Few topics cause more impassioned debate than euthanasia. Ill people with no other options, suffering beyond a point they wish to bear, make a strong case that they should be allowed help to end their lives. On the other hand, establishing clear, consistent, ethical rules to govern where, when and how physicians might be involved in ending lives, rather than saving them, is inherently difficult. People of good will can disagree as to what compassion requires.
In recent years, a handful of countries have authorized medically assisted dying in the form of lethal injections or other interventions administered actively by physicians. In the United States, assisted dying still takes only the comparatively passive form of “physician-assisted suicide,” in which doctors prescribe a lethal dose of medications for self-administration. The practice is lawful in 10 states and in D.C. We have supported limited assisted dying programs of this kind.
The expansion of euthanasia Canada is currently contemplating, however, goes too far. The country already has one of the world’s most permissive euthanasia regimes, which empowers patients to seek “Medical Assistance in Dying” (MAID) — a practitioner-administered lethal injection — for physical conditions they deem unbearable, whether terminal or not.
And on March 17, barring a last-minute change in government policy, Canada will authorize MAID upon the request of patients whose only illness is a psychiatric one, such as depression or schizophrenia.
Advocates frame this as an advancement for patient autonomy and equal rights for the mentally ill. In fact, it would risk the lives of vulnerable people who, by definition, might have trouble assessing reality and whose symptoms and conditions are notoriously difficult even for experts to specify. There might, indeed, be mentally ill patients suffering from symptoms so debilitating and intractable that their options are uniformly dismal. But designing a system to distinguish them reliably from others in mental distress, who would benefit from treatment, is at least extremely hard, if not impossible.
Certainly, Canada’s system is not up to the task. Its MAID regulations are looser than those of Belgium and the Netherlands, where psychiatric euthanasia has been lawful since 2002 — and where serious concerns have arisen about that practice. Since Canada legalized euthanasia in 2016, some 44,958 Canadians have been granted permission to receive MAID for terminal or “grievous and irremediable” medical conditions.
Most of these cases have occurred in the past three years, with each year seeing an increase of 30 percent or more. Authorities rejected only 3.5 percent of written requests for euthanasia in 2022. Last year, Quebec’s top end-of-life care regulator decried rampant noncompliance with the rules in that province. If a medical provider rejects a request, nothing prevents Canadians from shopping around for another who will say yes.
Mental suffering can indeed be as real and, to those in the grip of it, as subjectively unbearable as the pain of other types of disease. However, empowering a mentally ill person to invoke a physician’s aid in ending his or her suffering — by ending life itself — inverts the most basic goal of psychiatry, which is to prevent suicide rather than to facilitate it. Many in the grips of psychiatric distress view, temporarily, suicide as their only way out, only to later be grateful they did not kill themselves in the depths of their suffering.
The American Psychiatric Association’s official policy is that psychiatrists “should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.” Two other English-speaking countries that allow assisted death, Australia and New Zealand, exclude purely psychiatric cases. Many Canadian mental health professionals have argued offering MAID to those with psychiatric illness is especially unwise in a country whose mental health system struggles to provide treatment to all who need it. The Canadian Association for Suicide Prevention opposes it.
Last month, Canadian Justice Minister Arif Virani said the government of Prime Minister Justin Trudeau has the “option” to delay implementation further, pending a report on the issue from a parliamentary commission due Jan. 31. This was a welcome sign of second thoughts, however belated.
No doubt Canadian advocates mean to enhance individual freedom and equality as between those with physical and mental illness. Perhaps they have high confidence in the procedures they’ve developed to control psychiatric euthanasia. They need to remember that no procedural protections are perfect — and building them for psychiatric euthanasia is a profound challenge.
Good intentions tend to have unintended consequences. In the United States, Americans need to keep a close eye on their neighbor’s experience, and learn from it’
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