwinism of the 19th century — which Cambridge did so much to spread across the world like a virus and which held that some people simply should not be alive because their lives were worthless.

They will not tell you that Dignity in Dying, the United Kingdom’s oldest and most influential pro-euthanasia group, was founded by an eugenicist and drew most of its support from eugenicists.

But they will say, ah, this is all ancient history. This is a different movement, a modern movement. We only want it for a few people, who are going to die soon anyway, and who suffer from intolerable pain. This has nothing to do with the horrors of the past. I am convinced they actually believe this, that they are sincere.

They won’t tell you how in almost every country which has legalised euthanasia, the eligibility criteria have been expanded over and over again.

Zhu comments on the Netherlands euthanasia program:

Twenty years ago, the Netherlands became the first country in the world to legalise euthanasia. At the time, it was only available to consenting adults who had a terminal illness and were experiencing unbearable suffering. In other words, what most supporters of assisted suicide in this country claim they want to enact.

Today, in the Netherlands, it is legal to kill disabled infants. It is legal to kill children over the age of 12. It is legal to kill people with dementia who don’t remember they had consented to be killed. One woman, who suffered from dementia, was physically held down by a doctor and her relatives so that she could be injected with a poison and killed. The doctor was acquitted.

The Dutch government now wants to expand eligibility even further. They want to allow children between the age of 1 and 12 to be eligible for euthanasia. The current Dutch government has accepted a proposal to allow old people, who are perfectly well but feel they have finished living their lives, to kill themselves medically.

Zhu explains why euthanasia laws inevitably expand:

Why is that? Why does virtually every country which legalised euthanasia expand its remit further and further away from the terminally ill? It’s because they think — and they want you to believe that — dying is a “right”.

Human rights are good, right? Everyone should have them. If dying is a human right, how can we limit its access to euthanasia those who suffer from terminal illness? If you say something is a human right, and exclude a group — most of the population in fact — that is by definition discrimination. If this is really all about rights, why should a perfectly healthy person who wants to commit suicide be deprived of his autonomy to kill himself? If someone is standing on a bridge, ready to jump, what right do we have to stop him from killing himself and limit his right to die?

Zhu speaks of the Canadian euthanasia experience:

Maybe the speakers for the proposition will accuse me of fear-mongering. Yet, this is exactly how this logic played out in Canada. In 2016, Canada legalised the right to die for terminally ill people who were close to death. Exactly two years later, a Canadian court struck down the law as unconstitutional.

The court did so because, it said, it is discriminatory to only allow the terminally ill to die through assisted suicide. Of course, it was right. Now, in Canada, anyone with a serious illness or disability with no prospect of improvement can choose to die via assisted suicide. Until last month, Canada was going to legalize assisted suicide because of mental illness — because it would be discrimination against the mentally ill to do otherwise.

In fact, until a few months ago, if you called the health advice hotline in the province of Saskatchewan in Canada, one option was for anti-suicide help; another option was for assisted suicide. Think of the message that this sends to those who are struggling with mental health issues.

Zhu comments on the promise that the law will contain strict safeguards:

The supporters of this motion will ask you to believe that the “right to die” will come with strict and effective safeguards. No one is going to be pressured into killing themselves. They will not mention that right now, as we speak, people in Canada are killing themselves because of deafness, because they were in a wheelchair, because they had allergies. Surprise, the people who have committed suicide for these reasons had one thing in common. They were all poor and could not access adequate care or social support.

One woman, Sophia, killed herself because she was allergic to cigarette smoke and to chemicals in cleaning products, but she was too poor to afford housing which would not worsen her allergies. Another woman, a veteran who participated in the Paralympics, tried for years to get a wheelchair ramp from the government. Eventually, the caseworker asked if she had considered killing herself instead. Why not? She was legally eligible, after all, since she was disabled and would never walk again, and dying is a “right”.

Those are only cases which have been reported in Canadian media. We only know about Sophia, the woman who died because of poverty and because of her allergies, because she told her family to publicise her case after she had died so that it would never happen again to anyone else.

Yet we are here tonight, having this debate, ignoring the fact that in one of the world’s wealthiest countries, a country wealthier than this one in fact, disabled people are killing themselves because they are poor, and the government, which refuses to give them enough money to live on, is paying for them to die.

Zhu on the question of autonomy:

They will not tell you about those people who are coerced into dying because they want you to believe this is about autonomy.

Once the illusion of autonomy is shattered, so does their case.

It is not a coincidence that the people who are featured in pro-assisted suicide publicity campaigns are all articulate, well-off middle-class people. They do not face socio-economic pressures on their very existence — unlike Sophia, who died because she had allergies.

They want you to forget that we live in a world which all too often still does not value the lives of the poor, of the sick, of the disabled, which views them as an expensive burden.

Zhu speaks of the problem with modern healthcare systems and the aging population and concludes that the answer to the question is to encourage social caring rather than killing:

At a time when healthcare systems are on the verge of collapse all around the developed world, when intergenerational economic inequalities are worse than they have ever been, how long will it be before the right to die becomes a duty to die?

If you think this is too far-fetched, consider that a former prime minister of Japan said publicly that he wished old people would hurry up and die. 30 per cent of the Japanese population is over the age of 65. They require pensions and expensive healthcare and social care. Given the experiences of the countries that have legalized assisted suicide, given what we know about the cruelty of human nature, is it really so outlandish to fear what the invention of a “right to die” will do for the poor, for the disabled, for the vulnerable in our society?

Now, there are genuinely hard cases, of terminally ill people in unbearable pain, and the better side of our human nature wants to do something, anything, to help them. The solution is better healthcare, better social care, better palliative care. It is not to offer them a syringe of the same poison which is used in execution chambers in America and to call it healthcare. That is a perversion of the English language.

The solution is not to create a “right to die” which will inevitably be abused and enable some of the worst human instincts which we thought we suppressed a long time ago.

I urge the House to oppose this motion.

Considering Zhu was given 10 minutes to offer his position, he offered an excellent argument against assisted suicide.

US Drug Enforcement Administration (DEA) tightens regulations on Schedule II controlled substances

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Article: EPC-USA works to prevent assisted suicide by telemedicine (Link).

This is a big victory for preventing assisted suicide by Telemedicine.

The Drug Enforcement Administration (DEA) began a consultation on February 24 on proposed rules for prescribing drugs via telehealth. The proposed rule stated that when a person has not seen a medical practitioner and requires a Schedule II medication or narcotic that the prescription could not be prescribed via telehealth and the patient would be required to see a medical practitioner in person before receiving the prescription.

The proposed rule was important for the assisted suicide issue. The assisted suicide lobby wants to approve a death by lethal drugs without directly meeting with or examining the person and then have the lethal drugs sent to the person by courier.

Kristen Senz reported for The Journalists Resource on April 17 that the DEA approved new guidelines will go into effect on May 1. Senz reported:

Patients being treated remotely with buprenorphine for opioid use disorder, Ritalin for attention deficit disorders, ketamine for depression, or testosterone for gender-affirming care, among other controlled-drug treatments, will need to schedule an in-person exam, either with their telemedicine prescriber or a local provider who is registered with the federal Drug Enforcement Administration, according to the DEA’s proposed rules.

The draft regulations, which were first announced Feb. 24, allow telemedicine providers to initially prescribe 30 days’ worth of select medications, including buprenorphine, testosterone, or ketamine, before an in-person exam is required. Patients taking narcotic pain medication, or common ADD medicines, will need an in-person exam before any new prescriptions can be issued. Patients and providers who established treatment relationships remotely during the pandemic, when in-person exam requirements were temporarily waived, would have 180 days to comply with the new laws.

As the proposed DEA rules state, Schedule II controlled substances will require an in-person visit. Patients being treated for opioid use disorder can be prescribed via telemedicine but they will be required to have an in-person visit within 30 days of receiving a prescription for buprenorphine (Suboxone, Zubsolv, and Sublocade) via telemedicine, to obtain refills.

The new DEA rules are based on reducing the opioid crisis and make it more difficult for people to obtain Schedule II controlled substances for resale.

EPC-USA supports the DEA rules. We support tighter regulations for controlled substances in order to prevent opioid abuse, especially since some of these drugs can be used for lethal purposes.

Plan 75 film Director opposes the legalization of euthanasia.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Cinema daily published an interview by Chiara Spagnoli Gabardi on April 17 with Chie Hayakawa, the director of the controversial film Plan 75, an award winning film at the Cannes film festival.

Hayakawa's Plan 75 is a dystopian criticism of the negative attitudes towards aging and elderly people. If you consider what is happening with Canada's euthanasia law, Hayakawa's concerns should be taken seriously.

The interview is couched under the concept that Plan 75 a film that "expresses support for euthanasia" but Hayakawa states:

C.H : It’s not a film about pro or con euthanasia. There is a motif of assisted suicide, but it’s not a theme of this film. One’s attitude towards how we die is very personal thing, it’s not something I want to judge. By telling this story, I wanted to stimulate the audience’s imagination and compassion to other people’s pain and emotion. I have some understanding and empathy toward people who seek the right to death-in-dignity, but I have doubt about legislating it because there may be certain people who are not allowed to have an alternative choice to death due to social or psychological pressure.

Hayakawa opposes the legalization of euthanasia. Plan 75 is also a commentary on the negative social attitudes towards elderly people. He states:

C.H : TV and the media are spreading fear about being old and creating a potential outlet for people’s anger and complaints about life in an insecure society. People tend to turn their wrath against the elderly not to the government.

Hayakawa continues:

C.H : Yes. That was the point. If I tell a story about people who are suffering from illness, the audience will say, “it’s good for them to have that option.” It will be easily accepted and people will stop thinking further. I want people to imagine and feel compassion to those who have no other option or who take the choice against their will. Also I want them to imagine how distorted our society will be if we have such system like PLAN 75 which is willing to hold out a death option to those who are suffering instead of giving them a helping hand.

The Netherlands have been debating the concept of "completed life" for several years, whereby a person who is 75 could die by euthanasia. The Netherlands Council of State published a report from December 2020, explaining why they rejected a "completed life" bill that was sponsored by the D66 MP Pia Dijkstra. 

Canada's euthanasia law devalues people with disabilities.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Janine Benedet and Isabel Grant, who are law professors at UBC, wrote an excellent opinion article that was published in the Globe and Mail on April 17 titled: Canada’s permissive assisted-dying culture is devaluing people with disabilities. The writers are commenting on domestic murder and how Canada's assisted dying law affected the sentencing of a murder victim who was a woman with a disability.

We know that the home continues to be a dangerous place for women, and that an average of one woman in Canada every week is killed by a current or former male partner. And so, as a society, we are supposed to be taking domestic violence seriously. The Criminal Code has a provision that makes violence against an intimate partner an aggravating factor in sentencing, and another that states that where the victim is vulnerable because of age or personal circumstances, the primary sentencing objectives are denunciation and deterrence.

And yet, in Edmonton last month, a man who killed his wife in 2018 through a lethal injection of insulin was sentenced to just two years of house arrest after pleading guilty to manslaughter.

Why was the deliberate killing of 69-year-old Christiane Belzile by her husband Francois, then 73, treated so leniently? We believe the reason was simple: she was a woman with disabilities.

The lenient sentence was based on the fact that Christiane had a disability. The writers explain:

In 2011, after Mrs. Belzile had a stroke, her husband decided that he would be her sole caregiver, preventing her from receiving care from professionals. But she developed diabetes and dementia and, after a fall in 2018 that led to an infection, Francois told her they had “reached the end.” After the injection, when she stopped breathing, he tried to end his life.

If she had been a woman without disabilities, these actions might have been seen as examples of coercive control in an abusive relationship; instead, a combination of sexism, ableism, and ageism appears to have obscured the fact that she was exactly the kind of vulnerable victim the law must protect.

Instead, the judge accepted that Francois Belzile was suffering from “caregiver burnout” in imposing house arrest, even though Mr. Belzile had already received significant mitigation when the Crown reduced a first-degree murder charge to manslaughter.

The writers explain that Mr Belzile referred to his case as"Latimer Two":

Tracy Latimer

After his arrest, Francois Belzile referred to himself as “Latimer Two,” in reference to Robert Latimer, a Saskatchewan father who murdered his 12-year-old daughter Tracy, who had severe cerebral palsy, in 1993. Mr. Latimer went on to be sentenced to life in prison. Mr. Belzile’s lawyer told the sentencing judge that “the world has changed since Latimer, at least in Canada” – an argument that we believe sounded plausible because of the rapid expansion in Canada of medical assistance in dying (MAID) to persons with disabilities considered to be suffering intolerably, but who are not at the end of their natural lives.

The writers explain how this sentence is based on the disability of the victim.

When MAID was legalized in 2016, Canadians were assured that the law would protect vulnerable people from outside pressure, including from family members, and that it would be limited to those who could express a settled, informed choice to die after exhausting other options at the end of their lives. We were told MAID would protect against the possibility that individuals claiming to be acting out of mercy would take matters into their own hands. But by expanding MAID to those whose death is not imminent, with few safeguards and only a façade of monitoring, we have reached the point that killing can now be passed off as an extension of caregiving in a Canadian court.

Providing care to another human being is demanding work, mostly done by women. It should be better supported and better compensated, with options for assistance from professionals when needed. But a man who chooses to access none of those supports, and makes a unilateral decision that his wife is better off dead, should not be given a lesser charge and a considerable sentencing discount just because she was physically and verbally unable to resist.

The writers conclude:

Disability activists and scholars across Canada have warned in recent years against the expansion of MAID to disabled people who are not dying but are experiencing “intolerable suffering.” They worried that people with disabilities would seek MAID because they are denied the social and economic resources to live decent lives. They feared that people with disabilities would feel pressure to end their lives, and that non-disabled people, including doctors and other professionals, would undervalue disabled lives and normalize the premature deaths of people with disabilities. The legal system’s treatment of the killing of Christiane Belzile signals to us that they were right.

More articles on these topics:

• Canada passes Bill C-7 allowing euthanasia for mental illness (Link).
• Canada's law will provide not prevent suicide for some psychiatric patients (Link).
• Euthanasia for mental illness. Killing people with an uncertain prognosis (Link).
• Abbotsford police investigating euthanasia death (Link).
• Canada is not as advertised. Euthanasia is eugenics (Link).
• Canada's euthanasia law is the most permissive in the world (Link).
• (MAiD) euthanasia for disability and poverty (Link).
• (MAiD) euthanasia for mental illness and poverty (Link).
• Veterans affairs worker advocates euthanasia for PTSD (Link).\
• Abandoning people. Canada's broadening euthanasia laws (Link).
• Mother wants to stop 23-year-old son from dying by euthanasia (Link).
• Bereaved mother speaks out against euthanasia (Link).
• Woman died by euthanasia because of inadequate home care (Link).
• Infant euthanasia proposed by Quebec College of Physicians (Link).
• How poverty not pain is driving people with disabilities to euthanasia (Link).
• Ontario man seeks euthanasia to avoid homelessness (Link).
• Why did they kill my brother? (Link).
• Canada's doctors offer euthanasia before receiving a request (Link).
• Food bank clients asking for euthanasia based on poverty (Link).
• No other options. An expose on euthanasia in Canada (Link).
• Poverty and euthanasia creates public interest but euthanasia is abhorent on its own (Link).

France must resist legalizing euthanasia.

James Schadenberg

Kevin Yuill, who is the founder of Humanists Against Assisted Suicide and Euthanasia and an emeritas professor of American history at Sunderland University, has written a great article that was published in the Spiked on April 13 titled: France must resist assisted dying.

Yuill begins the article with a summary of the results and consequences of France’s “citizen’s convention”, which made recommendations on France's proposed euthanasia framework in early April:

Last September, French president Emmanuel Macron set up a so-called citizens’ convention, comprising over 180 randomly chosen members of the public. They were tasked with answering the question: ‘Is the framework of end-of-life accompaniment adapted to the different situations encountered, or should possible changes be introduced?’ Earlier this month, they delivered their recommendation, with 76 per cent voting in favour of introducing ‘active assistance in dying’ – which could mean euthanasia or assisted suicide.

French law currently prohibits euthanasia and assisted suicide (although it has evolved to allow French residents to refuse medical treatment). But it seems that this ban could soon be overturned. Now, armed with the approval of this citizens’ convention, Macron’s government is drawing up a draft bill on end-of-life care. This will include the potential legalisation of euthanasia or assisted dying.

Yuill claims that the abysmal state of France’s palliative care system plays a role in the increased support of assisted dying legislation. However, many of France’s doctors - the ones who would be tasked with killing people approved for euthanasia - are not only opposed to legalizing euthanasia but believe that allowing doctors to kill their patients would contradict the role of healthcare workers in caring for their patients. Yuill argues that France is legislating euthanasia when their priority should be repairing its palliative care system:

Part of the reason for the increasing support for assisted dying is the parlous state of palliative care in France. Residents in 26 of France’s 101 administrative departments have no access to palliative care whatsoever. In three departments, only one palliative care bed is available for every 100,000 inhabitants. Compare that to Britain, where more than five care beds per 100,000 inhabitants are available. As French academic Anna Elsner explains, ‘If there is no large-scale availability of palliative care, the fear of a “bad death” rises’. It’s this fear, she says, that ‘fuels [the] demand for the legalisation of euthanasia’.

Not everyone is in favour of legalising assisted dying, however. The church objects. As do France’s healthcare workers. The national council of doctors, L’Ordre des Médecins, is strongly opposed to its members helping people end their lives on principle. And a collective of 13 professional associations, which together claim to represent two-thirds of medical-care workers in France, have stated that: ‘Legalising death administered in whatever medical form would turn the concept of care into its opposite.’ This raises the very real prospect of a revolt by medical staff against the legalisation of assisted dying.

The French government should think very carefully before pushing ahead with its end-of-life bill. It may be cheaper for Macron to legalise assisted dying than to improve the palliative care on offer to French citizens. But this would be far from ethical.

Yuill then uses the Netherlands and Canada to show the dangerous consequences of what happens when a country allows doctors to kill their patients by euthanasia:

Moreover, the French government should look at what has happened in other nations that have legalised some form of assisted dying. What begins as an attempt to ease the suffering of those in severe physical pain often morphs into something sinister.

Take the Netherlands, where euthanasia and assisted suicide have been legal since 2002. With the number of euthanasia deaths increasing by about 10 per cent per year, assisted dying has evolved into something approaching a lifestyle choice. Indeed, 29 couples were euthanised together in 2022, after apparently meeting the Dutch criteria of unbearable suffering with no prospect of improvement.

Then, of course, there’s Canada. Since 2015, when assisted dying was introduced, the eligibility criteria for who can access assisted suicide and euthanasia has continually expanded. And as a result, the number of people being granted a medically assisted death has ballooned, from 1,018 in 2016 to 10,064 In 2021. Assisted suicide in Canada was supposed to be a limited practice for only the most serious cases of terminal illness, but it has become an increasingly mainstream intervention in healthcare. As an article in the World Medical Journal notes: ‘[Canada] has now arguably the most wide-open state-facilitated suicide process in the world.’

Yuill is right to point out that if legalized, euthanasia will not be a rare occurrence in France. Canada and the Netherlands demonstrate that safeguards built into euthanasia legislation will soon be removed as euthanasia becomes socially acceptable. The day after this article was released, the Netherlands announced their intention to expand euthanasia to children between the ages of 1 and 12, which clearly illustrates this point.

Once a country opens up the door to death by euthanasia, that door will soon be opened wider. France should listen to their doctors, who recently stated their opposition to euthanasia, and choose the life-affirming solution by fixing its palliative care system rather than allowing doctors to kill their patients through euthanasia.

The Netherlands plans to extend euthanasia to children.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The NLTimes reported on April 14 that the Dutch government has agreed to extend euthanasia to children, under the age of 12. The article states:

Health Minister Ernst Kuipers announced in a press release on Friday that he expects the regulation to be implemented within the year. The new guidelines will probably only apply to about five to ten children annually for whom “life termination is the only viable option to end the child's hopeless and unbearable suffering,” said Kuipers.

This means that the Netherlands government plans to extend the Groningen Protocol, which applies to newborns, to children between the ages of 1 and 12, rather than amending the euthanasia legislation to include children under the age of 12. 

Extending the Groningen Protocol is very concerning because it permits euthanasia of newborns who are experiencing current or possible future suffering. If you use the same definitions for children under 12, there will be euthanasia deaths of children who may have treatable conditions.

In October 2020, Netherlands Health Minister Hugo de Jonge announced that the government was planning to permit child euthanasia. According to the DutchNews.nl:

De Jonge added that current laws would not need to be amended. Rather, doctors would be exempted from prosecution for carrying out an approved euthanasia on a child.

The NL Times reported today that:

Following life termination, a review committee and the Public Prosecution Service will examine whether the procedure was carried out with due care.

This means that the decision will only be reviewed after the child has died.

Following the annoucement in October 2020, an effective campaign opposing child euthanasia in the Netherlands was launched by a group of Netherlands citizens and the Euthanasia Prevention Coalition. A petition with more than 100,000 people opposing child euthanasia.

I am also concerned that the Canadian govenment will decide to follow the lead of the Netherlands and also extend euthanasia to children.

There was a record number of Netherlands euthanasia deaths in 2022 with 8720 reported deaths representing a 14% increase from 2021 and 5.1% of all deaths in the Netherlands. 288 of the 8720 were based on the person having dementia. 

The World Medical Association declared in 1987  a statement that was referred in 2005 stating:

“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.”

More articles on the topic:

• Euthanasia experts advocate for child euthanasia with or without consent (Link).
• New York Times article promotes infanticide (Link).
• Newsweek promotes infant euthanasia (Link).
• Euthanasia of newborns with disabilities and infanticide.
• Dutch paediatricians want to legalise euthanasia for children under 12.
• Euthanasia of babies with disabilities.
• The Groningen Protocol for euthanasia of disabled babies in the Netherlands.

Legalizing euthanasia and/or assisted suicide is morally dubious and extremely dangerous.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Leon Kass

In August 1996 Dr Leon Kass, who was a physician, scientist and educator and later (2001 to 2005) the chairman of the President's Council on Bioethics, wrote an insightful article titled: Dehumanization Triumphant concerning the legalization of assisted suicide. 

Kass accurately predicted the outcome of the legalization of assisted suicide. Kass wrote:

Recent efforts to legalize physician-assisted suicide and to establish a constitutional “right to die” are deeply troubling events, morally dubious in themselves, extremely dangerous in their likely consequences. The legalization of physician-assisted suicide, ostensibly a measure enhancing the freedom of dying patients, is in fact a deadly license for physicians to prescribe death, free from outside scrutiny and immune from possible prosecution. The manufacture of a “right to die,” ostensibly a gift to those not dying fast enough, is, in fact, the state’s abdication of its duty to protect innocent life and its abandonment especially of the old, the weak, and the poor.

Kass recognized that the Oregon Assisted suicide law would give physicians (in some states nurses) the right in law to prescribe lethal drugs with full immunity from possible prosecution. These laws are not about a right to die but rather a right to abandon people at a difficult time in their life. Kass continued:

The legalization of physician-assisted suicide will pervert the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic, mindful that power to cure is also power to kill, has held as an inviolable rule, “Doctors must not kill.” The venerable Hippocratic Oath clearly rules out physician-assisted suicide. Without this taboo, medicine ceases to be a trustworthy and ethical profession; without it, all of us will suffer—yes, more than we suffer now because some of us die too slowly.

The doctor–patient relationship will be damaged. The patient’s trust in the doctor’s devotion to the patient’s best interests will be hard to sustain once doctors can legally prescribe death. Even conscientious physicians will have trouble caring wholeheartedly for patients once death becomes a “therapeutic option.” The prohibition against killing patients, medicine’s first principle of ethical self-restraint, recognizes that no physician devoted to the benefit of the sick can serve the patient by making him dead. The physician-suicide-assistant or physician-euthanizer is a deadly self-contradiction.

Kass recognized that legalizing assisted suicide would undermine the Hippocratic Oath and the doctor-patient trust relationship. This is exactly what has happened. Doctors and nurses who participate in euthanasia or assisted suicide have decided that certain lives are not worth living or protecting. Further to that they have redefined the meaning of Do No Harm. Kass continued:

Physician-assisted suicide, once legal, will not stay confined to the terminally ill and mentally competent who freely and knowingly elect it for themselves. Requests will be engineered and choices manipulated by those who control the information, and, manipulation aside, many elderly and incurable people will experience a right to choose death as their duty to do so. Moreover, the vast majority of those who are said to “merit” “a humane and dignified death” do not fall in this category and cannot request it for themselves. Persons with mental illness or Alzheimer’s disease, deformed infants, and retarded or dying children would thus be denied our new humane “aid-in-dying.” But not to worry. The lawyers, encouraged by the cost-containers, will sue to rectify this inequity. Why, they will argue, should the comatose or the demented be denied a right to assisted suicide just because they cannot claim it for themselves? With court-appointed proxy consentors, we will quickly erase the distinction between the right to choose one’s own death and the right to request someone else’s.

Kass accurately predicted that euthanasia and assisted suicide would begin with the assurances that it would be limited to the terminally ill and mentally competent who freely choose to have their life ended. When considering the Canadian experience with euthanasia, in a few short years the Canadian law went from being limited to people whose "natural death was forseeable" and requiring the ability to consent at the time of death, to allowing euthanasia for people with chronic or disabling conditions who are unable to consent at the time of death. Canada is now considering euthanasia for children, newborns and by advanced consent for people who are unable to consent. Kass continued:

The termination of lives someone else thinks are no longer worth living is now occurring on a large scale in Holland, where assisted suicide and euthanasia have been practiced by physicians for more than a decade, under “safeguards” more stringent than those enacted in the Oregon law. According to the Dutch government’s own alarming figures, there are over one thousand cases per year of direct in voluntary euthanasia; also 8,100 cases of morphine overdosage intending to terminate life, 61 percent without the patient’s consent. Although the guidelines insist that choosing death must be informed and voluntary, over 40 percent of Dutch physicians have performed involuntary euthanasia. As the Dutch have shown, the practice of assisted suicide is in principle unregulable, because it is cloaked in the privacy of the doctor–patient relationship.

In this paragraph Kass was refering to the Remerlink report. This is also a common problem in other countries, but at least the Netherlands did research to uncover the reality. The Netherlands officially legalized euthanasia in 2002 to further regulate euthanasia and control the problem of involuntary euthanasia, but in fact further reports from the Netherlands proved that involuntary euthanasia persisted even after it was officially legalized. Kass continued:

Legalizing assisted suicide would mark a drastic change in the social and political order. The state would be surrendering its monopoly on the legal use of lethal force, a monopoly it holds under the social contract, a monopoly it needs if it is to protect innocent life, its first responsibility. It should surprise no one if physicians, once they are exempted from the ban on the private use of lethal force, wind up killing without restraint. Here, by the way, is a genuine violation of the Fourteenth Amendment: deprivation of life without due process of law.

We must care for the dying, not make them dead. By accepting mortality yet knowing that we will not kill, doctors can focus on enhancing the lives of those who are dying, with relief of pain and discomfort, moral and social support, and, when appropriate, the removal of technical interventions that are merely useless or degrading additions to the burdens of dying—including, frequently, hospitalization itself. Doctors must not intentionally kill, or help to kill, but they may allow a patient to die.

Kass did not comment on the fact that legalizing euthanasia will change the practise of palliative care. Since some palliative care physicians will willingly participate in euthanasia and since many people who request euthanasia are being cared for by palliative care physicians, the demand that palliative care provide euthanasia is the inevitable outcome of legalizing euthanasia. Kass continues:

Ceasing medical intervention, allowing nature to take its course, differs fundamentally from assisting suicide and active euthanasia. Not the physician, but the underlying fatal illness becomes the true cause of death. More important morally, in ceasing treatment the physician does not intend the death of the patient, even if death follows as a result. Rather, he seeks to avoid useless and degrading medical additions to the already sad end of a life. In contrast, in assisted suicide the physician necessarily intends primarily that the patient be made dead.

One cannot exaggerate the importance of the distinction between withholding or withdrawing treatment and directly killing, a distinction foolishly dismissed in the recent Court of Appeals’ decisions. Both as a matter of law and as a matter of medical ethics, the right to refuse unwanted medical intervention is properly seen not as part of a right to become dead but rather as part of a right protecting how we choose to live, even while we are dying.

Kass is completely correct. There is a clear difference between killing and letting die. The Supreme Court of Canada, in its Carter decision, also foolishly dismissed the distinction between killing and letting die. The distinction is always a reality. When a person accepts the limits of life and agrees to the withdrawal of treatment, death is not the result of the withdrawal, but rather the person dies a natural death. Further to that, the person, after having treatment withdrawn, does not always die. But death by lethal drugs (euthanasia) always causes death, and is the cause of death. Kass continues:

Once we refuse the technical fix, physicians and the rest of us can also rise to the occasion: we can learn to act humanly in the presence of finitude. Far more than adequate morphine and the removal of burdensome chemotherapy, the dying need our presence and our encouragement. Withdrawal of human contact, affection, and care is the greatest single cause of the dehumanization of dying. People who care for autonomy and dignity should try to correct this dehumanization of the end of life, instead of giving dehumanization its final triumph by welcoming the desperate good-bye-to-all-that contained in one final plea for poison. Not the alleged humaneness of an elixir of death, but the humanness of connected living-while-dying is what medicine—and the rest of us—most owe the dying. The treatment of choice is and always will be company and care.

Once again Kass is completely correct. Providing pain and symptom management and caring for someone is humane and bolsters the humanity of a person. Caring is a human act, killing dehumanizes the person. When communicating with people who are considering death by euthanasia, I have always found that the reason that they are asking to be killed is different than the reason that they are being approved for death. After explaining their medical condition, once asked, they always talk about their loneliness, their lack of hope, that they feel like a burden on others. All of these feelings require a caring response, not a death by lethal injection.

Thank you Dr Kass.