The long-awaited reports from the Council of Canadian Academies (CCA) concerning the possible extension of euthanasia to children (mature minors), to incompetent people who made an “advanced request,” and to people for psychological conditions alone was released on Dec. 12. The Euthanasia Prevention Coalition opposes euthanasia but for the purpose of this article we will only comment on the issues within the report. Canada legalized euthanasia in June 2016 in response to the Supreme Court of Canada Carter decision in February 2015 that struck down Canada’s laws protecting people from euthanasia and assisted suicide. Euthanasia and assisted suicide are now referred to as Medical Aid in Dying (MAiD) in Canada.
After passing their euthanasia and doctor-assisted suicide law in 2016, the Liberal government asked the CCA to conduct three separate reviews “related to requests from mature minors, advance requests, and requests where mental illness is the sole underlying medical condition.”
The CCA report offered “positive” and negative outcomes to extending euthanasia to incompetent people who made an “advanced request” (AR) for euthanasia but they concluded that more research is needed. They stated: “Allowing ARs for MAiD could provide comfort and relieve anxiety and distress at end of life for people who want to receive MAiD, but are concerned about losing decision-making capacity prior to the procedure. However, removing a requirement for express consent immediately prior to the MAiD procedure raises the possibility that a person might receive MAiD against their wishes.”
The report recognized that the “advanced request” would only be implemented when the person becomes incompetent, meaning that a “third-party” would be required to make the decision for death. This becomes complicated with euthanasia decisions because the laws state that the person must be experiencing “intolerable suffering” which is determined by the person requesting euthanasia. The report then states: “However, the person must rely on others to recognize when the conditions described as intolerable suffering in their AR for MAiD have been met. An AR for MAiD would have to specify what criteria the person considers intolerable (e.g., being bedridden, not recognizing family members, difficulty breathing, or experiencing pain), but these are circumstances of anticipated suffering that may not reflect the lived experience of the person when they reach those circumstances. Uncertainty about how to approach an AR for MAiD increases if the person who has lost capacity appears indifferent to receiving MAiD, expresses a desire to continue living, or physically or verbally resists the MAiD procedure.”
The report also recognizes the difficulty with legislating advanced consent for euthanasia considering the fact that every province has its own advanced directive legislation. Consider the recent case in the Netherlands of a woman, 74, with dementia, who made an advanced request for euthanasia. When the doctor came to do the euthanasia the woman resisted and said no. The doctor, without telling her, put a sedative in her coffee, but the woman still resisted. The doctor then had her family hold her down while the doctor did the euthanasia injection. In this case, the woman was incompetent and the doctor did not consider that she may have changed her mind. This case outlines how a supposed “advanced request” for euthanasia can result in a euthanasia death without consent. Once again, the report leans toward the position that euthanasia is a medical act and it makes close comparisons between end-of-life treatment decisions and euthanasia. These comparisons are contentious considering that the Canadian parliament legalized euthanasia (MAiD) by creating an exception in the Criminal Code and not by defining it as a medical act. The report does not recommend extending euthanasia to incompetent people who have made an advanced request but rather it recommends that more research is required. Canada’s euthanasia lobby is pushing hard to extend euthanasia based on advanced requests. The Audrey Parker campaign was designed to pressure the government to approve advanced request.
Canada’s euthanasia law limits euthanasia to persons 18 or older. The CCA did not offer clear direction concerning the issue of child euthanasia. The report concluded that: “Many in Canada are grappling with the question about whether to extend MAiD to mature minors in a society already exposed to changing ideas about death and dying. Although the Working Group examined a wide range of evidence, it concludes that there are many gaps in knowledge that make it difficult to arrive at definitive answers.”
Sadly, the report does lean towards the side of accepting child euthanasia. It states: “The view that minors are in need of heightened protection is a widely shared concern. Despite research demonstrating that some minors are capable of making critical healthcare decisions, including end-of-life choices, some argue that minors as a group are too vulnerable to be given the ability to request MAiD. However, part of protecting potentially vulnerable patients is to ensure that they are listened to. Thus, it has been argued that, rather than denying healthcare choices to groups frequently labelled as vulnerable, society must provide the accommodations to ensure that everyone is protected not only from exploitation, but also from being ignored and excluded.”
Canadians are restricted through the criminal code and regulations from participating in many activities based on age. The driving age is 16, the voting age is 18, and, in Ontario, the drinking age is 19.
Thankfully, the report did not follow the direction of the Hospital for Sick Children (Toronto) report, which stated that there is no difference between end-of-life medical treatment decisions and euthanasia. The hospital’s report decided that based on their current end-of-life decisions policy, if the euthanasia law is extended to children, a “mature minor” could die by euthanasia without requiring parental consent.
Canada’s euthanasia law requires that a person experience physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable. The law also requires that a person’s natural death become reasonably foreseeable. Therefore, a person who is psychologically suffering can qualify for euthanasia, as long as their natural death is reasonably foreseeable. The CCA report does not offer recommendations for changing the law but it clearly underlines the problems with euthanasia for psychological suffering. The report leans toward opposing the extension of euthanasia to people with psychological conditions alone. The report makes many strong statements concerning the problem with euthanasia for psychological reasons. For instance, the report states: “A particular challenge for some people who request MAiD is that their desire to die could be a symptom of their mental disorder. Suicidal ideation is a common symptom of some mental disorders, and some mental disorders can distort a person’s thoughts and emotions, leading to a desire to die, hopelessness, and a negative view of the future, even when a person retains decision-making capacity. It may be difficult for a clinician to distinguish between a capable person who is making an autonomous decision for MAiD and a person whose pathological desire to die is a symptom of their mental disorder that impairs their decision-making.
Most mental disorders lack the prognostic predictability of the physical conditions that currently motivate MAiD requests in Canada. There is less certainty about how a person’s mental disorder will evolve over time and whether treatments and/or social interventions will be effective in relieving their suffering and improving their quality of life when compared to the physical conditions that currently motivate MAiD requests.”
Having a mental disorder is one of the most strongly associated risk factors for suicide. Systematic reviews and meta-analyses have found that up to 90 per cent of those who die by suicide may have had a diagnosable psychiatric disorder (as determined by a retrospective psychological autopsy). Furthermore, there is some evidence that some people who have sought psychiatric euthanasia and assisted suicide (psychiatric EAS) in jurisdictions that permit it share certain characteristics with people who attempt suicide.
The report acknowledges that based on the language in Canada’s euthanasia law, if the law were extended to allow euthanasia for psychological conditions alone, Canada would have the most permissive euthanasia law in the world. The report states: “MAiD law in Canada explicitly defines intolerable suffering in subjective terms. While a healthcare practitioner must ‘be of the opinion that’ these conditions are met, if a patient truly believes their suffering is intolerable, and believes that existing means to relieve their suffering are not acceptable to them, they thereby meet the criteria for intolerable suffering set out in the legislation.”
No other country permits euthanasia and assisted suicide where one of the eligibility criteria is based on an individual’s personal assessment of what conditions for relief of their intolerable suffering they consider acceptable. If Canada were to expand euthanasia using this criterion, it could become the most permissive jurisdiction in the world with respect to how relief of suffering is evaluated.
Considering the fact that Canada’s euthanasia law is completely subjective as to whether a person’s suffering is considered “intolerable,” the extension of euthanasia to people with psychological conditions alone would be a disaster. It would be impossible to determine whether a person is suffering intolerably or experiencing suicidal ideation and seeking an “assisted death.”
Clearly Canada has gone too far already. Canada needs to add clear definitions to its euthanasia law rather than extending euthanasia.
Alex Schadenberg is the executive director of the Euthanasia Prevention Coalition. This article is taken from three blog posts he wrote about the Council of Canadian Academies three reports on euthanasia and is reprinted with permission.