Bioethicists: ‘Terminally Sedate’ People Committing Suicide by Self-Starvation

This article was published by National Review online on May 25, 2026.

Wesley Smith

By Wesley J Smith

In a newly released paper in the prestigious journal Bioethics, three prominent bioethicists argue that when someone decides to commit suicide via self-starvation and dehydration — known in euthanasia movement parlance as “voluntary stop eating and drinking” (VSED) — doctors should be allowed to “terminally sedate” the person trying to die when necessary to prevent intractable suffering.

Patients who commit VSED are often not terminally ill. In fact, euthanasia organizations promote self-starvation to the elderly who are not dying and as a means of becoming eligible for assisted suicide where it is legal by making oneself “terminal” via lack of sustenance.

VSED must be distinguished from the common circumstance when actively dying people stop eating. That’s a natural process and often peaceful because the body cannot assimilate food as organs shut down. VSED, in contrast, deprives the body of sustenance it needs to remain alive toward the end of causing death, i.e., it is a suicide method.

Without palliation, many people attempting VSED would abandon the attempt. The bioethicists know this and claim that once the decision to commit suicide is made, doctors are duty-bound to medically ameliorate the suffering that inevitably results:

If a patient is adamant in their refusal of food and water, the same physician must respect the competent refusal by not force‐feeding the patient and should offer standard palliative care, as they would for any other dying patient. Medical support for patients undertaking VSED should be adequate and proportionate to their symptoms, as per any other form of palliative care. This is arguably not assisted suicide.

No, it is precisely that. First, but for the self-starvation, many people who undertake VSED would not be dying. Second, palliation permits the patient to complete the suicide that would otherwise be abandoned. Hence, the palliating doctor is facilitating the patient in becoming dead, i.e., it is a form of suicide assistance.

The authors acknowledge that if a doctor’s assurance of palliation factors into the decision to undertake VSED, that could be deemed assisted suicide:

We acknowledge that there may be some cases in which combining these two practices could amount to assistance in suicide. Jox et al. identify two key factors which, if present, arguably classify VSED cases as assisted suicide: (a) the promise of medical assistance is instrumental to the individual’s decision to pursue VSED, and (b) the physician shares, at least in part, in the individual’s decision to pursue VSED (amounting to some level of encouragement).

The authors next argue that VSED patients should be allowed to be rendered permanently unconsciousness if experiencing “refractory delirium”:

We propose the following criteria for VSED with TS in the setting of refractory delirium:
1. The patient is experiencing unbearable suffering.
2. The patient has lost decision‐making capacity.
3. The patient has previously stopped all fluids.
4. The patient has previously indicated that they would not wish for fluid to recommence if delirious.
5. Other measures to address confusion/distress have been attempted (or refused in advance), such as antipsychotics.

Ah, the old “strict guidelines protect against abuse” scenario.

Let’s discuss this in the real world. Strict restrictions rarely stay strict. For example, needle “exchange” to prevent the spread of HIV eventually slouched into outright needle give away, no used syringes required.

The same kind of slippage would happen if sedating people committing VSED were allowed. Eventually, such drugging would become a standard technique, its availability amplified by assisted suicide advocates.

The authors’ answer to this objection? Let doctors predetermine whether to facilitate the suicide with sedation:

We believe that this harm can be reasonably mitigated through a thorough pre‐assessment of individuals requesting VSED. Prior to initiating physician involvement in the VSED process, physicians should seek to confirm that the individual (a) has decision‐making capacity, and (b) expresses a genuine intention to end their life. This pre‐assessment should also seek to confirm that the individual is fully informed, their decision is voluntary, their decision is consistent with their known values, and that the individual is free from mental illness compromising their decision.

Wait: The authors wrote earlier that when “the promise of medical assistance is instrumental to the individual’s decision to pursue VSED, and “the physician shares, at least in part, in the individual’s decision to pursue VSED (amounting to some level of encouragement),” that it would amount to assisted suicide. Pre-assessment would fit those very criteria, no?

So, we see the slippery slope slip-sliding away in the very article calling for allowing sedation under strict guidelines to prevent abuse. If this proposal is implemented, the next step will be to quit beating around the bush and get on with the lethal jabs.

Why write about this, Wesley? Articles in professional journals are a means of constructing future public policy and people need to be warned about what is being planned before it is imposed from on high. Or to put it another way, these issues are too important to be left to the bioethicists.

Aunt Mary's Voice - A woman with Cerebral Palsy dies by dehydration.

[Names are withheld based on the privacy of the family.]

As proposals come forward for amending federal legislation to expand access for Canadians to medical assistance in dying, it is important to be educated about palliative care and how to maintain respect for life from beginning to natural death especially for the most vulnerable, those with physical disabilities who are deserving of assisted living not assisted death.

This is the story of very special woman who, because of her disability, was denied, by both her immediate family and the physicians in charge, the same “latitude and treatment” that would be given to someone else her age who was not physically disabled. Instead, our Aunt Mary was denied IV (food and water), medical investigative tests, and simply sedated to death. A person can survive 8 to 15 days without fluids, and on the eighth day of forced sedation and dehydration our beloved Aunt Mary left this world.

Legalizing Euthanasia: What we can learn from the Netherlands

Alex Schadenberg

Exeuctive Director, Euthanasia Prevention Coalition

Leo van Doesburg with The European Christian Political Movement (EPCM) and Diederik van Dijk with the NPV-Zorg voor het leven (NPV-Care for life) published a thorough article titled: Legalizing Euthanasia: What we can learn from the Netherlands, in response to the growing number of countries debating euthanasia and the growing practise of euthanasia in the Netherlands. (Link to the article).

Since the article is 20 pages, I have published the conclusion and I encourage people to read the full text (Link to the article).

Conclusion:

When the euthanasia law was adopted in 2001, it focused on persons who were terminally ill. As this publication showed, once the law was introduced, the grounds for performing euthanasia in the Netherlands have been broadened, becoming available to more and more groups of people.The arguments used were: ‘compassion’ (“it is better for him/her to die than to suffer any longer”) and ‘personal autonomy’ (“death is a personal matter; if someone wants to die, they should be helped”). This situation is, in our view, threatening because: 

1. Legal euthanasia undermines the idea that killing another person is bad. The legalization of the act of killing, shows a kind of justification. Particularly for those who are not able to make decisions for themselves, the following question needs to be answered: can we make life or death decisions and judge about the value of life of another human being? 

2. Legal euthanasia undermines the equality of people. Some groups are considered ‘suitable’ for euthanasia, while for other groups, we invest money in suicide prevention. What is the message given to the groups that are seen as ‘suitable’? For example, the discussions about the ‘completed life ending’ may indirectly emotionally press the elderly think about the possibility to terminate their lives. 

3. Vulnerable people become even more vulnerable. Having euthanasia as an option can lead people to harbor ideas of death which might be fanned further by the family, causing (indirect) pressure. Applying euthanasia for incapacitated people ignores the right of life for everyone. It also disregards the prerequisite ‘on request’, which initially was the cornerstone of the Dutch euthanasia law. The role of a government is to protect the vulnerable and to seek solutions to improve the quality of life of those who suffer, not to end their life. 

4. The ‘slippery slope’ has become a reality in the Netherlands. The reasoning “it is not fair that euthanasia is available for that group, but not for another group” is often mentioned (e.g., recently in the discussion for children aged 1-12). This shows that once legalized, euthanasia is difficult to be contained to one group of people. Numbers of euthanasia cases are growing every year, also for ‘special’ groups, like people with dementia or psychiatric disorders. 

5. Euthanasia has become normalized in Dutch culture. 99% of the Dutch citizens know what ‘euthanasia’ is, while only 53% know what ‘palliative care’ is.This has far-reaching consequences: 11% of Dutch citizens are afraid to get euthanasia in a secret way.

As a conclusion, we see that, although human dignity arguments were used to legalize or broaden the provision of euthanasia, in reality the human dignity of the vulnerable is in danger. Death is the opposite of life. We should not use the argument for dignity to assist people in dying, but focus on helping people to live. Therefore, it is imperative to invest in initiatives which alleviate loneliness in the elderly or isolated people and to fund good palliative care. It is our duty to protect the vulnerable among us against the dangers stemming from the expansion of access to euthanasia.

Child euthanasia comes to the Netherlands

This article was published by First Things on October 21, 2020

Wesley Smith

By Wesley J Smith

Once a society accepts the noxious notion that killing is an acceptable answer to human suffering, the definition of “suffering” never stops expanding.

The history of euthanasia in the Netherlands proves that maxim. The Dutch have allowed doctors to kill sick patients since the ’70s, taking an approach of quasi-decriminalization. Euthanasia was formally legalized in 2002. Over the decades, Dutch doctors “progressed” from euthanizing the terminally ill who ask for it, to the chronically ill who ask for it, to people with disabilities who ask for it, to the mentally ill who ask for it, and even to people with dementia who are unable to ask for it (as long as they left written instructions requesting it). The Dutch have also conjoined euthanasia with organ donation, creating a utilitarian impetus for lethal injection for both despairing patients and society. There have even been joint euthanasia killings of elderly couples who don’t want to experience the grief of widowhood.

*Sign and share the Petition opposing child euthanasia in the Netherlands (Link).

Now the country is getting ready to allow little children to be euthanized. When euthanasia was first legalized, 16 was the age limit. Later, it was lowered to 12. Now, the government is proposing legislation that will allow pediatric euthanasia starting at age 1. From the NL Times story:

For the children referenced in the new policy, doctors are only allowed to give palliative care, like sedation, or withhold nutrition over an extended period of time until the patient dies. Doctors describe this as “a gray area” between normal palliative care and active life termination, he said, and they have been calling out for more regulation. . . . [Health Minister Hugo] De Jonge said his proposal will protect the interests of children, and will afford more transparency to the “gray area.”

Four points bear making here. First, the story notes that young children can already be killed via slow-motion euthanasia, known in bioethics parlance as “terminal sedation.” Unlike legitimate pain control, terminal sedation aims to cause death by keeping the patient in an artificial coma and withholding all sustenance until the patient dies of dehydration (thirst) in about two weeks. This is not the same procedure as “palliative sedation,” an ethical pain-controlling technique that puts the patient into lesser or deeper levels of sedation as the patient requires. The purpose of palliative sedation is to maximize the patient’s comfort. In such cases, death comes naturally from the underlying condition—not from the sedation or withheld food or water.

Second, given the steady expansion of euthanasia eligibility in the Netherlands over the years, there is no reason to believe that the “terminal diagnosis” restriction will be followed—much less stick—for long. Some mentally ill people who are killed would otherwise live a normal lifespan, but that fact has been used as a justification for killing because it means the patient could experience many years of suffering.

Third, doctors already euthanize terminally ill and seriously disabled babies—that is, they commit infanticide—thanks to a bureaucratic checklist known as the Groningen Protocol. If a three-week-old baby with, say, spina bifida can be killed in the Netherlands without legal repercussions, eventually it will be permissible to kill children who become seriously disabled (particularly if the disability is cognitive).

Finally, the Dutch frequently justify expanding euthanasia eligibility by claiming they are merely coloring in “gray areas” to permit greater certainty and transparency. Yet these redefinitions of the law only go in one direction—increasing the number of people eligible for lethal injection. Besides, transparency does not transform an act that is immoral into somehow being moral. It just makes the entire society complicit.

The Netherlands won’t be the first country to permit child euthanasia. Belgium removed all age restrictions a few years ago. We know, based on government reports, that children as young as nine have been killed by doctors. One assumes their parents gave the go-ahead. But children are not so many pets to be put down when the owners think the time has come.

Pediatric euthanasia may soon come to this side of the Atlantic. Canada permits lethal injection euthanasia for adults—known as “medical assistance in dying” (MAID). As the country is preparing to expand its eligibility criteria, some hope that will include children—perhaps without parental consent. An article published last year in the Journal of Medical Ethics supported pediatric euthanasia. It was written by doctors who practice at a Toronto children’s hospital. Since Canadian children considered sufficiently mature may legally refuse life-extending care without parental consent, the doctors wrote, they should also be allowed to request a lethal injection. From “Medical Assistance in Dying at a Paediatric Hospital”: 

If . . . a capable [legally underage] patient explicitly indicates that they do not want their family members involved in their decision-making, although healthcare providers may encourage the patient to reconsider and involve their family, ultimately the wishes of capable patients with respect to confidentiality must be respected. If we regard MAID as practically and ethically equivalent to other medical decisions that result in the end of life, then confidentiality regarding MAID should be managed in this same way.

Can you imagine visiting your sick child, only to learn that hospital doctors killed her without your knowledge or consent? The rage and agony would be unimaginable.

So what is the bottom line? Once a society embraces killing as an acceptable answer to human suffering and redefines assisted suicide as a “medical treatment,” the culture’s entire mindset shifts. Helping suffering people live ceases to be the overriding objective: These patients are rarely offered suicide prevention. Instead, death becomes the imperative, and not just for adults but eventually for sick and disabled children too—perhaps with organ donation thrown in as a plum to society.

It’s all so disheartening. As Canadian journalist Andrew Coyne once wrote about the growing popularity of euthanasia: 

“A society that believes in nothing can offer no argument even against death. A culture that has lost its faith in life cannot comprehend why it should be endured.” 

When the euthanasia death angel comes for children, who can say he is wrong?

Wesley J. Smith is a senior fellow at the Discovery Institute. His latest book is Culture of Death: The Age of “Do Harm” Medicine.

The Netherlands debates child euthanasia and "completed life."

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Netherlands government is debating the expansion of their euthanasia law to include children (1 - 12 years) and people who are not sick or dying but believe that their life is "complete."

Once euthanasia becomes legal the laws seem to expand over time.

The NL Times reported that the Netherlands Coalition government is fighting over a proposal to extend the euthanasia law to include children. According to the NL Times:

The Rutte III cabinet is clashing over a plan to allow doctors to provide euthanasia for terminally ill children between the ages of 1 and 12 who are suffering unbearably. The D66 and VVD support this plan. But the Christian parties, ChristenUnie in particular, are vehemently opposed, AD reports.

The Netherlands euthanasia law permits euthanasia for children as young as 12, so long as the parents or guardians have consented and after the age of 16 the person can consent to euthanasia themselves. The NL Times reported:

According to AD, doctors are only allowed to give palliative sedation to children in this age group, or allow them to die by withholding nutrition, which can be a lengthy process.

Last year the government had a report drawn up to feel out support for euthanasia for terminally ill children. A large part of doctors, parents and a majority in parliament, including the VVD and D66, were in favor. The report also showed that there are a handful of cases per year of children suffering unbearably and hopelessly while they wait for their illness to take them.

Earlier this year, a bill to extend euthanasia in the Netherlands to people who are healthy, but "tired of living" was submitted by Pia Dykstra (D66 party). An article in the NL Times reported that: 

The legislative proposal allows people over the age of 75 who feel that they have come to the end of their life and have a persistent wish to die to ask for euthanasia.

Euthanasia laws seem to naturally expand over time. Once you allow killing for one reason, there becomes many reasons to kill. Canada is experiencing the same contagion as it debates Bill C-7, a bill to expand Canada's euthanasia law.

Analysis of Canada's 2019 MAiD Annual Report

This article was published by Toujours Vivant - Not Dead Yet on Sept 8, 2020.

By Amy Hasbrouck, Director Toujours Vivant - Not Dead Yet.

Does the MAiD Program shown in the first annual report meet the Supreme Court’s requirements?

In July of 2020, Health Canada issued the first annual report on Medical Assistance in Dying (MAiD) using data drawn from the monitoring system that went into effect in November of 2018. The report covers MAiD provided throughout Canada during the 2019 calendar year.

Before we talk about the substance of the report, it’s important to remember that, in the 2015 Carter decision, the Supreme Court of Canada said that protecting vulnerable people required “a carefully-designed system imposing stringent limits that are scrupulously monitored and enforced.” Yet as Alex Schadenberg of the Euthanasia Prevention Coalition has pointed out, the law has no method for families to appeal a determination of eligibility they believe is wrong.

• Canada's MAiD report: 26% increase in 2019 euthanasia deaths. The hidden story of abuse (Link).
  

Further, Health Canada has denied any responsibility to ensure compliance with the MAiD law’s safeguards. In the final regulation, Health Canada says: “[Monitoring] is fundamentally distinct from a process that seeks to assess individual medical or nurse practitioners’ compliance with the Criminal Code exemptions. Investigating instances of non-compliance with the eligibility criteria and procedural safeguards set out in the Criminal Code falls outside of the scope of the federal monitoring regime, and is under the purview of local law enforcement.” If Health Canada offloads compliance onto local law enforcement, how does Health Canada propose to ensure that the law is “scrupulously monitored and enforced”?

On page 17 of the report, Health Canada says that “all cases of MAiD are captured.” But that’s not the same thing as saying that all euthanasia deaths were reported. The report doesn’t include deaths by Continuous Palliative Sedation (CPS), euthanasia that doctors didn’t declare, or other life-ending acts without explicit request. There are no eligibility criteria, approval process or safeguards to be met for continuous palliative sedation. Studies in jurisdictions where euthanasia is legal which traced the cause of all deaths during a certain period of time have found that many euthanasia deaths were not reported, even when the doctors knew they were performing euthanasia. As well, Québec’s monitoring system, which has a two-track verification design, has consistently shown that doctors are not reporting all euthanasia procedures they perform. Nor does Health Canada discuss how many reports contained incomplete or inaccurate information, or how these were corrected. Thus, Health Canada may have reported all the MAiD declarations they received, but they didn’t count all euthanasia deaths.

At the same time, Health Canada admits there remain “data gaps.” They point out that, because an oral request can start the eligibility determination process, “many assessments for MAID are taking place with the written request only being completed once a finding of eligibility has been determined or a date for MAID has been established.” Thus the number of written requests reported in 2019 (7,336) is probably substantially lower than the real number of people who asked for euthanasia, because those who are determined ineligible upon making an oral request are not counted by the monitoring system. As well, not all requests that pass through MAiD case coordination or referral systems are captured because some employees of such services are not required to file MAiD reports. Nor does Health Canada document the role of euthanasia advocacy groups in facilitating MAiD approvals and procedures.

The report uses two different figures for the number of MAiD deaths being reported, which creates some confusion. In footnote 1, Health Canada says: “When all data sources are considered, there were a total of 5,631 MAID deaths in Canada in 2019. This includes 242 MAID deaths that were reported voluntarily by the provinces and territories. The detailed analysis on requests for MAID (7,336 written requests), and cases of MAID (5,389 provisions), are available only for the reports collected through the federal monitoring system (for requests received on or after November 1, 2018).” A clarification is provided on page 16. “[A]ggregate data for MAID deaths in 2019 is based on two data elements: MAID provisions in 2019 resulting from a written request prior to November 1, 2018, and data collected under the Regulations for the period January 1, 2019 to December 31, 2019.” So if a person asked to die before November 1, 2018, and was euthanized after January 1, 2019, their death was counted in 2019, but was not subject to the new monitoring system’s reporting requirements. This was the case for 242 people.

Of the 7,336 written requests for MAiD in 2019, 1,947 (26.5%) did not result in euthanasia.

• 1,113 (15.2%) died before approval or euthanasia 
• 571 (7.8%) were deemed ineligible due to:
  
  • lack of capacity – 184* (32.2%),  
  • natural death was not reasonably foreseeable – 159 (27.8%),  
  • not in an advanced state of irreversible decline – 134 (23.5%)
    

• 263 (3.6%) requests were withdrawn.

There were 5,631 MAiD deaths in 2019 (including 242 requested before November 1, 2018)

• Accounted for 2% of all deaths in Canada (ranging from .3% of deaths in NL to 3.3% in BC) 
• All but a handful (< 7) were by euthanasia.  
• Total since 2016 = 13,946
  

*These numbers are estimates based on the percentage of 571 people found ineligible. The report did not provide the exact figures.

The annual report reflects corrections and adjustments to the statistics given in the interim reports. The number of MAiD deaths has increased each year.

• 1,015 in 2016 
• 2,833 in 2017
• 4,467 in 2018 = 58% increase over previous year,
• 5,631 in 2019 = 26% increase over previous year.
  

On page 19, Health Canada explains the small number of assisted suicides by saying “providers are less comfortable with self-administration due to concerns around the ability of the patient to effectively self-administer the series of medications.” They do not talk about the individual’s choice, nor the apparent conflict between the idea of MAiD as a form of self-determination, and the small number who choose the more autonomous option of assisted suicide. This is important because, according to Statistics Canada, intentional self harm (suicide) was the 9th leading cause of death in Canada in 2018,** accounting for 3,811 deaths, whereas MAiD accounted for 4,467 deaths in 2018. But because MAiD isn’t counted either as suicide or as a separate “cause of death” it doesn’t take its place as the 9th leading cause of death in the country. In 2019, MAiD accounted for 2% of all Canadian deaths.

**The 2019 statistics are not available.

The monitoring system did not collect crucial demographic information that would show the impact of discrimination, economic and social pressures on requests to die. Health Canada is not tracking information about the person’s race, ethnic background, income, indigenous status, sexual orientation, disability status, first language, or other grounds of discrimination. Indigenous and racialized Canadians have been calling for accurate data collection to document racism in the health care system for decades, and we raised the issue in our comments on the draft monitoring regulations. As well, though the monitoring system collects data on where euthanasia was performed, it doesn’t ask about the person’s living situation when the request is made.

There are three “catch-all” categories in the section on underlying medical conditions (4.1) that total 19.8% (or 1,067) of all cases; “Multiple Comorbidities,” “Other Condition” and “Other Organ Failure.” An explanatory note says that: “other conditions” includes “a range of conditions, with frailty commonly cited.” When “miscellaneous” medical conditions make up 20% of cases, and include non-terminal conditions such as frailty, something smells fishy.

As we observed in our comments on the draft regulations, the monitoring system does not collect data on whether suicide prevention services were provided in response to requests for MAiD. The data in Section 4.3 regarding palliative care and disability support services gives no indication what services were provided, or whether the services met the person’s needs. Health Canada reports that 82% of people received palliative care, and 89% of those who needed them received disability support services. The authors conclude these findings: “seem to suggest that requests for MAiD are not necessarily being driven by a lack of access to palliative care services,” (p. 24) though they admit that “the data … [do] not speak to the adequacy of the services offered.”

Without suicide prevention intervention, or effective palliative care and disability support services, a person’s consent to euthanasia cannot be voluntary, capable, and free of external pressure.

A few items worth noting about who provided MAiD, and where it occurred:

• The monitoring system doesn’t record the medical specialty of the practitioner who provides the written second opinion. 
• While 20.6% of euthanasia were performed in “palliative care facilities” (p. 27) only 9% of MAiD practitioners were palliative care specialists. 
• As Richard Egan pointed out in his analysis of the Canada report, “Despite two thirds of cases with cancer as the underlying condition, only 1.7% of clinicians administering euthanasia gave their specialty as oncology.” 
• Mr. Egan also notes that even though euthanasia is not allowed for psychiatric conditions, 1.2% of euthanasia were administered by psychiatrists.
  

In its introduction to data on the kind of suffering reported by people asking to die (Section 6.1), Health Canada claims: “It is not the practitioner’s interpretation of the intolerability of an individual’s suffering; only the individual requesting MAID can determine whether their suffering is unbearable.” Yet there is ample evidence that medical professionals’ negative views of disability do affect how people value their disabled lives. This is why peer support is so essential to adapting to aging, chronic and degenerative illness and disability.

“Nature of suffering”

• Loss of ability to engage in meaningful life activities – 82% 
• Loss of ability to perform activities of daily living – 78% 
• Inadequate control of symptoms other than pain (or concern about it) – 56%  
• Inadequate control of pain (or concern about it) – 54%  
• Loss of dignity – 53%  
• Perceived burden on family, friends or caregivers – 34%  
• Loss of control of bodily functions – 32%  
• Isolation or loneliness – 14%  
• Emotional distress/anxiety/fear/existential suffering – 5% 
• Loss of control/autonomy/independence – 4% 
• No/poor/loss of quality of life – 3%
  

The medical practitioner is responsible for ensuring compliance with the law’s safeguards; the only “proof” that safeguards were met is the clinician’s opinion and assurance to that effect. Of course, nearly all clinicians said they asked the person what they wanted, but did that conversation take place privately, away from the influence of family or others who might sway the decision? One telling statistic is that only 14% of practitioners based their determination of the voluntariness of the person’s request on prior knowledge of the person. This suggests that few providers had the deeper knowledge that comes of long-standing relationships with the people they were assessing for eligibility to die.

The questions and concerns raised by this first annual report lead us to believe that Canada has not met the Supreme Court’s mandate to create “a carefully-designed system imposing stringent limits that are scrupulously monitored and enforced.” 

Amy Hasbrouck is the President of the Euthanasia Prevention Coalition

Pandemic palliative care protocol. Selecting people to die and abusing the purpose of palliative care.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of certain resources are limited then decisions are made which are often unjust and lack equality.

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment.

In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care.

A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment.

A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.

Diane Coleman, Not Dead Yet.

People with disabilities genuinely fear that they will not be considered "worthy" for treatment, even when the benefit of the treatment is recovery. Further to that, some people with disabilities already require ventilator support to live. Should these people be denied ventilator support or have it withdrawn against their needs and wishes simply because another person requires a ventilator?

Pandemic palliative care: beyond ventilators and saving lives.

The CMAJ (March 31) published a protocol on the care of Covid-19 patients who are being withheld or withdrawn from treatment titled: Pandemic palliative care: beyond ventilators and saving lives. The authors of the protocol include Dr James Downar, the former chair of the Dying with Dignity Physician Advisory Committee and Dr Sandy Buchman, President of the Canadian Medical Association.

Read: Euthanasia doctor developed Ontario Covid-19 triage guidelines (Link).

The authors are asking for a response to the protocol. This is my assessment.

The protocol claims to be based on fairness and equality, but actually institutionalizes the inequality and injustice that lead to people with disabilities and other vulnerable groups being selected for death based on negative and discriminatory attitudes.

The protocol states:

Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill. Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity.

This statement tells us not to have blanket statements in our healthcare directive requiring comfort measures only. Certain medical conditions may lead to recovery with treatment, but with the above wording, no treatment will be provided.

This statement is also unethical. Withdrawing a ventilator is a treatment decision that requires consent from the patient or the power of attorney. Decisions to withdraw treatment are treatment decisions that in some jurisdictions require consent in the same manner as decisions to provide treatment. 

People with disabilities who require a ventilator fear that decisions will be made to extubate them because their health condition is not clinically improving. People with disabilities may not "clinically improve" not because they are treatment resistant but because of the nature of the disability. It is discrimination to deny treatment based on disability.

The protocol states that when a person is denied treatment that they must be provided palliative care. The authors state that they are not abandoning the patient when they provide palliative care and yet the triage system has already abandoned the patient.

The protocol leads to an abuse of the ethical use of palliative sedation.

Palliative sedation or terminal sedation is properly used for a patient who has symptoms that cannot be effectively alleviated in any other way. For instance, a person who is living with Neuropathic pain may only be effectively relieved of the pain through sedation. The authors of this protocol are proposing the use of sedation as a means of causing death, instead of (MAiD) euthanasia which is legal in Canada. The protocol states:

In our opinion, palliative sedation is preferable to medical assistance in dying (MAiD) for patients with severe respiratory failure caused by SARS-CoV-2, given the 10-day reflection period, number of witnesses and assessors required, and the current requirement for full capacity to determine eligibility for MAiD. 

When analyzing euthanasia data from the Netherlands and Belgium you will notice a significant number of "assisted deaths without explicit request." This protocol is endorsing the same procedures that are done in the Netherlands and Belgium to circumvent the euthanasia law. Downar is well aware that he is advocating for intentional acts to cause death. In 2014 Downar participated in the study:  Characteristics of Belgian "life ending acts without explicit request."

The protocol changes the ideology of palliative care. The concept of palliative care is to provide pain and symptom relief when a person is dying, to palliate the symptoms but never to hasten death. The protocol is suggesting that palliative care can replace active treatment, even when treatment may lead to recovery. So palliative care becomes a way of providing a comfortable death for people who have been medically abandoned.

The protocol claims that it will lead to greater equity. The protocol acknowledges that people who live with mental illness or other conditions face substantial challenges to receiving healthcare and they conclude that: "Palliative care thus becomes the compassionate option to counterbalance this inequality."

Palliative care is better than "sending them home to die" and to not palliate symptoms is to abandon the patient again. Nonetheless, this protocol institutionalizes the inequality and injustice. The protocol states that you must be kept comfortable as we abandon you. But it doesn't stop there, the protocol advocates for the abuse of the use of "palliative sedation" meaning, we will not only palliative your symptoms, but in certain circumstances we will end your life without your explicit consent.

Further information:

• US Department of Health and Human Services will uphold human rights in relation to health care resource allocation (link).
• Covid-19 reveals a deadly failure of priorities (link).

Belgian doctor charged with murder in the deaths of 9 patients.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

CHR van Hoei Hospital

On September 24 I reported that a Belgian doctor had been charged with murder in the deaths of four patients in the palliative care department of the CHR van Hoei Hospital.

HLN news has now reported that the doctor lost his contract with the hospital and has been charged with murder in the deaths of five more patients, making it nine total murder charges.

According to HLN news, the physician claims that the deaths were not murder but palliative sedation, more accurately referred to as terminal sedation.

The physician claims that he just wanted to stop the pain and these cases were not euthanasia.

Wim Distlemans

Dr Wim Distelmans, who is co-chair of the Belgian euthanasia control commission and operates a euthanasia clinic, told the Belgian news that palliative sedation is not regulated and occurs 4 times more often in Belgium than euthanasia. Distelmans stated (google translated)

“What happens too often is that doctors dramatically increase the doses of the drugs via the baxter to speed up the end of life. That's hypocritical, because they say to the family, "We just keep him asleep." In fact, such a doctor puts an end to life. You can't even call it euthanasia, because the patient didn't ask for it, "

The intentional overdosing of palliative patients is common and is ethically the same as euthanasia. These cases of terminal sedation represent an abuse of the proper use of sedation. Palliative sedation, when done correctly and ethically, should not cause the death of the patient and should not become confused with murder.

A 2015 Belgian study showed that more than 1000 people died an assisted death without request in 2013. Data, such as this, should create great concern, but in Belgium it has simply been a statistic. This case may begin to deal with the number of intentional deaths without consent occur in Belgium.

I will continue to follow this case. Currently the court is not publishing the facts of around these cases.

Québec - 1331 reported euthanasia deaths (April 1, 2018 - March 31, 2019) At least 13 deaths did not comply with the law.

Fourth report from Québec's Commission on end-of-life care

By Amy Hasbrouck and Taylor Hyatt 

Toujours Vivant - Not Dead Yet.

On October 2, Québec’s Commission on end-of-life care released its fourth report for the period April 1, 2018 to March 31, 2019. The Commission reported a substantial increase in the number of euthanasia over the previous years. They reported:

Link to the analysis by Amy Hasbrouck and Taylor Hyatt on the previous Third Québec report (Link).

• There were 1,331 euthanasia were reportedly performed this year April 1, 2018 - March 31, 2019). Added to the 1,630* for the 28 months from December 10, 2015 to March 31, 2018, bringing the total to 2,909 euthanasia in Québec since the program began. We’ll talk in a few minutes about why those numbers don’t add up.
• Continuous palliative sedation (CPS) was performed on 1,243 people during the reporting period. Added to the 1,704 CPS performed during the 28 months from December 10, 2015 to March 31, 2018, this brings the total to 2,947. 
• Euthanasia and CPS each accounted for 1.9% of deaths in Québec during the reporting period, for a total of nearly 4% of all deaths in the province. 
• *As explained in footnote 19 on page 27, 1,630 euthanasia deaths is a corrected total from the Commission’s summary report issued last spring. Apparently “two MAiD reported by an institution as having been administered were not administered.” 

The exact number of euthanasia deaths is hard to pin down from the report.

• On pages iii, 12, 27 (footnote 19), 37 and 38, the report says “1,279 people received MAiD between April 1, 2018 and March 31, 2019.” This figure, when added to the 1,630 from previous years, gives the reported total of 2,909.
• But on page 23, the report says “according to reports from institutions, 1,937 requests for MAiD were made between April 1, 2018 and March 31, 2019; of these, 1,271 were administered and 672 were not administered.” 
• The 1,271 figure, added to the 60 euthanasia performed by doctors outside of institutional settings and reported by the Collège des médecins du Québec (CMQ), gives a total of 1,331 euthanasia. 
• Maybe you’ve noticed that 1,937 minus 672 does not equal 1,271, but rather 1,265. The six missing people are accounted for in a note in figure 3.17 which does not show the outcome of the six euthanasia requests in region 10. The Commission explains: 
• “In order to respect the rules of confidentiality, and because of the risk of identification related to the disclosure of a small number of individuals, the exact distribution of the euthanasia administered and not administered could not be provided.” 
• As for the 1,279 figure used elsewhere in the report, we don’t know where it comes from, or if it includes the 60 euthanasia reported by the CMQ. And if you think we’re being nit-picky, just remember that euthanasia laws are supposed to impose “stringent limits” that are “scrupulously monitored and enforced.” 

This year, the Commission received 1,400 euthanasia reports, some of which document euthanasia performed before the reporting period. 

“The Commission notes that 86 forms were received more than six months after the administration of MAiD and some of them more than one year later.” 

A few things to note about the Commission’s process:

• The Commission can only evaluate compliance with the law; it has no influence over other aspects of the medical practice, even if they could affect euthanasia. So, for example, if the doctor makes a mistake in diagnosis or the cause of a decline in capacity, that would probably fall outside the Commission’s area of responsibility.
• Two-thirds of the commissioners must agree that a violation has occurred for a finding of non-compliance to be made. Such cases are referred to the institution’s Council of Physicians, Dentists and Pharmacists (CPDP) and the Collège des médecins du Québec. There is no remedy for the loved ones of ineligible people who are euthanized, or where safeguards are ignored. 
• This year the Commission introduced a new procedure for evaluating reports, in response to the growing number of euthanasia. Declarations are examined by a sub-group including at least three commissioners; if all group members agree that the eligibility criteria were met and the safeguards complied with, the case is recommended for approval by the whole commission. If there is disagreement in the small group, the case is referred to the full commission for further discussion. 

The commission took a first look at 1,384 reports, and needed more information or had questions on 31%, or 430 of them. The Commission found that 96% of the 1,354 cases it ruled on complied with the law, but it could not reach a decision in 41 cases (3%) because they didn’t get the information they requested from the doctor. The commission found that 13 euthanasia (1%) did not comply with the law.

• Four people were not eligible: 
• Three people did not have a serious and incurable illness (they all had broken hips); 
• One person’s medical insurance card had expired. 

• In nine cases, safeguards were violated. 
• The second doctor examined the person before the euthanasia request was signed in five cases. 
• The doctor did not conduct the interviews to ensure that the request was informed, that the person’s suffering persisted and they still wanted euthanasia. “In two cases, the physician who administered the MAiD met the person only on the day of the [euthanasia].” 
• One request form was witnessed by a non-qualified person. 
• “In one case, the second doctor consulted had a family connection with the doctor who asked for the opinion.” 

Of those who asked for MAiD, 65% received it.
The three most common reasons euthanasia was not administered were:

• The person was not eligible (246 people, or 37%)
• The person died before the evaluation process was completed or before MAiD could be administered (224 people, or 33%) 
• The person withdrew their request (127 people, or 19%). 

Forty percent of those approved were euthanized within ten days of making the request.

The Régie d’assurance maladie du Québec (RAMQ) reports that 682 doctors billed for services related to MAiD. According to the CMQ, of 23,478 doctors registered, 480 say they performed euthanasia in 2018.

If there’s a take-away message from this report, it would probably be that the number of euthanasia deaths is increasing rapidly, and procedures are still handled in a slip-shod manner. We still wouldn’t get on an airplane with a 1% chance of crashing, and a 3% uncertainty factor.

Summary Report on End-Of-Life Care (euthanasia) In Québec.

The following report was published by the disability rights group, Toujours Vivant - Not Dead Yet on April 12, 2019 and republished with permission.

By Amy Hasbrouck and Taylor Hyatt

Québec’s Commission on end-of-life care issued a summary report of the status of end-of-life care in Québec. The report deals with palliative care, continuous palliative sedation (CPS), euthanasia (administered or not), and the activities of the Commission itself. But the document only includes data up through March of 2018.

The report presents some obvious findings:

• The number of euthanasia and CPS are increasing. 
• Some doctors, hospitals, and regions provide more palliative care, CPS, and euthanasia than others. 
• Most of the people who die by euthanasia and CPS are over 60 years old and have cancer.
  

The report identifies some problems, such as that the Commission doesn’t have the data necessary to say how many people who need palliative care aren’t getting it. But we are aware of, or can predict other problems that are not addressed by the report, such as:

• People forced to live in institutions are requesting and receiving euthanasia; 
• We don’t know how doctors decide if a person is subject to “external pressure” to request euthanasia, and whether psychosocial, economic and discrimination-related factors are taken into account, besides coercion and abuse. 

Palliative care
 
The Commission admits it doesn’t have data to prove that the gaps in palliative care services observed in a report published in 2000 still exist, but they’re pretty sure that’s the case. The only data available count people who are receiving palliative care services, or who apply for euthanasia.

Service gaps exist in all areas where palliative care is delivered; home-hospice services, hospital-based palliative care units and free-standing hospices.

The report focuses on palliative care as an option only for people at the end of life. This despite the fact that effective pain relief is essential to many people with disabilities, and the authors propose expanding euthanasia to people who are not at the end of life.

The section on palliative care doesn’t address services to prevent institutionalization and requests for euthanasia, which are central to the Truchon/Gladu and Lamb cases.

Continuous Palliative Sedation
 
Of the people who died by Continuous palliative sedation:

• The report provides more detail about symptoms that justified CPS than about the kind of suffering that lead to requests for euthanasia: 
• Psychological / existential distress = 58%; 
• Physical pain = 28%; 
• Difficulty breathing = 25%; 
• Delirium and agitation = 20%.
  

• Ninety-four percent filled out and signed the consent form. In the other cases: 
• The form was not signed, but was in the medical file; 
• The form was missing from the file; 
• “oral” consent was given by the person or their family; 
• The form was not signed because the substitute decision-maker was absent.
  

• According to medical records, 83% of people received palliative care before asking for CPS and 6% never had palliative care. Information was not available in the remaining 11% of cases.

• Eighty-one percent died within three days of when CPS was started.

Euthanasia (administered)

• The number of requests was ten times more than anticipated before the program started. 
• “According to data gathered by the Commission, 1,632 people received MAiD in Québec between December 10, 2015 and March, 31, 2018.”  
• Footnote 33 states “the Commission is aware that the total of MAiD (1,632) … does not exactly correspond to the total declared in the reports from institutions and the Collège des Médecins du Québec shown in the latest report of the Commission’s activities,” published in December of 2018. That figure was 1,664, a difference of 32 euthanasia. The Commission does not explain this discrepancy. 
• It’s unclear whether the 1,632 figure comes from the total reported by institutions and the CMQ, or from doctors’ forms. In fact, nowhere in the 124-page summary report does the Commission explain why the number of euthanasia reported by institutions and the CMQ has been higher in the three annual reports, than the number declared by doctors. 
• Of the doctors’ declaration forms submitted to the Commission, 84 came in more than six months after euthanasia was provided. 
• By the Commission’s count, more than 60 euthanasia had not been reported by doctors as of March 31, 2018; 11 doctors’ reports were still missing when the summary report went to press. 
• As well, footnote 57 mentions “around 20” euthanasia that were not reported by the doctors or facilities, but which came to light following audits by institutions that found the information in their pharmacy records.
  

• The average time between signing the request and administration of euthanasia was 12 days. 
• The Commission describes the reasons for euthanasia request (suffering) in the broadest possible terms; Physical suffering, psychological suffering, or both. Not surprisingly, 89% reported both. The report did not specify how many people had what kind of discomfort (physical pain, breathing problems, nausea, existential suffering, feelings of loss of dignity, problems with self-esteem, grief, etc). 
• Of note, the Commission appears to have checked off “physical suffering” even where it wasn’t an issue. Footnote 43 states: “In light of the totality of information listed on the forms, physical suffering was determined to be present even if the form indicated that it was well managed or that there was only minor physical discomfort.” 
• The Commission says that 80% of people were receiving palliative care when they requested euthanasia, and 89% were getting it when MAiD was administered. However the Commission makes no assurances as to the quality or quantity of that service. This percentage of palliative care access is higher than that reported in a study from McGill University we reported on last December. 
• The authors note that the number of euthanasia performed at home in Quebec (20%) is half that of other parts of Canada (>40%) and Europe. Some people were admitted to hospital just to be euthanized. 
• The Commission estimates there could be up to 1,500 euthanasia performed in Québec during the fiscal year ending March 31, 2019. That’s almost as many as in the 28 previous months. 
• The data confirm the theory that there are a few “death doctors” who specialize in medical homicide, plus many other physicians who do one or two euthanasia per year.
  

Euthanasia not administered

• Of the 2,462 requests, 830, or just over 1/3, did not result in euthanasia. Such requests are not reported, so the commission had to look at the medical records of the people who made a request to determine the outcome, and to learn why euthanasia did not take place. The reasons fell into three broad categories: 
• the person was deemed ineligible, 
• the request was withdrawn; or 
• the person died before euthanasia can be carried out.
  

• The reasons euthanasia was not administered: 
• The person was not eligible when the request was made (191) because:  
• They were not at the end of life – 97; 
• They were incapable of giving consent when the request was made – 58; 
• They did not have “intolerable suffering” when request was made – 48; 
• They did not have a “grievous and irremediable medical condition” – 37; 
• Their medical condition was not in an advanced state of irreversible decline – 35; 
• (Some people were ineligible for multiple reasons.)
  

• The person became ineligible during the evaluation process (164) because: 
• They lost capacity to give consent – 156; 
• Their suffering was relieved such that it was no longer intolerable – 3; 
• Other – 5.
  

• The person died before the evaluation was completed – 168; 
• The person withdrew their request or changed their mind – 167; 
• The person died before euthanasia could be administered – 67 
• Other / information not available – 73.
  

• The authors note that the variability between different locations comes from diverse interpretations of eligibility criteria, especially “end of life” and “constant and unbearable” suffering. 
• The Commission suggests that the fact that 51% of people who asked for euthanasia were not at the “end of life” and 30% were incapable of giving informed consent corresponds with the public’s desire to expand eligibility to these populations. Our view is that the fact that some people are excluded means the eligibility criteria are working, at least somewhat.
  

The application process

• Oral requests are often not documented on the request form until the evaluation process is nearly completed. 
• The authors say people are being discouraged from making a written request for euthanasia, and are being told, informally, that they wouldn’t be eligible. 
• The Commission downplayed problems with delays in receiving form, and numbers of errors and incomplete forms.
  

The activities of the Commission

• The report says nothing about what the Commission intends to do about the deaths of people who were deemed ineligible, or where the safeguards were not complied with
•  In 11 cases, the person was not eligible for euthanasia; 
• In 10 cases, the doctor didn’t talk with the person to ensure they were giving free and informed consent, and the persistence of their suffering; 
• In 9 cases, the consulting doctor examined the person before the euthanasia request was even signed; 
• In 5 cases the form was countersigned by someone who was not a health-care professional; 
• In 2 cases the doctor did not ensure that the safeguards were complied with.
  

• The Commission’s backlog of evaluations is glossed over. They’ve evaluated 1,498 of the 1,632 euthanasia declared (92%), leaving a backlog of 134 cases even a year later. This is especially pressing given the commission’s estimate for the number of euthanasia for the fiscal year just ended. 
• There are references to improvements promised by the electronic reporting system. But the report skips over problems mentioned in the annual reports related to:  
• How many forms are incomplete or have errors; 
• How many letters and phone calls are necessary to correct or complete the forms, or to track down missing forms; 
• Euthanasia reports that are not transmitted at all.
  

• Nor is there any discussion as to how these problems will be dealt with in the future. 
• The media coverage of the release of this summary report was a frenzy of pro-euthanasia propaganda, criticism of the number of people who are being denied their “right” to euthanasia, and calls to expand eligibility and speed up the evaluation process. We hope that our observations, our sober second thoughts, will not be completely lost in the hubbub.