Encouraged to Die?

When Ross Douthat wrote about Canada’s love affair with the “holiness of euthanasia” in a December New York Times column, he hit a nerve.  His primary argument is reductionist, facile, and oracular but correct in its essentials: “What if a society remains liberal but ceases to be civilized?” Is Canada, in truth, Douthat’s moral dystopia, the inexorable endpoint of a corrupting liberal trajectory? A cautionary tale for an American society caught in an embattled landscape of irreconcilable philosophies?

Yes and no.

What provokes Douthat is the pending law before the Canadian Parliament that will expand its Medical Assistance in Dying (MAiD) legislation. In 2016, medical assistance in dying became legal in Canada as long as certain conditions were met, including the restriction that only patients with terminal illness were eligible. Indeed, the natural death of the patient must be deemed as reasonably foreseeable and the suffering irremediable. In 2019, a Quebec judge ruled that this legal restriction was unconstitutional and that Parliament needed to amend the MAiD legislation to include adults who didn’t have a reasonably foreseeable death. In 2021, the revised MAiD came into force and almost immediately there were cries for even further amendments, including the right for those suffering from mental illness to elect their time of death. Parliament imposed a two-year study period before any further alterations, with new legislation to be debated and most likely enacted in March.

But this appears to be a step too far for many Canadians—liberal creatures that we are—and pushback has been formidable. The Association of Chairs of Psychiatry in Canada—the lead psychiatrists of Canada’s seventeen medical schools—called on the federal government to delay the expansion of assisted dying to people with mental illness. These psychiatrists, and many others in private practice, are especially vexed over the law’s irremediable condition clause, arguing that it is very difficult, if not impossible, to predict accurately who will and who will not recover from a mental disorder. The Chairs Association makes the point that experts will need to find some common ground on “operational definitions of irremediability for different mental disorders” because no such consensus currently exists. In addition, many psychiatrists are disturbed by the simple clinical reality that physicians might find it challenging to distinguish between a client who is suffering from acute suicidal ideation, and one who is rationally seeking an assisted death as the final remedy for unendurable pain.

It is important to acknowledge that the primary concern of the psychiatrists is not the law per se, but its expansion to include mental-health candidates without any kind of training regimen established for evaluating these candidates. Medical school curricula need to be upgraded, safeguards put in place, and the full airing of contentious issues around prognosis assured before any expansion of the legislation is enacted.

Professional associations of psychiatrists aren’t alone in raising concerns. The executive director of the Canadian Association for Suicide Prevention, Sean Krausert, has cogently argued that “ending the life of someone with complex mental-health problems is simpler and likely much less expensive than offering outstanding ongoing care. This creates a perverse incentive for the health system to encourage the use of MAiD at the expense of providing adequate resources to patients, and that outcome is unacceptable.”

This use of MAiD as an option for those suffering grievously, and with little access to a timely and comprehensive health network, is more than unacceptable; it is outrageous. Nuala Kenny, a pediatric physician, bioethicist and Sister of Charity (Halifax)—and a vocal critic of MAiD from the outset—has watched with dread the persistent efforts to further liberalize the legislation:

Bill C-7 legislating medically assisted death is titled incorrectly Medical Assistance in Dying. Good medical and palliative care provide assistance in the process of dying. MAiD is assisted death. The legislation at the beginning provided safeguards for a ‘reasonably foreseeable natural death,’ professional medical assessments, a ten-day waiting period, and ongoing study of difficult issues. All this has now been overturned or liberalized. MAiD provides a quick, cheap, technological response to human, familial, social, and spiritual matters. It is the antithesis of compassion.

Although the number of known cases of unethical pressure on those burdened with great suffering to consider MAiD as a rational choice with an easily expedited protocol is low, such cases exist and are surfacing in the media. The most egregious have involved Canadian war veterans who were counseled to consider assisted dying. The public outcry forced both the veterans affairs minister, Lawrence MacAuley, and Prime Minister Justin Trudeau to assure Canadians that this was the recommendation of one misguided employee, now terminated—and that this is not government policy, nor will it ever be.

These official denials, however, are less than persuasive. The case of retired corporal Christina Gauthier, a former paralympian, highlights the insidious allure of the quick fix. Suffering from a deteriorating medical condition as a result of permanent knee and spine injuries incurred during military training, Gauthier testified to a House of Commons Veterans Affairs Committee that a caseworker from Veterans Affairs Canada offered her MAiD after her failure over five years to get a wheelchair ramp installed in her home. Although this may be a rare occurrence, as the authorities insist, it is a logical outcome in a society that finds itself with a stretched and cumbersome health-care system, that struggles to provide appropriate-level palliative and hospice care across a widely dispersed population, and that is, as a consequence of the Charter of Human Rights and Freedoms, willfully captive to the doctrine of personal autonomy.

There is liberal, and then there is liberal. The country that passed same-sex marriage legislation long before the United States, that has banned capital punishment for decades, that was one of the first nations to sanction South Africa over apartheid, and that welcomed more Syrian refugees than any other Western power is the same liberal nation that, under the rubric of compassion and free choice, is about to usher in an assisted-death law that knows no limits.

The Toronto Star recounted the story of a man suffering from a chronic but not terminal illness. His condition was exacerbated by social and emotional factors that included childhood sexual abuse, mental-health stresses, and poverty. His government allowance left him with only a couple of hundred dollars a month after he had covered his rent expenses, and he was unable to walk the two flights into and out of his residence. Under the current legislation he qualified for MAiD, was approved, and died last summer. Had the state seen to his needs, provided support for his various maladies, and given him a decent government income that allowed him to live with some dignity, he could have managed his chronic illness. MAiD was his escape, his solution, his free choice.

But was it really a free choice? William Sweet, professor of biomedical ethics and philosophy of law at St. Francis Xavier University, thinks it was anything but. “As for extending MAiD in cases of mental illness, reducing morality as a consequence to a matter of consent when that clear consent can be compromised by their condition shows minimum concern for the value of life and the dignity of the person. On this point many secular medical experts are in agreement with the majority of Catholic ethicists.”

Public outcry and protests from medical associations at the speed with which the government is moving has prompted it to delay indefinitely the March deadline until there is a greater consensus among parliamentarians and the experts.

It is clear that the government will not rescind the current legislation but will consider more carefully the extension of MAiD to those suffering from mental illness. Perhaps in the process they might listen to the advice of Theo Boer, a Dutch bioethics professor who cautioned the French government over its proposed assisted-suicide legislation by citing the experience of the Netherlands: its policy of legalized euthanasia was at the outset for mentally competent adults suffering from a terminal illness, but that has since been expanded to allow for young children to seek it as well. “If the most defined and controlled system in the world can’t guarantee assisted choice remains a last chance,” Boer wrote in Le Monde, “why will France do better?”

Or indeed, Canada.