Canada's euthanasia system abandons people in need under the guise of autonomy.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Diana Duong and Lauren Vogel wrote a commentary on Canada's current (MAiD) euthanasia law that was published in the Canadian Medical Association Journal on April 3, 2023. They write:

Canada is on track to have one of the world’s most expansive assisted dying programs, but concerns about safeguards and clinical standards persist.

More than 31 000 people (as of December 31, 2021) have received medical assistance in dying (MAiD) in Canada since the service became legal in 2016, with the number of recipients growing steadily each year.

They offer old statistics since the federal government hasn't published the 2022 euthanasia data. They then comment on the expanding eligibility for euthanasia:

Canada currently allows MAiD for capable, consenting adults suffering from “grievous and irremediable” conditions, excluding mental illness as a sole underlying condition.

Approvals for MAiD follow two tracks, with expedited access for people whose natural death is foreseeable and a 90-day waiting period for other recipients.

People with mental illness as their sole underlying condition were supposed to gain access to MAiD under the second track this spring. However, the federal government recently postponed that expansion to March 2024.

They comment on the report from Canada's special joint committee on MAiD:

Canada’s special joint committee on MAiD issued a report in February this year recommending the government expand the service to people with mental illness and mature minors, and via advance requests so that people can receive MAiD if they become incapacitated.

The cross-party committee of MPs and senators heard from close to 150 expert witnesses and received more than 350 briefs and other correspondence during six months of consultations in 2022. However, their recommendations were not unanimous, with Conservative members dissenting.

They then comment on MAiD for mental illness:

A recent poll by Angus Reid found that although six in 10 Canadians support MAiD in its current form, only one in three support allowing people to seek MAiD purely based on mental illness.

Uncertainties persist about how to assess if a person with mental illness is capable of consenting, how to distinguish between MAiD requests and suicidal thoughts requiring treatment, and how to determine if the suffering caused by psychiatric disorders is truly irremediable.

However, the special joint committee noted that these challenges aren’t unique to providing MAiD to people with mental disorders or universal to MAiD requests related to mental illness.

Psychiatric MAiD remains rare in other countries that allow it, accounting for 1%–2% of assisted deaths, according to Tyler Black of the University of British Columbia. In the Netherlands, for example, adults have an 8% lifetime risk of suicidal thoughts, yet just 0.0004% receive psychiatric MAiD annually.

“There is simply no credible foundation for the fear that allowing MAiD for psychiatric conditions would create a flood of deaths in Canada,” Black stated.

Whether or not there is a flood of deaths based on MAiD for psychiatric conditions Black clearly misses the point. 

• How can a person be approved to be killed when their condition may be the cause of their suicidal ideation? 
• How can a psychiatrist determine that a person with psychiatric conditions has an irremediable medical condition, meaning he or she will not recover? 
• And how can a person be approved for death for psychiatric reasons when the treatment that they need is both difficult to obtain and might require several different therapies before success is attained?

They then state that the Canadian government remains committed to implementing euthanasia for mental illness:

Even so, the special joint committee raised concerns that “there has not been sufficient time to develop standards of practice” for providing MAiD to people with mental conditions. As such, they recommended the government reconvene the committee later in 2023 to “verify the degree of preparedness” before the law changes in 2024.

The government has appointed an expert group to create MAiD practice standards and is supporting the development of an accredited training curriculum for clinicians by the end of the year.

They then comment on the variation in the interpretation of the euthanasia law.

There is still a lot of variability in the clinical interpretation of MAiD laws, said Madeline Li, a cancer psychiatrist and former head of University Health Network’s MAiD program.

Because the law focuses primarily on patient autonomy, there isn’t much room for clinical judgment, which has led some MAiD providers to approach assessments in a checklist fashion, Li said. “We say, ‘Let’s figure out if you can have it,’ but we don’t back up and say, ‘Let’s talk about whether you’re making the right decision for you.’”

Li recalls the moral distress she felt providing MAiD to a young man with a highly treatable cancer. Seven other clinicians had been uncomfortable with the man’s request, but because he refused treatment, his condition was technically irremediable and thus eligible for MAiD.

“I gave MAiD against my clinical judgment because I will always do what’s in the best interest of a patient if they have made a clear and reasoned decision,” Li said. However, she described feeling “stuck” because, unlike other countries, Canada doesn’t require patients to try alternatives to MAiD — only to consider them seriously.

Moreover, Li said, the law doesn’t require clinicians to meaningfully discuss a patient’s desire for death or the societal factors that may contribute to their request. Practice guidelines and training can emphasize the importance of these discussions, but unless they’re enshrined in law, they’re ultimately optional.

Madeline Li brings up some very important points. Canadians are not required to attempt effective treatment before being killed by euthanasia. A study of people with lung cancer showed that some people were died by euthanasia without first confirming their diagnosis and without attempting effective treatment. Therefore people who have a condition that may be cured are dying by euthanasia.

The authors then comment on some "wrongful" deaths by euthanasia.

Canada has already seen cases of people seeking MAiD owing to a lack of disability support, inadequate housing, or fears of homelessness. Meanwhile, at least four veterans have reported feeling pressured to consider MAiD by a federal caseworker who has since left their position.

“We have learned that as you expand MAiD… it switches from being initially something that was compassionate relief for end-of-life suffering to facilitating suicide for ending life suffering, and that’s very different,” says Sonu Gaind, chief of psychiatry at Humber River Hospital and a professor at the University of Toronto’s Temerty Faculty of Medicine.

They then quote Jocelyn Downie who stated that extending euthanasia to people with psychiatric conditions, alone, was not an extension of the law but a recognition that the Carter Supreme Court decision already granted it.

Downie is the most pro-euthanasia academic in Canada and is wrong about Carter. Carter approved euthanasia for physical and psychological suffering, but not for psychological suffering alone.

The authors then outline the issue of euthanasia for "mature minors."

Looking beyond competent adults, the special joint committee recommended the government allow MAiD for minors with terminal illnesses who are deemed capable of making the decision, with no minimum age limit.

Very few jurisdictions allow MAiD for minors, with the Netherlands allowing access for those aged 12 and older and Belgium setting no minimum age so long as the child has the capacity to make the decision.

Some witnesses pointed out that minors in Canada already make decisions about withholding or ceasing treatment, even when those decisions may hasten death, while others felt the decision to seek MAiD was too weighty for minors to make.

It is true that "mature minors" have the right to make medical decisions for themselves, but it is also recognized that the nature of their consent is different than the consent offered by a fully competent adult.

The authors then outline the issue of euthanasia by advanced request.

Under Canada’s current MAiD laws, people with a terminal illness who have arranged for MAiD on a particular day but become incapacitated beforehand can still receive the procedure if they don’t demonstrate refusal or resistance.

However, the special joint committee heard that this puts pressure on people to arrange MAiD sooner than later, and MAiD providers remain hesitant to administer the procedure without explicit consent.

The committee recommended the government allow people diagnosed with serious and incurable conditions leading to incapacity to make advance requests setting out the conditions under which they would want to receive MAiD.

While the committee noted strong support for the measure, some witnesses raised concerns about difficulties interpreting advance requests and the potential for coercion and abuse.

Among other safeguards, witnesses emphasized the importance of periodically reaffirming advance requests for MAiD, sharing the documents with family and health providers, and including clear, observable criteria for triggering the request, such as being bedridden or unable to eat.

Similar to the issue of "mature minors" euthanasia based on an advanced request can't assure that the person hasn't changed their mind, and furthermore, a person who has become incompetent has no legal ability to change their mind. Euthanasia by advanced request changes the nature of consent and opens the door to euthanasia without consent.

The authors complete their article by commenting on Bill 11 in Quebec.

The committee also recommended that legislators look to Quebec’s experience for guidance. The province recently tabled legislation to allow people with serious and incurable illnesses to make advance requests for MAiD.

Under Bill 11, advance requests for MAiD must be free and informed, notarized in the presence of witnesses, and clearly describe the level of suffering a person deems intolerable. Capable patients can withdraw their requests at any time, and two professionals must sign off before an incapacitated person receives MAiD per an advance request.

The bill would also require palliative care hospices to offer MAiD, as some hospice patients are forced to take ambulances to other facilities to receive the procedure.

Quebec Bill 11 will permit euthanasia by advanced request and it will force palliative care and hospices to participate in euthanasia, against the conscientious objections of the staff or the facility.

Canada is heading into the abyss of unabatted killing. As Madeline Li admits, the decisions to kill or not to kill are based on patient autonomy. When euthanasia for mental illness alone is added to the acceptable criteria, it will mean that people with suicidal ideation, related to their treatable mental condition, will be able to die by euthanasia. Further to that, in our current situation, people are dying by euthanasia even though their medical condition might have an effective treatment, since the law does not require a person to first attempt treatment. Finally, we already have people with disabilities, and others, who are seeking euthanasia based on issues related to poverty, homelessness and an inability to receive effective medical treatment.

Sadly Canada's euthanasia law abandons those in need under the guise of autonomy.