Can Connecticut live with assisted suicide?

While cleaning up my emails I read an excellent article by Lisa Blumberg that was published by the New Haven Register on April 2, 2023. Blumberg argues that the Connecticut assisted suicide bill is designed to legalize assisted suicide and then expand the law. Here is what Blumberg writes:

Lisa Blumberg

Proponents of legalizing assisted suicide insist that the practice would be tightly controlled. Doctors would only be able to write lethal prescriptions for state residents with a six months prognosis who are mentally competent and who have made two requests at least 15 days apart. The drugs must be self-administered. As Dr. Diane Meier, a palliative care specialist has said, hoever, “the entire heartfelt adherence to restrictions that are announced when you first get the public to vote in favor of this go up in smoke once the practice is validated.”

Proponents seem to feel that it is a good strategy. J.M. Sorrell of Massachusetts Death with Dignity in referring to “the hoops you have to go through” under the bill Massachusetts is considering has stated, “Once you get something passed, you can always work on amendments later.”

Almost all of the few states that have legalized assisted suicide are considering loosening eligibility requirements. California has reduced the reflection time between requests to 48 hours. Bills introduced in Hawaii, New Jersey, Oregon and Washington would do likewise.

Following New Mexico’s approach, Hawaii, Oregon and Washington are considering bills allowing nurse practitioners and, in the case of Washington, physician’s assistants to determine eligibility for assisted suicide and write death causing prescriptions. This belies the complexity in judging life expectancy and implies that assisted suicide is an ordinary medical procedure like wrapping a sprain.

Mistakes in prognosis occur regularly. 12-15 percent of hospice patients outlive their prognosis by six months or more. Sometimes a pessimistic prognosis may be based on the assumption, erroneous or not, that the person will not receive the in-home support needed to stay alive.

What constitutes “terminal illness” is elastic. An Oregon health official has opined that conditions can be deemed terminal even if there is lifesaving treatment but the person does not want it, is uninsured or cannot afford it. This viewpoint sweeps in any chronic condition that might turn fatal if not medically managed. This is not a theoretical concern. Among the persons who died in Oregon in 2021 under its assisted suicide law were people with conditions such as arthritis and anorexia.

Indeed, a Colorado doctor has written of helping thirty somethings with anorexia obtain so-called “aid in dying” drugs. Anorexic persons do not meet eligibility requirements. As Dr. Angela Guarda, director of the eating disorders program at Johns Hopkins University, said, “Anorexia is treatable, not terminal … it is impossible to disentangle this request (to die) from the effects of the disorder on reasoning, and especially so in the chronically ill, demoralized patient who is likely to feel a failure.

If a state legalizes assisted suicide, there will be an assisted suicide industry, albeit probably a small one, seeking to pursue its interests. In Oregon, the requirement that only state residents be eligible for assisted suicide was challenged by a doctor in court and the state chose not to fight it. The state is amending its statute accordingly. Vermont is seeking to do so as well. It is not clear how lack of a residency requirement will play out in this day of teleconferencing.

Proponents scoff at any concern about assisted suicide morphing into “voluntary” euthanasia of the disabled, although this is what has happened in Canada and in other countries that legalized assisted suicide. In California, four doctors and two patients brought a federal lawsuit challenging the provision in the state’s law that patients self-administer the lethal drugs.Their argument was that this discriminated against people lacking functional ability to do it themselves. With major disability groups filing an amicus brief in strong opposition, the case was dismissed but assisted suicide laws may fuel more such cases.

A Connecticut legislator explaining why she is a proponent used a quote attributable to Nietzsche. “One should die proudly when it is no longer possible to live proudly.” Hopefully she did not intend the obvious implication behind the quote that some folks need to hurry and die.

Before you support the legalization of assisted suicide and view it as just “aid in dying,” think carefully about the values you want for the health care system and the type of society you want to live in.

Lisa Blumberg of West Hartford is a lawyer, writer and disability rights activist.

Previous articles by Lisa Blumberg.

• Assisted suicide: It's not that simple (Link).
• Assisted suicide is bad medicine. How can legislators represent us if they cannot talk to us? (Link).
• Separating myth and reality in aid in dying (Link).

Humanists Against Assisted Suicide and Euthanasia respond to pro-euthanasia briefing on "Canada's Assisted Dying Laws"

Published by Humanists Against Assisted Suicide and Euthanasia (HAASE)

Kevin Yuill

By Trudo Lemmens and Kevin Yuill

A Humanists UK Briefing on “Canada’s Assisted Dying Laws” has been released this month. The Briefing states that it is an analysis of Canadian assisted dying practice to see ‘if there are real problems and, if so, what can be learned from them’. The main conclusion of the pamphlet is ‘we don’t believe that anyone in Canada has had an assisted death who shouldn’t have been able to’. This is a bold pronouncement as, it seems, Humanists UK is more confident in the Canadian system than are some of the MAiD providers themselves. One recently reported on her moral anguish of having ended the life of a cancer patient who had a 70% chance of full recovery but refused all treatment and insisted on receiving MAiD.

Trudo Lemmens

The Briefing is part of Humanists UK’s long advocacy of legalising assisted suicide and euthanasia in the UK and its Crown dependencies. They seem to want to import the Canadian system of euthanasia and assisted suicide – more or less – to the UK. They have variously stated that ‘[b]eing able to die, with dignity, in a manner of our choosing must be understood to be a fundamental human right’. Does that mean all requests for assistance with suicide must be honoured? If not, who should and shouldn’t have this right? In the past, they supported extending eligibility to ‘those who are incurably suffering, permanently incapacitated and who find their lives intolerable’, which resembles the language used in the recently expanded Canadian law it discusses in the briefing. That seems to mean all those with a permanent disability – a large percentage of the population – who find their lives intolerable. Presumably, those who are not physically disabled will not be eligible, no matter how intolerable their lives are. At another point they said they supported it for those ‘who are physically unable’ to end their lives. We have asked Humanists UK for clarification of just who and who should not have assisted suicide – none was forthcoming. They don’t seem to know themselves.

The Briefing wishes for ‘a tolerant world where rational thinking and kindness prevail’. But Humanists UK can hardly be characterised as tolerant or rational when it comes to dissent from their position on assisted dying and they are anything but kind to those who disagree with them, calling what they say ‘misinformation’.

It is easy to see why Humanists UK decided to write this pamphlet. A stream of disturbing stories about lethal injections being given out liberally for intersecting reasons of poverty, homelessness, disability, and depression has made many in the UK question whether assisted dying would be appropriate here. Nathan Stillwell, a Humanists UK assisted dying campaigner, accused ‘some people’ of ‘knowingly or unknowingly pounc[ing] on misinformation from Canada in order to hinder the campaign here’.

The Briefing, however, does precisely that. It misleads its readers – knowingly or unknowingly – about how many problematic cases there are, about the cases themselves, and about Canadian law, creating an inaccurate portrayal of both the Canadian law and practice of ‘Medical Assistance in Dying’ [MAiD], the euphemistic Canadian term that encompasses both euthanasia and assisted suicide, but in practice involves nearly exclusively the former (provision of a lethal injection by physicians or nurse practitioners was the cause of all but 7 of the 10,064 MAiD deaths in 2021).

The Briefing is often simply wrong but above all it fails to show why Canada’s experience with euthanasia should be treated as anything other than a cautionary tale for the rest of the world. There are many informative reports and discussions available and readers of the Briefing should avail themselves of them – we have referred to some below.

Canada has in a period of about seven years witnessed the highest number of assisted death cases, with more than 30,000 cases, and in 2021, the last full year of reporting, more than 10,000 cases. This is expected to increase significantly, considering that the law was expanded outside the end-of-life context only in March 2021 and is planned to expand further, including for mental illness in 2024. Some provinces already have the highest proportion of deaths by physician-provided lethal injection in the world: seven per cent of people in Quebec currently die by euthanasia. Understanding how this occurred and what problems have arisen seems important for any jurisdiction debating a form of legalization of the practice.

The authors of the Briefing rightly recognize that ’facts surrounding some of the cases featured in the coverage are often hard to verify due to doctor/patient confidentiality.’ What they do not say is that it is inherently challenging to satisfactorily investigate these deaths after the fact. The chief witness is dead. The cases where outraged or traumatised family members – often informed only shortly before their loved one is euthanised – protest at being stonewalled by MAiD providers are inevitable because of doctor/patient confidentiality. Family members and loved ones have often not been consulted. Nor will they be if the patient insists.

The briefing is extremely selective. It considers only a very few cases where it disputes both the facts and the way the cases were reported, and fails to mention key issues. It ignores, for instance, the extensively documented case of John Lyon, a suicidal ex-policeman who suffered from mental illness (though he qualified for a lethal injection because of his physical impairments). The Briefing might have examined the case of 37yr old Jennyfer Hatch, whose MAiD death was celebrated in a beautiful advertisement by clothes retailer La Maison Simon but who had long sought treatment for her painful condition. Bill Gardner’s articulate response to being offered MAiD was also available. The Briefing ignores the series of cases publicly discussed in a Disability Filibuster, presented by Disability Advocates to a Joint Parliamentary Committee, and available on a publicly accessible website. It failed to mention a detailed fact-checked investigative report by Alexander Raikin, which includes statements by MAiD assessors and providers. This report was also discussed in the UK by Yuan Yi-Zhu.

Instead, the Briefing uses confidentiality and privacy law as a convenient shield, just as in Canada, institutions and providers appear to have used privacy law as a shield to prevent family members who complained from gaining full access to medical records.

This could and should have been a reason to dig deeper, to consult all available sources, and to take testimony of individuals, family members, friends, and disability advocacy organizations more seriously. Instead, the Briefing places extraordinary trust in defensive and vague statements by institutions and professionals involved in the practice, largely ignoring fact-checked media accounts.

If confidentiality is so problematic, how can the Briefing so confidently trust that there is no one who ‘has had an assisted death who shouldn’t have been able to’? In what other area of policy making would it suffice to argue along the lines of ‘trust the institutions and those involved in a practice and distrust or ignore statements by potential victims’? 

The Humanist Briefing’s discussion of Case reports

Not only is the Briefing selective with its case reports, it’s inaccurate or confused about those that it does discuss. For instance, it rightly points out how problematic it is that army veterans struggling with PTSD and with physical disability were offered MAID by a case worker, when they applied for supportive care. But then it claims this was the result of a ‘rogue’ employee. Later, it states: ‘there is a need to inform individuals that assisted dying is available’. So what did the rogue employee do that Humanists UK would not advocate? And indeed, the organization of MAiD assessors and providers funded by the government to develop guidelines and training explicitly recommends to put MAiD on the table for everyone who ‘might qualify’.

The Brief seeks to reassure the reader that ‘none of these veterans applied for, much less were approved for, an assisted death’. That’s not the point – it is that disabled people are being informed that, as an alternative to treatment, there is a much cheaper and 100% effective ‘medical treatment’ available – being euthanized.

Persons with a physical disability – like the Paralympic veteran mentioned in the Briefing – are likely to qualify for MAID if they say they suffer intolerably. It would entirely depend on the judgment of the physicians assessing the request if this process would have ‘stopped’. Considering other cases that we have seen in Canada, it is very likely that she would have been approved had she eventually asked for it.

In the Roger Foley case, the Humanist Briefing authors want to reassure the reader by stating that ‘Roger Foley never applied for an assisted death’. That is again precisely the controversy: that he never asked for it and insisted on adequate home care, but was offered MAID as an option when he expressed suicidal thoughts. Audio clips confirm that he was offered MAID without asking for it. Roger Foley talks about this openly and has documented this. The Humanist Report could have consulted Roger Foley. Instead, it relies fully on the hospital’s hiding behind ‘privacy and confidentiality‘ to suggest we cannot know more.

‘Assisted Dying for Hearing Loss’

As with the veterans’ cases, the Humanist Briefing misrepresents why Alan Nichols’ death by MAID was so controversial when it states that media wrongly reported he was approved for assisted dying because of ‘hearing loss’. Media reports flagged Nichols’ death by assisted dying as problematic because it was questionable that he fulfilled the explicit requirement under the law at that time, i.e. that his death be ‘reasonably foreseeable’, and because concerns about mental health and capacity for decision-making.

Alan Nichols was not terminally ill. He had suffered from seizures earlier in his life and had a cognitive disability in addition to severe hearing loss (he had a cochlear implant). He was brought to an emergency room as part of a wellness check where he was diagnosed as suicidal. He was treated briefly for depression and involuntary hospitalized where he remained until he received a lethal injection, less than three months later. His family was informed only three days before his scheduled death. They were given no reasonable opportunity to discuss with him other options. When the family filed a complaint, the health authority submitted a letter of response in which it defended an open interpretation of ‘reasonable foreseeable death’ and stated that it did not require Alan Nichols to have a terminal illness.

These facts are not ‘misinformation’.

Moreover, they are easily available; a public case report was published on the website of the International Network of the History of Neuropsychopharmacology, where four leading psychiatrists also provide commentary and mostly express their deep concern about the case. The Humanist Briefing could have consulted this case report and commentaries and the health authority’s official response it contains. They could also have consulted the family’s moving public testimony before a Parliamentary committee, where family members were extensively questioned and even parliamentary supporters of MAiD appeared to recognise that the case raised concerns.

Instead, the Briefing wrongly states that the professional regulatory authority (College of Physicians and Surgeons of British Columbia) ‘investigated’ the matter. The College explicitly refused to do so. The federal police also initially refused to do so, stating it was a medical issue for the College to investigate. When asked a second time by the family, the police allegedly failed to interview the family. It sent the family a copy of the original request form signed by Alan Nichols, which stated ‘hearing loss’ as the basis for his unbearable suffering, seemingly in support of their final decision that the legal criteria were fulfilled. While we must hope that hearing loss was not the sole basis for the health care providers’ final approval of his assisted death, the health authority provided no clarity as to what the basis really was. And frankly, any health professional should have been alarmed when a patient indicates ‘hearing loss’ as the reason for their unbearable suffering on a form where they request to receive assisted death.

Regardless of all that, the Humanist Briefing’s claim that ‘[h]earing loss is not a serious illness, disease, or disability that causes unbearable physical or mental suffering’, with which it suggests that it could never be a basis for MAiD in Canada, is also wrong. Again, the confusion over who does and who does not – and who should and should not – receive euthanasia permeates this Briefing as it does Humanists UK’s advocacy of ASE in general.

Hearing loss and deafness are disabilities that can be associated with ‘irreversible decline of capability’, and therefore can make someone qualify for MAiD under some of the MAiD providers’ very broad interpretation. The law’s additional requirement of intolerable suffering has been interpreted as being entirely subjective, with physicians agreeing to end the life of patients with disabilities based on the patient’s claim of such intolerable suffering.

Both Canada’s euthanasia advocates and Humanists UK seem to make it up as they go along. National broadcaster CBC’s Investigative Programme The Fifth Estate in ‘Is it too easy to die in Canada: Surprising approvals for medically assisted death’, featured among other cases a man in his twenties, who was approved and scheduled to receive MAID. He struggled with adjustment to vision loss resulting from complications of diabetes, and with pain associated with the treatment. His family discovered his scheduled death by chance and organized a social media campaign asking the government to stop the procedure. The physician felt compelled to cancel it, perhaps also because MAiD for mental illness is not yet a legal basis for MAiD, and mental health issues resulting from the vision loss may have motivated the request. The young man is interviewed in the programme and confirms he is happy to be alive. If vision loss can be a basis for approval of assisted death in Canada, it is reasonable to presume that some physicians would grant it for Deafness or severe hearing loss. Note that no regulatory authority appears to be investigating this young man’s approval for MAID.

Assisted dying for lack of social support or housing

The Briefing acknowledges two examples of cases where persons asked for MAID, one receiving it, for lack of adequate housing. It suggests that these cases were misrepresented in the media by opponents of assisted dying and ‘special interest groups’. It quotes at length a submission to parliament of Dr Chantal Perot, a MAiD provider and advocate. CTV, the media outlet reporting on this case in detail, obtained testimony from friends who confirm that the woman – who remains anonymous – did not want to die but that lack of adequate housing drove her to her death. The Briefing refers only to Perot’s submission.

Faced with reports of assisted dying of persons living in poverty, the Briefing authors say that ‘it would be gravely immoral to forbid someone less well-off the same right to an assisted death when a richer person with the same condition would be able to proceed’. The majestic equality of MAiD in Canada allows those who do not have access to adequate housing, social and disability support, and funding for some forms of health care that are not publicly funded in Canada the same option to die as those who have the money to provide it for themselves. As Anatole France observed: ‘The law, in its majestic equality, forbids rich and poor alike to sleep under bridges, to beg in the streets, and to steal their bread.’ The bleakness of the future for those who are poor and disabled is distinct from the situation of the better off.

By offering death as solution to social context-induced suffering, Canada is creating a cheap escape route for its social justice obligations. How an organization devoted to helping people ‘be happier and more fulfilled’ can explain this away is mind-boggling. The history of euthanasia and assisted suicide indicates that along with compassion comes the motivation to streamline society, to save costs and to make it more efficient by removing lives that are not useful to themselves or others. Not surprisingly, Humanists UK and other advocates are reticent about such calculations. Another missing report is one produced by the Canadian federal parliamentary budget officer that estimates the cost-savings of MAiD, which are considerable. If cost-savings were not the motivation behind Canada’s MAiD law, the realization that it does save costs is increasingly acknowledged and disincentivizes any revision of the rapidly expanding practice. Other utilitarian considerations would also have been worth mentioning, such as the fact that Canada has become the country with the most significant organ retrieval following MAiD. In fact, organ donation following MAiD is already directly promoted by the organization coordinating blood and organ donation in the country.

The Briefing’s reference to ‘the role of religious groups in the media’

Again, the Briefing is selective in its characterisation of those opposing legalised euthanasia and assisted suicide or the further expansion of it. Far too much of it is dedicated to cheap and lazy tropes. References are made to ‘covid conspiracy’ media sources, ‘anti-choice activists’ and ‘ultra-right wing’ US funding. For those concerned about conspiracies, the Briefing contributes its own conspiracy about these ‘powerful’ groups. It stops just short of accusing those who oppose ASE of being part of a Popish plot.

In its hurry to point the finger at religious groups for their apparent ‘misinformation’ about Canada, it conveniently ignores all Canadian disability advocacy organizations (more than 100 explicitly opposed expansion), several Indigenous organizations, three United Nations Special Rapporteurs and one Special Expert on Human Rights, the federal Canadian Human Rights Commissioner, many academic experts from law, medicine, bioethics, and other disciplines, many social justice and anti-poverty advocates, and several officials dealing with specific issues such as the federal Ombudsman of Prisons, who have all expressed concerns about the Canadian MAiD expansion or some components of the practice. Is this also all ‘misinformation’?

Misleading claims about the case law at the basis of MAiD and its further expansion

The Briefing is inaccurate when discussing Canadian law. It makes two problematic statements about the 2015 Supreme Court case that lies at the basis of Canada’s MAID legalization: ‘Canada’s laws have indeed changed from when assisted dying was first introduced in 2016, but these staggered changes are mostly due to Canadian MPs legislating for less than was required by the original Canadian Supreme Court decision that led to assisted dying in the first place, back in 2015.’ ‘The Supreme Court in 2015 ruled that competent Canadian adults suffering intolerably and enduringly have a constitutional right to a doctor’s assistance in dying.’

The 2015 Supreme Court decision in Carter ruled that an absolute prohibition was unconstitutional. Yet, it also explicitly refused to recognize a ‘right to die with dignity’ via physician assisted dying. It emphasized that it ruled only about MAiD in the circumstances of the case, which involved a person approaching her natural death. The Supreme Court also explicitly stated that it was not ruling about assisted dying for mental illness and in the case of minors. More details of the limits of the ruling and how it applies to the context of mental health the Briefing could have found in a recent letter signed by more than 30 law professors, including several constitutional and human rights law experts, and in law journal publications.

The Supreme Court of Canada is not a legislator. It gave Parliament in 2015 a year to enact a ’strict regulatory regime‘ that needed to balance access to some form of MAiD with protection against premature death of others. It left room, as required in a regime of separation of powers, to enact what it deemed fit for that purpose. Stating that the Supreme Court declared a broad constitutional right to MAiD is wrong; suggesting that there has been no further expansion since Parliament’s first law is disingenuous.

The Humanist Briefing is further misleading UK readers with the following statement:

‘So after another court case, the Court ruled again in 2019 that the law should be changed to fit the original ruling. … In 2021, the law was amended by Parliament to remove the “reasonably foreseeable” criterion.’ The Briefing makes it appear as if there was a second Supreme Court decision that rejected the ‘reasonable foreseeable natural death’ safeguard from the first bill. That is not the case. A lower, first instance court in the province of Quebec ruled this way. The Attorney General, who is in Canada also the Minister of Justice, refused to appeal the decision, an unusual decision for a statute so broadly supported by parliament two years earlier. No higher court has confirmed this ruling, which is not binding in other provinces and in higher courts. while there were several reasons, including constitutional ones, to do so. The expansion of the euthanasia law was not one necessitated by a constitutional ruling.

The report then misleadingly goes on to suggest that Canada took eight years to implement MAID in order for ‘safeguards to be developed, studies to be carried out, doctors to be trained, and guidance to be updated’. Advocates, including politicians, who supported broad access to MAID pushed to have it broadly accessible from day one. There was no conscious development of further safeguards: in fact, several safeguards, including the ‘reasonably foreseeable death’ restriction and a mandatory waiting period (to enable reflection and reconsideration), were removed with the second bill. There was no broad consultation or public discussion about this change, which was pushed through Parliament during the pandemic.

The expansion towards mental illness and mature minors

The report claims that the 2019 ruling somehow required a review of the expansion towards mental illness and mature minors (‘as per the 2019 ruling, there have been regular reviews‘). In addition to failing to clarify again that the 2019 ruling was a lower Quebec court decision, this statement is false. The 2019 ruling does not impose a review of expansion towards mental health and for mature minors.

The report further states that a federal committee ‘recommended that eligibility should include treatment-resistant mental illnesses subject to additional safeguards’. This is also incorrect. The phrase ‘treatment-resistant mental illnesses’ is not used in the federal report. In fact, the report recognizes that it is impossible to predict with certainty that persons with mental illness will not get better, but it nevertheless supports provision of MAID for reasons of mental illness. Second, the report does not recommend additional safeguards. It makes recommendations about how to implement the current requirements of the law in the context of mental illness, but does not recommend, for example, that all reasonable treatment options must be exhausted. The majority of Canadian mental health experts, none mentioned in the Briefing, have opposed MAiD on the basis of mental illness. One expert report strongly opposed expansion outside the end-of-life context and particularly permitting MAID for sole reasons of mental health, and pointed out that requiring exhaustion of all treatment options would be the most minimal requirement. Two prominent resignations, including of a mental health advocate, that affected the credibility of the federal committee, and a widely publicized public call by the Association of Chairs of Psychiatry of Canadian Universities to suspend the implementation of MAiD for mental illness are not mentioned in the Briefing.

The Humanist Briefing suggests that the ‘potential inclusion of mental illness and mature minors will move the Canadian law closer to that of Belgium and the Netherlands.’ Belgian and Dutch law explicitly require that physicians agree that there are no other options for relief of suffering, and thus that available medical treatments have been exhausted, which the Briefing acknowledges in its further discussion.

Canada’s law is not moving closer to Belgium and the Netherlands; it is going much beyond the liberal Belgian and Dutch regimes. This is important to keep in mind when also reading the problematic portrayal by the Humanist Briefing of media-reported cases. The open-ended nature and lack of detailed review of cases makes it so much more problematic to reject outright the seriousness of the Canadian cases, as the Briefing does.

The need for better safeguards

After ignoring all problems with the Canadian regime, the Briefing concludes: ’We don’t know that anyone has had an assisted death in Canada who shouldn’t have been able to, but the following are all important, well-tested safeguards that are missing in Canada but any UK system should learn from.’ The contrast between the report’s confident affirmation that there are no problems in Canada and the acknowledgement of missing safeguards should make it clear how unreliable and biased the preceding analysis really is.

At least we have here some recognition of problems, even though the Briefing remains too confident about how some suggested improvements will make the Canadian system safer.

Those really interested in learning about the pitfalls of the Canadian system should take the case reports, pointedly missing from the Briefing, more seriously. But they should also examine the official reports with a more critical eye that the Briefing appears to have done.

Indeed, the Briefing’s authors must have consulted at least the official Health Canada reports on MAID, since they mention some falsely reassuring statistics from the 2021 report: the average age of 76, the fact that ‘80% had received palliative care and 65% had cancer’ Professor Harvey Chochinov has challenged the palliative care data on the grounds that they were reported by MAiD providers, who did not specify what constituted palliative care. In many cases, people received palliative care only in the weeks preceding their MAiD death. And of course, a cancer diagnosis tells us nowadays not so much about medical prognosis that this should be seen as reassuring.

Moreover, the Health Canada reports contain other red flags that the Briefing could have identified. For example: in 2021, 57.6 % of the more than 10,000 people who died by MAiD declared that ‘inadequate control of pain (or concern)’ was a basis for their intolerable suffering, while we know that with adequate care, problems of pain control ought to be highly exceptional. Equally worrisome is how many identified ‘perceived burden on family, friends, or caregivers’ (35.7%), ‘loss of control of bodily functions’ (33.8%), ‘isolation and loneliness’ (17.3%), and even ’emotional distress, anxiety, fear, existential suffering’ (3%) as key components of their unbearable suffering. That the Briefing remains silent about all these issues just confirms its remarkable effort to find no concrete issues of concern.

Of course, there will be disagreements about a contentious subject as assisted dying. People can disagree about the wisdom and need of legalising some form of assisted suicide or euthanasia. But a fair assessment of the risks and benefits of an inherently irreversible practice resulting in death seems essential. This makes learning from other jurisdictions that have gone this path so important. The Humanists UK briefing does a disservice to the well-informed debate that should take place in the UK.

Yours sincerely,

Trudo Lemmens (LicJur, LLM bioethics, DCL) is Professor and Scholl Chair in Health Law and Policy, Faculty of Law, University of Toronto.

Kevin Yuill CEO of Humanists Against Assisted Suicide and Euthanasia (HAASE)

Washington State failed assisted suicide law.

This article was published by the Australian Care Alliance.

Washington State’s Death With Dignity Act, based on Oregon’s, came into operation on 9 March 2009. It was significantly amended on 6 April 2023. 

The amended Act allows for one of the two “qualified medical providers” who “medically confirm” that the applicant has a terminal illness which “will, within reasonable medical judgement, produce death within six months” to be a “physician assistant” or “advanced registered nurse practitioner”. 

The two assessing medical providers must not have “a direct supervisory relationship with each other”. 

Physician assistants in Washington operate under the provisions of Chapter 18.71A of the Revised Washington Code. It provides for physician assistants “to practice medicine according to a practice agreement with one or more participating physicians, with at least one of the physicians working in a supervisory capacity.” There is nothing in the Act to prevent a physician assistant signing off as the second medical provider on an assisted suicide assessment made by one of the participating physicians at the same practice who is not the direct supervisor of the physician assistant.

The provision treating an assessment by a “physician assistant” that person will die within six months as a making that prognosis “medically confirmed” necessarily increases the risk of wrongful deaths from errors in diagnosis and prognosis. The evidence set out below indicates that even where the two assessing medical providers were physicians, between 5% and 17% of applicants for assisted suicide assessed as dying within six months outlived this erroneous prognosis. 

Increase in numbers 

In the first full calendar year of operation, 2010, some 87 prescriptions for lethal substances were provided under the Act. By 2021 this had nearly fivefold to 400.(1)

Deaths from lethal substances prescribed under the Act increased nearly fivefold from 51 in 2010 to 291 in 2021, increasing by 15.5% between 2020 and 2021.(2)

Lethal substances unaccounted for in the community 

Not all of those who are prescribed lethal drugs end up taking them. Some die of natural causes. 

There is no tracking of lethal drugs that are not used by those for whom they are prescribed so these lethal drugs are available in the community and could be used accidentally or intentionally to cause death. 

Of the 2545 prescriptions for lethal drugs issued since 2009 only 1506 (59.2%) have been reported as used leaving some 1039 doses of lethal drugs unaccounted for.(3)

Pain control not the issue but being a burden is 

54% of those for whom a prescription for lethal substances was provided in 2021 did not cite any concern about pain control as a reason for asking for the prescription.

However, 56% cited concerns about being a burden on family, friends or caregivers.(4)

Poor screening for mental health and short term doctor patient relationships 

In 2018 just 4% of those given a lethal prescription were referred to a psychiatrist or psychological for evaluation. For 2019 and 2020 the numbers referred were so low that the data had to be suppressed under the “Department Small Numbers Guidelines”!

The amendments to the Act which came into effect on 6 April 2023 now allow for the referral for a mental health screening to made to a social worker, a mental health counsellor or a psychiatric nurse practitioner. This can only increase the risk of wrongful deaths of those with mental illness. 

In 2018 in some cases the prescribing doctor knew the patient for less than a week before writing the prescription, and in half the cases (50%) the doctor knew the patient for less than 25 weeks.(5)

This information is not provided in the annual reports from 2019 onwards. 

Faulty prognosis 

Although the Act specifies that only persons who have a disease that will “produce death within six months” may request lethal doses of medication from a physician, the data shows that in each year between 5% and 17% of those who die after requesting a lethal dose do so more than 25 weeks later with one person in 2012 dying nearly 3 years (150 weeks) later, one person in 2015 dying nearly two years later (95 weeks); one person in 2016 dying more than two years (112 weeks) later and one person in 2018 dying more than two years (115 weeks) later.(6)

For 2019 and 2020 this information is not available. The 2021 annual report only states that 19% of those who died after being prescribed a lethal dose died more than 120 days (four months) after first request.(7)

Not a peaceful death 

In 2018 one person took one full day and six hours (30 hours) to die after ingesting the lethal dose. 

In 2017 one person took 6 hours to lose consciousness after ingesting the lethal dose and one person took 35 hours to die after ingesting the lethal dose. 

In 2016 one person took 11 hours to lose consciousness after ingesting the lethal dose. 

In 2015 one person took 72 hours (3 days) to die after ingesting the dose. 

In 2013 one person took 3 hours to lose consciousness after ingesting the lethal dose and one person took 41 hours (1 day and 17 hours) to die after ingesting the dose. 

In 2009 two people awakened after initially losing consciousness. 

In 2014 one person suffered seizures after ingesting the lethal medication. At least 18 patients have regurgitated the lethal medication. Seven of these cases occurred in 2016 alone.(8) In 2018 some 8 people (4.25% of those for whom information is available) experienced “Regurgitation, Seizures, Awakening or Other” complications. The report does not specify how many people experienced each of these.(9)

This may be related to the use of new experimental cocktails of lethal drugs being used since the price of the previously used drugs, secobarbital and pentobarbital (Nembutal), escalated.

The first of the new cocktails is a mix of phenobarbital, chloral hydrate and morphine sulfate. It was prescribed in 88 cases in 2015 and 106 cases in 2016 but no longer prescribed in 2017 no doubt due to the fact that it was found to be very caustic and to cause a profound burning in the throat.(10)

The second experimental cocktail includes morphine sulfate, propranolol, diazepam, digoxin and a buffer suspension. It was prescribed used in 4 cases in 2015, 53 cases in 2016, 130 cases (66%) in 2017 and 195 (78%) in 2018.(11)

The annual reports from 2019 onwards do not report on complications, on which lethal drugs were used or on the full range of times between ingestion and loss of consciousness or ingestion and death. 

In 2021, 13.6% of people took longer than 10 minutes to lose consciousness, some of them more than 20 minutes but how much longer is not reported and 19.2% of people took more than two hours to die, but how much longer than 2 hours is not reported.(12)

If they struggled who would know? 

There is no requirement under the Act for a physician or any other person to be present when the lethal dose is ingested. Between 2009 and 2018 there were 240 cases where no health-care provider was present when the lethal dose was ingested and a further 178 cases where it is not known if a health-care provider was present.(13) In other words in some 418 cases people have died ingesting a dose of lethal medication, legally prescribed under Washington law, and nobody knows whether the person freely ingested the lethal dose or they were cajoled, coerced or forced to do so by another person. 

Failure to enforce compliance 

As of 26 May 2022, for 46 out of 400 applicants who were prescribed a lethal substance in 2021 the most basic document – the Written Request for Medication to End Life Form – had not been received although it is a legal requirement that the attending physician do so within 30 days of writing the prescription. No disciplinary action seems to ever have been taken to address this significant rate (11.5%) of non-compliance with the law.

Conclusion 

Washington continues its experiment with prescribing various cocktails of lethal drugs to be taken, often with no witness present, leaving people at risk of distressing complications and at risk of being killed by a family member or someone else interested in their early death. 

It has reduced the information contained in its annual reports since 2019, continues to fail to enforce compliance despite a significant rate of basic non-compliance by attending physicians, and in April 2023 amended the law in a manner likely to increase wrongful deaths from errors in diagnosis and prognosis as well as of those with mental illness. 

It is not a safe model for any other jurisdiction to follow.

1Washington State Department of Health 2021 Death with Dignity Act Report, p. 1, (Link)
2 Ibid.
3 Data derived from Annual Reports at: (Link).
4 Washington State Department of Health 2020 Death with Dignity Act Report, Table 3 on p. 10, (Link).
5 Ibid., Table 3 on p.12
6 Washington State Department of Health, Death with Dignity Act Reports, 2009-2018 available at: (Link).
7 Washington State Department of Health 2021 Death with Dignity Act Report, Table 3 on p. 8 (Link).
8 Ibid.
9. Washington State Department of Health 2018 Death with Dignity Act Report, Table 4 on p. 13, (Link).
10 JoNel Aleccia, “In Colorado, a low-price drug will tamp down cost of death”, USA Today, 15 Dec 2016, (Link).
11 Washington State Department of Health 2016 Death with Dignity Act Report, p. 9, (Link).
12 Washington State Department of Health 2021 Death with Dignity Act Report, Table 3 on p.8-9, (Link).
13 Washington State Department of Health, Death with Dignity Act Reports, 2009-2018 available at: (Link).

Euthanasia: Wrong is wrong, even if people are doing it.

By Meghan Schrader

Meghan Schrader

Meghan is an autistic person who is an instructor at E4 Texas at the University of Texas (Austin) and a EPC-USA board member.

I was reflecting the other day on how I first became aware of the issues of euthanasia  and assisted suicide, and what my experience indicates about a "majority" support for euthanizing people with disabilities. 

Back in 1998, during my last year of middle school, I had to take a class called Creative Problem Solving. It was basically an ethics class where people had to think through our opinions about controversial social issues. Our class studied the death penalty in-depth, but we talked about other issues too, and one of the issues we talked about was whether it was ok to help people with disabilities die by suicide.

John Kelly’s 1998 editorial about the death of 21-year-old, newly quadriplegic African American man Roosevelt Dawson at the hands of doctor Kevorkian was in the Boston Globe at that time; I think that’s what inspired my Massachusetts teacher to lead the discussion. He described the case; telling us that Dawson had been released from the hospital following a paralyzing infection, despite the hospital knowing that he intended to go to Dr. Kevorkian. “Wait, you mean they let him out of the hospital even though they knew that he was planning to die by suicide?” I asked. “That’s a violation of the Americans with Disabilities Act.” One other person agreed. “It’s wrong to kill people,” he said. However, almost everyone else in the class said nothing. I think that one other person said, “Well, I wouldn’t want to live like that either.” As a Special Education student, the connection between what we were discussing and the oppression of disabled people generally was blatantly obvious to me. “But think about all the technology we have nowadays,” I objected. “There are plenty of ways to accommodate people who are quadriplegic to lead fulfilling lives.” At the time, the term “ableism” wasn’t really in the public lexicon, so I used the only words I could come up with: “that’s discrimination,” I said, “it’s wrong to help people kill themselves because they have disabilities.” The lone other objector in the class agreed.

Then the teacher read a poem by Canadian poet Earl Birney. In it, two mountain climbers, Bobbi and David, ascend a peak together. On the way up, David kills a wounded bird. Bobbi notes: “That day returning we found a robin gyrating In grass, wing-broken. I caught it to tame but David took and killed it, and said, ‘Could you teach it to fly?’” Hence, the character David basically has the perspective that utilitarians and often general society has toward disabled individuals: accommodating disability is a hassle and eliminating disabled people is the easiest thing to do.

Then, in an ironic twist, David falls fifty feet, leaving him severely injured. Since David can’t feel his legs, he assumes that he will be paralyzed for life, and will need a wheelchair. Bobbi offers to stay with him or go for help, but David wants her to push him off a nearby cliff.

The teacher stopped reading the poem at that point and posed this question to the class: Should Bobbi push David off the cliff?

Again, there was the same pattern, with me and this one other guy objecting. “Of course she should not push him off a cliff,” I said, “she hasn’t even called 911 yet. What if he’s not paralyzed? And even if he was, that doesn’t mean that his life is worthless and she should push him off a cliff.” “Yeah, everyone has the equal right to live,” the objecting young man said.

As with our earlier discussion about Roosevelt Dawon’s suicide, most of the people in the class simply sat silently, looking uncomfortable. But, one of the class’s consummate bullies was more vocal about his perspective: “Of course she should push him off the cliff,” he said. “He’s a useless lump of flesh and he’ll burden everyone around him. What use does he have to society?” (This same bully had contributed to our class discussions about the death penalty by proudly saying that he would be willing to kill his own mother in the electric chair; I hope that he grew out of that type of thinking.)

Unfortunately, the bully’s perspective was the one that prevailed: most of the people in the class who were finally willing to say something agreed that Bobbi should push David off the cliff. And, what do you know, when the teacher finished the poem, we learned that she did just that.

I think that this anecdote from my eighth-grade classroom illustrates that personal choice shouldn’t always be sacrosanct. The Davids of the world aren’t entitled to conscript society into the rule of Bobbi so that the medical system can help them apply their nihilistic views about disability to themselves. Preventing violence and hate means that in equitable societies, majorities are obliged to cede some of their power to protect the rights of minorities.

From what I can tell, that middle school discussion was basically a microcosm of what most of contemporary human society has done in regard to euthanasia and its impact on the lives of disabled people. Most people either ignore it, or they are ok with it. However, this is a clear example of a time when communal support for an evil idea has been wrought from social conditioning and bigotry. Majority support doesn’t make something right, and the majority should not always get what it wants.

Swiss Prosecutors ask appeals court to re-examine case of a doctor who assisted the suicide of a healthy woman

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Pierre Beck

Swissinfo.ch reported on April 6 that Swiss prosecutors have asked the appeal court to re-examine the case of Dr Pierre Beck who assisted the suicide of a healthy 86-year-old woman who wanted to die with her husband.

In October 2019, a Geneva court gave a suspended sentence of the former vice-president of the assisted suicide group EXIT, Pierre Beck, for assisting the suicide of an 86-year-old healthy woman. 

At that time Swissinfo reported that Beck admitted to acting beyond the criteria of the law but he said that he didn't regret his action and faced with a similar situation he would likely do it again.

Swissinfo reported on December 9, 2021 that Switzerland's Supreme Court overturned the conviction of Beck on a technicality.

On Thursday, the Federal Court in Lausanne overturned this decision. Although judges were divided about the legality and nuances of the case, a majority of three against two concluded that Beck could not be found guilty under the Federal Act on Medicinal Products, but that the case should go back to the cantonal court in Geneva and be examined under the Federal Act on Narcotics and Psychotropic Substances, which includes pentobarbital.

Beck had admitted to assisting the suicide of an 86-year-old healthy woman because she wanted to die with her husband.

Swissinfo reporting on April 6, 2023 stated:

“The mere fact of a physician prescribing pentobarbital to a person in good health, capable of discernment and wishing to die, does not constitute behavior punishable by the law on narcotics,” read the court last court verdict issued in February.

But The Genevan public prosecutor’s office on Thursday said it has asked the Federal Supreme Court to take another look at the case.

Beck knowingly broke the law and did so without remorse.

A record number of euthanasia Netherlands deaths in 2022. 288 dementia euthanasia deaths.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition.

There were a record number of euthanasia deaths in the Netherlands in 2022, with 8720 reported euthanasia deaths representing 5.1% of all deaths and an increase of 14% from last year. The Dutchnews.nl reported:

The number of people dying in the Netherland with the help of euthanasia rose nearly 14% last year to 8,720, according to new figures from the regional monitoring committees, or RTE. 

The percentage is higher than in recent years and took the proportion of euthanasia deaths up from 4.5% to 5.1% of all deaths last year. The number of deaths by euthanasia had been increasing by around 10% a year.

• Article: Netherlands 2021 euthanasia deaths increased by 10.5% (Link)

The number of euthanasia deaths based on dementia significantly increased to 288 in 2022 from 206 in 2021, an increase of 34%. At the same time the number of couple euthanasia deaths increased by 23% to 379 with 58 couples dying at the same time. 115 people died by euthanasia for psychiatric conditions which was the same as 2021.

The number of euthanasia deaths that did not fit the criteria of the law increased to 13 cases in 2022 up from 7 in 2021. It must be noted that the Netherlands has a self-reporting system for euthanasia deaths meaning, the doctor who is the primary assessor is the same doctor who does the euthanasia and is the same doctor who reports the death. People rarely self-report breaking the law.

The number of Netherlands euthansia deaths may be even higher based on research indicating that 20% - 23% of the Netherlands euthanasia deaths are not reported.

The Netherlands euthanasia lobby is continually trying to expand the law.

The NL Times reported that the Netherlands Council of State published a report in December 2020, rejecting a "completed life" bill that was sponsored by the D66 MP Pia Dijkstra. Completed life is a concept that a person could ask and receive a lethal drug cocktail simply because they believe that they have no further reason to live.

A Netherlands man was arrested on Febuary 21, 2022 in the deaths of four people who died after ingesting a suicide powder. It was reported that the man, who was connected to the Coöperatie Laatste Wil (CLW) euthanasia group, may have sold the suicide powder online to at least 500 people.

On June 30, 2022 the DutchNews.nl reported that Netherlands Health Minister Ernst Kuipers announced the intention to extend euthanasia to children, but without changing the law by extending the Groningen Protocol, The Groningen Protocol permits euthanasia of babies. As of the writing of this article euthanasia has not been extended to children in the Netherlands.

In December 2022, a Dutch court rejected a challenge to the Netherlands euthanasia law by the group - Coöperatie Laatste Wil. The group launched a court case in October challenging the Dutch euthanasia law because it restricts killing to doctors. The group wanted anyone in the Netherlands to be able to assist a suicide with legal immunity.

The number of people dying in the Netherland with the help of euthanasia rose nearly 14% last year to 8,720, according to new figures from the regional monitoring committees, or RTE. The percentage is higher than in recent years and took the proportion of euthanasia deaths up from 4.5% to 5.1% of all deaths last year. The number of deaths by euthanasia had been increasing by around 10% a year.

Read more at DutchNews.nl:

The number of people dying in the Netherland with the help of euthanasia rose nearly 14% last year to 8,720, according to new figures from the regional monitoring committees, or RTE. The percentage is higher than in recent years and took the proportion of euthanasia deaths up from 4.5% to 5.1% of all deaths last year. The number of deaths by euthanasia had been increasing by around 10% a year.

Read more at DutchNews.nl:

The number of people dying in the Netherland with the help of euthanasia rose nearly 14% last year to 8,720, according to new figures from the regional monitoring committees, or RTE. The percentage is higher than in recent years and took the proportion of euthanasia deaths up from 4.5% to 5.1% of all deaths last year. The number of deaths by euthanasia had been increasing by around 10% a year.

Read more at DutchNews.nl:

Portugal's Parliament passes its fourth euthanasia bill. Is this bill also unconstitutional?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Portugal's parliament

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

The Portugal Resident reported that:

A new version of a law seeking to legalise euthanasia was approved in Parliament today (March 31) after being changed to address the demands of the Constitutional Court, which rejected it for a second time on January 30.

The changes to law state that euthanasia can only be performed if assisted suicide is impossible due to a patient’s physical incapacity. All references to “physical, psychological and spiritual suffering” as conditions to be elligible have also been eliminated, as judges believed that this could lead to “many interpretations” and be “abused legally.

President de Sousa

President de Sousa, who has been opposed to euthanasia, can sign the bill, veto the bill or send the bill to Portugal's Constitutional Court.

On January 31, 2023 I reported that 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 had 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."

The three previous bills were either declared unconstitutional or vetoed based on imprecise language. The euthanasia lobby appear to be following Canada's lead by passing euthanasia bills that lack definition. Legislation that is not sufficiently defined will naturally expand over time.

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.

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.