Medical assistance in dying (MAID) in Canada has morphed from relief of end-of-life suffering to socially sanctioned suicide, and expansion advocates now openly accept arguments they formerly denied. We should take a cautionary note of these shifting sands.
First introduced in 2016 for when death was foreseeable, well over three per cent of all Canadian deaths are now through state-provided euthanasia, with rates approaching or exceeding five per cent in some provinces. Rates will certainly rise since Bill C-7 opened the door last year to euthanasia of non-dying people with disabilities who have decades left to live. The public premise has been that MAID is for medical conditions we can predict will not improve (i.e., “irremediable” conditions). Sadly, that primary safeguard has been bypassed. As someone who supported MAID when it was introduced for end-of-life suffering, but cautioned against unfettered expansion, I believe this represents a fundamental betrayal of the public promise.
The push for psychiatric euthanasia epitomizes the changing arguments used to justify MAID expansion.
After a year’s worth of assurances that euthanasia would not be provided for sole mental illness, in 2021, Bill C-7 was amended last minute to introduce a “sunset clause” to remove the safeguard against psychiatric euthanasia by 2023. When arguing for the sunset clause, expansion advocates claimed “irremediability” of mental illnesses could be predicted, that standards could be set, and that psychiatric MAID was not the same as suicide.
The expansionist Halifax Group wrote in 2020 that “it is possible for a practitioner to be of the opinion that a person’s mental disorder is incurable” and called for “standards for clinical assessments” and “the introduction of the additional eligibility criteria and procedural safeguards.” Yet, when it came to setting standards after passage of the sunset clause, the 2022 mental illness federal panel tasked with recommending safeguards and protocols failed to provide any.
Instead, the federal panel concluded “it is not possible to provide fixed rules for how many treatment attempts, how many kinds of treatments, and over what period of time” that treatment should have been tried prior to providing death for mental illness, and falls back on an individual assessor’s subjective “case by case” judgment.
The inability to set scientific standards for determining the incurability of mental illness should not be surprising. The Centre for Addiction and Mental Health had already reviewed evidence and concluded clinicians cannot reliably predict when any individual case of mental illness will not improve. What may be surprising is that the federal panel chair co-authored the 2020 Halifax Group report providing earlier assurances that standards could be set and incurability predicted. By 2022, her new panel tasked with recommending safeguards suggested that psychiatric euthanasia “can be fulfilled without adding new legislative safeguards.”
While in 2020 expansionists were reassuring that psychiatric euthanasia would only be for incurable conditions, by 2021 they were acknowledging people who could get better would receive psychiatric euthanasia. In its report (again, co-authored by the same federal panel chair), the expansionist Quebec psychiatric association AMPQ acknowledged “it is possible that a person who has recourse to MAID … could have regained the desire to live at some point in the future.” By 2022, the federal panel even acknowledged that MAID and death by suicide may be the same thing, suggesting “society is making an ethical choice to enable certain people to receive MAID on a case-by-case basis regardless of whether MAID and suicide are considered to be distinct or not.”
I do not recall society making that “ethical choice.” Sadly, Canada’s justice minister, responsible for allowing MAID expansion, seems to have adopted this viewpoint, normalizing suicide to the point of suggesting we should make it easier for those suffering from mental illness to decide to die. Minister David Lametti recently made the claim that psychiatric MAID for mental illness “provides a more humane way for [people with mental illness] to make a decision” when “for physical reasons and possibly mental reasons, [they] can’t make that choice themselves to do it themselves.”
The expansion of Medical Assistance in Dying has not been about evidence, but an ideology that sacrifices the most marginalized, writes Sonu Gaind @Psych_MD @UofT #AssistedSuicide #MAID #MentalHealth #cdnpoli
Incidentally, two members of the initial 12-member federal panel resigned, including the panel’s health-care ethicist and a consumer advocate with lived experience. They cited flaws in the process and recommendations, including concerns about “the chair being a nationally recognized, strong advocate” for the expansion of MAID for mental illness, the “lack of reporting transparency regarding dissenting opinions or views” and an unwillingness of panel members “to put forward any serious safeguards that would require the law to change.”
Similar to other earlier assurances, expansion activists initially provided reassurances that an expanded MAID would not put marginalized populations at risk, citing North American evidence showing those who were well-off, better educated and white were more likely to get MAID. This misleading justification reflected the use of MAID in end-of-life situations. It ignored evidence showing that when expanded beyond end-of-life care, marginalized groups seek MAID to escape resolvable life suffering.
After Canada’s MAID expansion to the non-dying disabled in 2021, with Canadians publicly saying “I die when I run out of money” and international headlines asking “Why is Canada euthanizing the poor?”, expansionists changed their tune once again. Instead of denying that life suffering could fuel MAID requests of the marginalized, expansion activists now suggest preventing suicide in these situations would “translate into removing the agency of decisionally capable patients without offering them a way out of their predicament.”
The chimera has evolved rapidly. Starting with promises in 2016 that MAID would only be for incurable medical conditions, that there would be responsible standards and safeguards with expansion, and that the poor, marginalized, and suicidal would not be at risk, expansionists now openly acknowledge that non-dying disabled who could get better will get euthanized, claim further safeguards are not needed, and accept that poverty and suicidality will fuel some MAID requests — all while continuing to push for further MAID expansion, including to children.
This peeling away of false justifications reveals the reality that MAID expansion has not been about evidence, standards or safe protocols, but about ideology (pages 72 to 82 in the World Medical Journal). Tragically, this ideology sacrifices the most marginalized among us to avoidable and premature deaths fuelled by social suffering.
The nascent Society of Canadian Psychiatry, the Canadian Association for Suicide Prevention, the academic chairs of Canada’s 17 departments of psychiatry and literally hundreds of psychiatrists across the country have cautioned about the vacuum of evidence and standards informing the planned March 2023 implementation of MAID for mental illness and pushed for a pause.
On Dec. 15, the government announced it would delay its planned March 2023 implementation of psychiatric euthanasia but reiterated its ideological commitment to it. Yet, the federal panel chair (whose committee failed to provide any specific guidelines for determining incurability) and other expansion activists dismissed widespread concerns about the absence of any standards and objected to the delay. Instead, the panel chair continued providing non-specific reassurances that we would have been prepared in three months to assist with suicides for mental illness, wrongly suggesting the push for pause reflected ideology rather than the obvious absence of any common sense evidence-based standards.
Throughout this process expansion activists have dismissed that those cautioning against a slippery slope were crying wolf. Meanwhile, reassurances regarding expansion “being safe” have obscured the shift from assisted dying for relief of end-of-life suffering to facilitated suicide for ending life suffering. Given the chimera-like nature of justifications for expansion, perhaps it is these arguments that were wolves in sheep’s clothing.
There are many voices in this debate. Hopefully, the federal government has realized the risks of continuing to rely solely on the echo chamber of the most ardent expansion activists for guidance, and moving forward ensures future MAID policies are guided by evidence and not only ideology. Any other course would be morally, medically and politically irresponsible.
K. Sonu Gaind is a professor of psychiatry at the University of Toronto, a former president of the Canadian Psychiatric Association (which he notes has failed to provide critical, evidence-based input to MAID expansion consultations) and founding director of the Society of Canadian Psychiatry. He sat on the Council of Canadian Academies Expert Panel on Assisted Dying and Mental Illness, was retained as an expert in the Truchon and Lamb cases by the former attorney general of Canada and is chief of psychiatry and physician chair of the MAID team at Humber River Hospital. Twitter: @Psych_MD