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.”
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
Comments
It's with some concern I see the author has indulged in some of the same intellectual dishonesty he accuses MAID advocates of engaging in. There is no doubt that Canada is a caring society only superficially, and as a MAID's supporter myself, I have warned MAID advocates that they really have to pay attention to the justifiable concern of challenged communities - that persons with challenged lives have historically been deemed less valuable - whether the challenges are a result of workplace injuries, illlness, or from inception at birth. That said, it is ironic that the author looks for greater rigor, presumably from the psychiatric profession: that 'rigor' was blown up more than a decade ago when U.S. medical studies found that 75% of homeless people with a serious mental health diagnosis actually had physical brain injuries. So by all means, let's have a debate about what it means to be a caring society that doesn't condemn people to unnecessary discrimination and suffering of ANY sort - and ease right off the moral rhetoric.
I think I see what you're getting at--but if I do, it doesn't really contradict anything the author said. I mean, sure, preferentially "assisting" marginalized, impoverished people to kill themselves is just adding insult to the main injury of marginalizing so many people in the first place . . . but that doesn't make it incoherent to have an article that's about the insult. You can only talk about so much stuff at once.
That "debate" you mention is ongoing though due to the binary nature of our current politics, so it goes back and forth, back and forth, and will continue to in the foreseeable future until progressives get a perspective, if ever. This situation is an example of how that isn't a slam dunk as we argue amongst ourselves about details instead of focusing on the big picture. Netherlands and Belgium already have MAID for mental health reasons, and I doubt there is any malice aforethought there OR here. Quite the contrary; I would imagine the medical profession always erring on the side of care to a fault, often to a paralyzing degree. So when someone FROM that profession makes accusations of irresponsibility, OR ideology, and is a man I might add, I wonder if a) it's a turf war or b)HE'S actually the one influenced by ideology such as a culture strongly informed by religious faith (note the root word of culture.)
I agree with your assessment of the "rigor" of the psychiatric profession in general though; they have recently declared that prolonged grief (lasting more than a year) is a mental disorder?
Wow Tris Pargeter. While the limitations of time and realities of life/family limit replying to every comment, your comment pushed beyond any threshold and I had to respond.
While I can appreciate (and would like to share) your confidence in the “medical profession always erring on the side of care to a fault”, you might want to read some of the words of the MAiD providers themselves here (spoiler alert, it may disabuse you of our shared/wished for confidence): https://www.thenewatlantis.com/publications/no-other-options
More to the point of why I needed to respond to your comment - I was struck by your ‘wonderings’ in your ‘a)’ and ‘b)’ comments. Regarding your ‘a)’, speculating about a “turf war”, the only tension I’m aware of is whether or not evidence informs our policies. In my mind that is not about turf. My colleagues and I who are concerned about the lack of evidence-based guidance so far informing MAiD expansion would be happy to cede ground to any groups who actually provided evidence-informed input (indeed we have been pressing some key groups for the past two years to contribute actual evidence relevant to mental illness and MAiD, which they have declined to do).
Regarding your ‘b)’ point, which to me is more personally troubling - as far as I know, you know nothing about me. You have read this piece I wrote and perhaps you have seen the photo attached to it (which shows a brown man), and you specifically comment “and is a man I might add” when questioning the integrity of my arguments. It is true I was born male. I had no control over that. You don’t appear to challenge the specific arguments I make (which mostly point out what others have literally said), instead you suggest that my arguments are based on “ideology”. I’m not sure what “ideology” you think that taints my article with. Regarding ‘gender inequity’, while I don’t point this out in this piece (word limits), I have often cited evidence from the few European countries allowing it that shows the expansion of MAiD to mental illness is also associated with a 2:1 ratio of completed female:male psychiatric euthanasia (compared to a 50:50 gender balance for MAiD for end-of-life conditions).
And as per the photo you may have seen, I was also born brown. It may be true that that sensitizes me to how the so-called ‘autonomy’ that Canada’s MAiD expansion promises is a privileged autonomy (and keep in mind, even before expansion, anyone with even 10 years left to live could get MAiD, you didn’t need to be ‘on death’s door’). Similar to most colonial policies, while MAiD expansion might increase autonomy for the privileged few, it does so at the expense of the marginalized exposed to racism, sexism, ableism, ageism, and any range of other ‘-ism’s. Feel free to read https://theconversation.com/the-next-national-apology-future-canadians-… for more on this.
M. Pargeter, as you request, I do “note the root word of culture” when you apparently question my motivations/influences and you write “as a culture strongly informed by religious faith”. I have no idea whether you identify as male, female, non-binary or other, or are white, black, brown, or any other colour. Once again, while you may have seen my picture you don’t know me or any of my belief systems, including not knowing whether I adhere to any religion at all, yet you seem entitled to publicly imply whatever you are implying from your comments. Please do clarify on what basis you write publicly that you “wonder if HE'S actually the one influenced by ideology such as a culture strongly informed by religious faith”; and please feel free to identify whatever religious faith you think I might be informed by, in your mind.
Regardless of whether you chose to reflect on what some of your assumptions might reveal, which you seem to feel entitled to make in a public forum, I hope others can self-reflect and make their own reasoned judgements.
Thank you for replying and for the good, informative links, which I did read. The fact that MAiD is now legislated as a human right while palliative care is not clearly reveals our increasingly dire systemic shortcomings that I'm assuming are not as much of an issue in more socially progressive Netherlands and Belgium?
I have also made assumptions about you but they have nothing whatsoever to do with your race. In the first link, the "about" section of The New Atlantis" mentions that academics mainly write for each other, understandably, so there's bound to be lots of healthy jockeying for position, literally, hence my term "turf war;" having professional pride is natural. And my further assumption that men are generally uber-competitive isn't a stretch.
On my other speculation that your opinion might be influenced by religious faith, (pretty much the definition of ideology) I'm drawing on a common conservative disparagement that it's progressives who are motivated by ideology rather than THEIR specialty of "common sense," despite the fact that the political right wing are the ones who are disproportionately religious, i.e. ideological. I hear this as justification in both their anti-abortion and anti-MAiD stances, "holier than thou" despite the glaring hypocrisy of adhering to the political philosophy that totally demonizes the left-wing socialism that would at least help mitigate both babies born into poverty and people desperate to escape its cruel repercussions.
I can see that expanding MAiD in the current context of our system could far more readily become as horrifying as when so many seniors died from covid in our "care" homes.
Everything involving people is ultimately political, especially issues involving life and death, so where even a pandemic and climate change have simply become a tool for the insane cult that the right wing has become, one of the few things I have at least some faith in (I am an atheist) is that the progressive left-wing is humanity's only hope because they are the only ones capable of at least "reading the room" and adapting accordingly. And they are the only ones capable of at least initiating the changes in our system that are so obviously needed.
There have been criticisms of the Netherlands system, amounting to children anxious to receive inheritances finding the two doctors necessary to authorize planned death. The percentage of all deaths in Netherlands that were medically "assisted" was nearly 15% in some cities.
Whether we think suicide is a good idea or not, I don't see what the rationale is for the medical profession assisting it in cases of able-bodied people with mental disorders. I mean, the original thing was that people at end of life, who were suffering terribly from terminal illnesses, were not physically capable of ending their own lives--so if we thought it was reasonable for them to do so, someone was going to have to help.
But if people with, say, serious depression really want to kill themselves, they're physically capable of doing it. Even aside from the basic point that I'd really rather they DIDN'T kill themselves, I don't see why anyone else should be helping them do something they can do themselves--let alone the medical "first, do no harm" profession.
I also think there are some serious risks here . . . when did they stop sterilizing First Nations women, again? Oh, that's right, they never really did. If this goes through, how long till we start seeing rather questionable "assisted" suicides of racialized people?
I note that proponents quoted in the article suggest some of the people are not capable of committing suicide, for "possibly mental reasons". OK, and this is a problem because? If someone isn't mentally capable of killing themselves, then, wild idea here, maybe they should stay alive.
We do know people who are 'capable' kill themsleves in a variety of ways. A work collegue killed herself by jumping off a bridge. Problem was she took her eight year old daughter with her.
A close friend of almost 60 years had a brother with a tormenting mental illness for 50 years +. He jumped from the 10th floor. The police wouldn't let my friend see the body because of the result.
I'm sure you didn't intend levity with the phrase "wild idea", and there are sometimes terrible intended or unintended consequences. Again, the moralism is not helpful to the discussion. Robert Latimer was and still is convinced that he was morally correct when he murdered his 12 year old to relieve her of her 'suffering'.
What I'd like to know is how, here in Toronto, a MAID committee allowed the "assisted death" of a woman with a non-terminal physical illness, multiple chemical sensitivities, aka environmental injury, whose only reason for seeking it was that her landlord refused to comply with Ontario's Accommodation of Ontarians with Disabilities Act ... and she asked for very reasonable accommodations, that would keep uncleaned cigarette smoke from being pumped into her tiny rental accommodations.
I'd like to know how the MAID committees are being monitored.
I'd like to know how psychiatrists get to decide, the same psychiatrists who ignore the basics of medicine (and don't look for physical causes of the distress of their patients) but instead go straight to drugs to "fix" them. I had a very, very interesting conversation with two people, one day.
One was a psychiatrist who did nutritional workups, and "cured" most of his patients with vitamins and a few dietary changes.
The other was a medical doctor, a family physician, who told me about research he'd been involved in at an Alberta university, many, many years ago ... in which they'd determined specific food allergies, sensitivities and intolerances, such that e.g., schizophrenics no longer exhibited schizophrenia. The patients *wanted* to be healthy, but they had lousey drug compliance because the side effects of the drugs they were prescribed were miserable.
The thing that strikes me over and over again is twofold: physicians, I thought, are supposed to be about saving lives, and relieving suffering: not killing people. Because, really, that *is* what MAID is.
For those afflicted with unquestionably progressive and terminal conditions, and know what's in store for them and their loved ones, and decide they'd prefer to leave their estates and life insurance policies intact, I suppose that's one way. I don't know what I'd do, myself, were I in that position, and pray I don't find myself in a position to find out.
For anyone whose memory is so short as to not remember all that's gone down in Ontario's long-term care facilities, it's bizarre to imagine that our governments have any intention of doing anything other than milk those who need help for every cent of profit available, and let'em die.
I'd still like to know who told the long-term care facilities not to send their residents to hospital if they became ill. Basically, they set up death traps, and then confined the residents there. Many died needlessly, abandonned by the government, by the health care system, and by "society."
MAID at this point isn't what it was initially billed as. It's now a Final Solution to poverty, old-age, illness, disability ... and how is it, for heaven's sake, that one has to be "of sound mind" in order to dispose of one's possessions by Will, but can without being of sound mind be coerced into "accepting" ... gosh, I don't know whether to call it suicide or murder.
That is, plainly and simply, sick. From start to finish. From those who push for legislation to enable such, to those who legislate, to those who authorize, and those who do the deed. Shame on the whole lot of them.
The debate over MAID expansion is about as useful as the debate over whether climate change is really happening. It's one thing when the physical pain is too much, but what's going on now is absolutely disgusting.
The goal of the long-term disability industry is to not get involved with underwriting the costs of treatment of chronic diseases such as long-COVID and long-Lyme. MAiD would seem to fit well with shareholder preferences and industry goals. We have a growing, ignored and hidden epidemic of Lyme and tick-borne diseases in Canada that the insurance industry red-flagged as being too expensive to treat in 1994. Complex disseminated Lyme is an invisible, debilitating disease caused by Borrelia burgdorferi and we know that it is treatable using a combination of antibiotics. PHAC is headed by two infectious disease doctors and PHAC’s priority is the preservation of the antibiotic supply over returning Canadians to health. Family docs have to live with their patients and have been abandoned by their infectious disease colleagues. Infectious disease doctors refuse to recognize chronic Lyme disease and are very uncomfortable with microbes that can cause neurologic disease. Physicians who treat Lyme appropriately are in danger of being investigated and losing their medical licence. Diseases that kill suddenly grab doctor’s attention but Lyme seldom kills outright, you just wish you were dead. Patients are being disbelieved and disrespected; suicide is not an uncommon outcome. Physicians can do something the rest of us can’t, they can bury their mistakes.
In medicine the dead shall speak to the living except autopsies are expensive and no longer done unless violence has been involved. Medicine has lost its way and there are no medical sleuths searching for the root cause of disease. No one in medicine is being trained with advanced microscope and lab techniques. Shareholder preferences control medicine and shareholders are not interested in cures, new antibiotics or vaccines. The paradigm of modern medicine is to palliate with treatments that provide lifetime annuities to the pharmaceutical industry.
The Lyme disease disaster for Canadians is an excellent example of how the ‘self-regulating’ medical colleges and medical associations have woven themselves into the publicly funded health care system positioning themselves as the only experts. The PHAC evaluation report released on 30 May 2022 recommends that federal public health authorities attempt to manage stakeholder expectations "setting clearly defined roles and expectations for stakeholder groups". This report also reiterates the false dichotomy between "science groups" [i.e. only IDSA ideologues] and "patient stakeholders. This dichotomy implies [falsely] that patient stakeholders are not operating based on credible science evidence. This is belittling and reflects PHAC's one-sided support for the IDSA "acute Lyme only" perspective, instead of a more balanced science-based ILADS approach.
No outside scientific expertise is allowed no matter how much harm is done to the public, and in fact they ridicule true ethical scientists while themselves practice unethical anti-science and pseudo-science. It is all about ego and controlling an agenda and has little to do with public good. Patients are just road-kill on the way to industry profit. I fear many of these medically abandoned patients with a treatable disease will be applying for MAID.
Bingo!!!