Donna Wilson says YES
Registered nurse and professor of nursing at the University of Alberta
I finished my first nursing program in 1976 and began working in hospitals. At that time, we were witnessing an explosion in life-saving medications and other healthcare technologies. It was so very exciting to think that people would no longer die of injuries and common illnesses.
What we now call “avoidable” deaths were normal occurences before today’s healthcare technologies became readily available. It wasn’t that long ago that life support became possible. Antibiotics only came into wide use after the Second World War. Canada’s first intensive care unit opened in 1958, but it wasn’t until the 1970s that all larger hospitals routinely had ventilators and heart monitors.
These and other lifesaving technologies were welcome, but a major issue quickly surfaced: the belief that physicians had a moral obligation to use these interventions, even if they were considered futile and even if the patient didn’t want them. Much broad-based concern subsequently arose over patient rights and persistent vegetative states.
The 1975 Karen Ann Quinlan case in the US brought these matters into stark view, as her physicians refused to stop her ventilator despite her irreversible brain damage. In 1976 her parents fought successfully in court to discontinue her ventilator. Quinlan lived another nine years in a coma in a nursing home because of daily tube feeding.
In 1984 the Canadian Nurses Association, Canadian Medical Association, Catholic Health Association and other legal/health groups issued the Joint Statement on Terminal Illness, saying “in conditions of ill health and inevitable death… no resuscitation is appropriate and ethically acceptable. It is also recognized that it is the patient’s right to accept or refuse treatment.”
Life extension remained the norm, however. My first research study in 1991/1992 was on long-term tube feeding, a common practice then in nursing homes and hospitals.
The turning point in Canada was our first widely covered “right to die” case, when Sue Rodriguez requested assisted suicide. Her request was denied in 1994, although four of the nine Supreme Court judges sided with her over changing Canada’s Criminal Code so that adults who wanted to die could have their death assisted by other people.
Additional citizen petitions to the courts led to the June 2016 legalization of MAID for people whose death was reasonably foreseeable. In March 2021 MAID eligibility was expanded, because more citizens petitioned for MAID access. Ill people who were uncertain about when they would naturally die gained the right to have MAID approved for later possible use.
Healthcare technology will improve and society will ever evolve. So it doesn’t surprise me that more people would like the right to apply for and receive assistance to end their life earlier than if nature took its course. We are each best able to determine if our own death is preferable to living longer.
Trudo Lemmens says No
Professor and Scholl Chair in Health Law and Policy at the University of Toronto
We need to refocus MAID on its original purpose: allowing patients who are approaching death to ask healthcare providers to end their life in exceptional circumstances. This means withdrawing Track 2 MAID, the consensual killing of disabled persons whose natural death is not reasonably foreseeable, and strengthening other safeguards, as urged by the UN Committee on the Rights of Persons with Disabilities.
When the Supreme Court ruled in Carter that an absolute prohibition on euthanasia and assisted suicide violated the Charter, it instructed Parliament to balance protecting people against premature death with some form of access to physician-assisted dying. Parliament therefore initially focused its MAID law on end-of-life, with reasonably foreseeable death as a crucial safeguard. It required unambiguous consent, irremediable illness, intolerable suffering and irreversible decline of capability. MAID was deemed exceptionally justifiable based on compassion for people suffering intolerably from irremediable illness, and to provide them more control over their dying.
MAID promoters immediately pushed to stretch access criteria and challenged the end-of-life safeguard. When a Quebec court ruled that providing MAID only at the end of life was unconstitutional, the federal government failed to appeal and instead rushed through its expanded 2021 MAID law, removing safeguards and allowing MAID for disabled persons whose death wasn’t reasonably foreseeable.
Canada now has arguably the most open-ended euthanasia law, with a record of 60,000 deaths. Some 4.7 per cent of all deaths in Canada are by MAID, second only to the Netherlands. Most fall within Track 1 (foreseeable natural death), but many of these people may have had years of life left. Since the expansion, more than 1,000 disabled persons have died under Track 2.
For MAID expansionists, high numbers are a success story. But reports from Health Canada, the Ontario Chief Coroner’s office and various media reveal that many people ask for MAID not due to irremediable suffering in dying but for suffering in life that must be addressed by adequate healthcare and social supports. Suicidal patients, often with intersecting physical and mental disabilities, with years or decades of life left if supported to live, are increasingly hastened to death by MAID.
Killing people or encouraging suicide remain prohibited under the Criminal Code, including for physicians. But the exemption for MAID has given health professionals discretionary powers to end life as a form of therapy, opening the door to abuse and overzealousness. MAID law, weak guidance and oversight, and aggressive MAID promotion have undermined the prohibition. It tells disabled people facing serious challenges that ending their life is a reasonable option. In the name of false compassion, it pushes people over the edge when they need support. It’s hard to imagine a greater social injustice. Further expansion of MAID is unconscionable.
donna wilson responds to Trudo Lemmens
MAID eligibility should be expanded to Canadians with diagnosed mental illnesses. Currently, we are in a three-year pause ending March 17, 2027, to prepare for this extension. After that, people with impactful mental illnesses will be able to request MAID. As in all MAID cases, by law, the requester must complete an application and be assessed as meeting all criteria by at least two nurse practitioners or physicians. MAID will continue to hinge on an autonomous and non-coerced decision being made for professional assistance to end one’s own life earlier than if nature took its course.
Before rebutting Trudo Lemmens, I’ll highlight two key reasons for this expanded eligibility.
The first is that people are the best judge of whether or not their life should continue. As a nurse I’ve seen many terminally ill and dying people awaiting death. They and their family really suffer. I remember one man telling me (before MAID legalization) he’d put down his dog when it suffered, but his sister, who was dying a terrible death, couldn’t have her suffering ended. We have better pain options now, but ill people still suffer in so many ways. The 2023 MAID report highlights two (almost universal) concerns of people who request MAID: loss of ability to perform activities of daily living, and loss of ability to engage in meaningful activities. This is understandable, as 95.9 per cent of MAID recipients had an end-stage illness—cancer in two-thirds of cases—with death immediately foreseeable. As a long-time palliative care advocate, I started to advise Health Canada in the 1990s on the need for hospices, as Canada lagged behind other developed countries in compassionate care options. We still do. The 2023 report shows that 75 per cent of MAID recipients received palliative care, but we lack support for high-quality home and nursing home deaths.
The second reason is that diagnosed mental illnesses have significant long-term effects. Unemployment is common, as is poverty. Over time fewer friends and family can be counted on, and adults living with a mental illness often end up homeless. Most live with multiple physical ailments as they age prematurely. These are people who are diagnosed with a mood disorder (major depression or bipolar), anxiety disorder, substance abuse disorder or another mental illness such as schizophrenia, eating disorder, obsessive-compulsive disorder, PTSD, attention-deficit/hyperactivity disorder or dementia. Most have the capacity to decide if death is preferable over continued life.
MAID is planned, controlled and openly reported; it is a safe and effective procedure for people who choose it.
Lemmens would “refocus MAID on its original purpose: allowing patients who are approaching death to ask healthcare providers to end their life in exceptional circumstances. This means withdrawing Track 2 MAID, the consensual killing of disabled persons whose natural death is not reasonably foreseeable.” His argument reminds me of ones used to try to prevent MAID legalization. Chief among them was the slippery slope fear: that we would become so accepting of killing people that we wouldn’t care or notice when disabled people are encouraged (or forced) to have MAID. Lemmens’s use of the term “disabled” illustrates this fear. The slippery slope has not materialized anywhere MAID is legal. MAID legalization means death-hastening is planned, controlled and openly reported; it is an effective medical procedure for people who choose it and who meet the legal requirements for it.
Lemmens’s wish isn’t reasonable, as many individuals and organizations support the 2020 amendment extending MAID to people who don’t have an evident death date. In 2023 there were 19,660 MAID requests, with 15,343 people receiving MAID, 2,906 dying before they could receive it, 915 deemed ineligible, and 496 withdrawing their request. Most people fear dying and death; having MAID as an end-of-life option is compassionate.
Going back to the 2016 policy would mean assisted death could only occur a few hours or days earlier than if nature took its course. Canadians would again know they need to suffer through almost an entire terminal illness. They’d need to be awake and alert at the time MAID was scheduled, so they could say or indicate they still want it. To achieve this last-minute consciousness, painkillers and sedation are often withheld.
It’s important to try to understand why anyone would have MAID limited to only those in such an advanced state of illness that their death is imminent. Lemmens is a bioethical theorist, not someone with evident healthcare degrees or healthcare employment to show him first-hand how much ill people and their families suffer. His use of the term “patient” is telling. That outdated term reflects subservience to healthcare professional dominance.
Lemmens appears to think MAID is too easy to obtain, something the annual MAID reports show to be untrue. I believe MAID should be available to all Canadians, including those with diagnosed mental illnesses.
trudo lemmens responds to Donna Wilson
Donna Wilson suggests MAID should be expanded because more people want to “receive assistance to end their life earlier than if nature took its course.” She further sees MAID as a response to a medical system otherwise excessively focused on stretching lives. This reflects common misconceptions about MAID and trivializes concerns about state-funded healthcare-provider ending of life.
The argument that legalizing euthanasia is needed to counter aggressive life-extension was once common but no longer holds. Respect for refusal of life-prolonging measures has been essential to medical law and practice for decades. More-holistic medical practices, particularly palliative care, emphasize quality of life and patient and family empowerment, not technology-driven life-extension. Unfortunately, the expansion and prioritizing of MAID risks undermining palliative care.
In fact, MAID via lethal injection (which is not just “receiving assistance”) medicalizes dying itself. This may be why some physicians embrace MAID so enthusiastically. Physicians can have trouble accepting that they have no “fix” for suffering patients. MAID gives them the illusion of medical control over dying, an event that otherwise escapes control. Rather than a reaction against technology gone wild, MAID is a technical way to deal with an essential human experience.
Wilson’s ethical justification that “people want it” also ignores the official justification for MAID as well as the complexity of healthcare and end-of-life decision-making, and the broader context in which choices are made.
No jurisdiction accepts choice as a sufficient basis for legalizing euthanasia. All have criteria that reflect how physicians can only offer it for compassionate reasons in exceptional circumstances. Even standard medical procedures aren’t justified solely based on choice. Healthcare providers must offer evidence-informed care that respects professional standards. Less risky procedures must be tried first. Brain surgery to control seizures is unacceptable, even if patients want it, if less intrusive options may work. Remarkably, Canada’s MAID law introduced death as therapy even when other options to ease suffering exist. Ending of life has become a consumer good “on demand.” This also lets society and our health system off the hook for failing to ensure timely care.
Broadly legalized MAID sends a message: death is prioritized over care for disability and disease-related suffering.
Over-reliance on “choice” ignores the complexity of healthcare decisions. For the UN Committee on the Rights of Persons with Disabilities, Canada’s MAID system’s reliance on choice “creates a false dichotomy.” Choices are determined by psychological (e.g., despair after a disabling accident), economic, cultural and social factors. Poverty, loneliness, power-differentials between physicians and patients, ableist attitudes—rampant in healthcare—family pressures and lack of timely care undermine choice. The Committee also warns that our MAID law sends a message that death can be prioritized in response to disability and disease-related suffering; that a life with disability doesn’t require the same protection against suicide.
Imagine what the 2027 introduction of MAID for sole reasons of mental illness—and its eventual expansion to minors—could entail. Unlike other diseases, many mental illnesses have suicidal ideation as a diagnostic criterion. The trajectory of mental illnesses is uncertain, and psychiatrists can’t reasonably predict who won’t get better. MAID is said to be needed for irremediable medical conditions in people with irreversible decline. But physicians would offer it to people who will likely get better with good mental health care, in which conveying hope is crucial. Imagine a 17-year-old with autism who struggles with depression and refuses care, believing no further option exists. MAID assessors could offer that person death as a form of therapy. Some would prudently explore other options. But MAID here is already dominated by providers who often seem to prioritize access over protection. Recent cases discussed in reports by the Ontario Chief Coroner’s office and in the media reveal that assessors without strong expertise in mental health care or complex conditions already approve or provide MAID to patients with such intersecting illnesses, including some with suicidal ideation.
An ongoing Alberta controversy shows how people can get approved for MAID even when doubts exist about their eligibility. The case involves a woman in her 20s who according to her father has autism but no clearly diagnosed irremediable illness. Neither health authorities nor regulators have been willing to intervene, even though half of the physicians in three subsequent requests for MAID deemed her ineligible, and questions abound about her lack of care and “doctor-shopping” for approval. Rather than expand MAID “because patients want it,” let’s investigate why people ask for it, how we can improve care, and how our existing MAID regime needs to be changed to protect people against premature death.
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