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Will a new Canadian law overturn long-held ethical norms in psychiatry?
Dr Komrad has made a video to accompany this article. You can watch the video here. - Ed.
Currently, several countries, such as Belgium, the Netherlands, Luxembourg, and Switzerland, allow patients who are suicidal to receive death by either lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide). In 2002 Belgium, the Netherlands, and Luxembourg (all 3 collectively known as Benelux) legalized both these practices. Laws in those countries permitted voluntary death for patients whose physical or psychological suffering was unbearable and could not be effectively treated by means that were acceptable to them.1 A terminal condition was not a necessary criterion.
This opened the door for some patients with psychiatric illness to have suicide provided for them, rather than prevented. Now between 100 and 200 patients with psychiatric illness are euthanized upon request annually between Belgium2 and the Netherlands.3
These laws are being passed around the world, and they could profoundly change the practice of psychiatry. In concerned response to those developments, the American Psychiatric Association issued a position statement in 2016: “A psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”4 Psychiatrists traditionally have done all they could to prevent suicide. Should they really facilitate it instead?
Developments in Canada
Canada is the latest nation to legalize voluntary death for psychiatric conditions. In 2016, Canada passed Bill C-14, a law permitting medical euthanasia and physician-assisted suicide, together known as medical aid in dying (MAID).5 By November 2020, more than 19,000 individuals nearing the end of life had been voluntarily euthanized.6
A key eligibility criterion of this law was that a patient’s natural death is predicted to be reasonably foreseeable, a unique Canadian terminology that was not statutorily defined. Although it was associated with the end of life, how close was never decided. Because death from mental disorders was not seen as strongly predictable, mental illnesses were not considered eligible conditions. This feature of the law was a check on the kind of psychiatric euthanasia practiced in the Benelux countries.
In 2019, however, a Quebec Superior Court ruling challenged the constitutionality of restricting the C-14 right of euthanasia to those whose death is reasonably foreseeable.7 As a result, a new federal bill was introduced to extend euthanasia eligibility, without limiting it to the end of life. This new initiative, Bill C-7, followed the Benelux model; it and removed the prior exclusion of those who have non-terminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable.8
Initially, Bill C-7 clearly excluded psychiatric disorders, as it did in the original C-14 law. However, there was ambiguity in this proscription, because psychological suffering (which is not defined in either legislation) continued to be a criterion for eligibility. In addition, many protested that such an exclusion discriminated against those with mental illnesses. The Canadian Psychiatric Association (CPA) was one such voice, declaring broadly that, in the interest of parity: “Patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAID as available to all patients.”9
This led to a dramatic turn of events in the (unelected) Canadian Senate when it considered Bill C-7 in February 2021. In an unprecedented move, Senator Stan Kutcher, MD, who is also a psychiatrist, declared that the exclusion of individuals with psychiatric disabilities would be discriminatory. He introduced an amendment that would allow MAID for mental illness 18 months following the passing of the bill.10 When the modified legislation was returned to the House of Commons, discussions were shut down after 3 hours by a liberal coalition and the bloc party from Quebec (a province that has promoted euthanasia and aimed to restrict conscientious objection to euthanasia by health care professionals). As a result, the vote was forced and, on March 17, 2021, the C-7 expansion of euthanasia in Canada became the law of the land complete with a last-minute amendment to sunset the mental illness exclusion after 2 years.11
In this interval, an expert panel will establish standards for evaluating patients and procedures to distinguish between those patients with psychiatric disorders whose suicide should be prevented and those for whom it should be provided. Nonetheless, as the Euthanasia Prevention Coalition’s executive director, Alex Schadenberg, observed in response to a query, “there isn’t a prosecutor in the land who would prosecute someone for doing euthanasia for mental illness before the 24-month time frame has passed because it is technically legal.”
Objections to Psychiatrist-Assisted Suicide
This is a profound change in the trajectory of the euthanasia law, and the practice of psychiatry for Canada, which is now the largest nation that will soon allow MAID for psychiatric conditions. It has rocked the professional mental health community in Canada who fought to forestall the inclusion of psychiatric disorders for euthanasia. Once these procedures were deemed medical procedures, distinguishing eligible patients would be challenging, if not impossible.
Countries that have allowed MAID in a limited number of cases have quickly found themselves descending a slippery slope. Wesley J. Smith, JD, prominent critic of these policies, observed: “Once a society embraces doctor prescribed death as an acceptable answer to human suffering or as some kind of fundamental liberty right, there are no brakes. We need only look at European countries that have gone down the Euthanasia Highway to see how society is impacted deleteriously by accepting killing as a suitable answer to the problem of human suffering.”12 Indeed, in Belgium and the Netherlands policy makers and legislators are debating extending euthanasia beyond medical conditions to include those who feel they have a completed life13 and are tired of living.14 There even is a discussion of demedicalizing euthanasia by providing lethal pills over the counter.15 Pegasos, a Swiss voluntary assisted dying association based in Basel, currently provides euthanasia for nonmedical suicide tourists.16
Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of Bill C-7, the psychiatrist editor of the Journal of Ethics in Mental Health reported17:
A few days ago, a 30-year-old patient with very treatable mental illness asked me to end her life. Her distraught parents came to the appointment with her because they were afraid that I might support her request and that they would be helpless to do anything about it. It’s horrific they have to worry that by going to a psychiatrist, their daughter might be killed by that very psychiatrist.
The disability advocacy community has objected to the way that Bill C-7 untethers MAID from the end of life.18 They are concerned that allowing non-terminal, disabled individuals euthanasia implies that their lives may be not worth living. Furthermore, they recognize individuals with disabilities may not have adequate access to state-of-the-art treatment, and euthanasia could become a cost-saving alternative to suffering when adequate solutions are not available or affordable.
An evaluation by the United Nations expressed strong worry about how Bill C-7 impacts individuals with chronic disabilities19:
We are deeply concerned that the eligibility criteria set out in Bill C-7 to access medical assistance in dying may be of a discriminatory nature, or have a discriminatory impact. By singling out the suffering associated with disabilities being of a different quality and kind than any other suffering, they potentially subject persons with disability to discrimination on account of such a disability.
There is also strong objection among many First Peoples of Canada because of conflicts with their cultural values, their limited access to state-of-the-art treatments, and staggering suicide rates.20 The Canadian Catholic Bishops, who always oppose euthanasia, are particularly aghast at allowing MAID for the disabled and mentally ill.21
Bill C-7 also sets up a 2-tier system, abolishing some of the original Bill C-14 safeguards. For instance, patients who are terminally ill can be evaluated for euthanasia and possibly receive it on the same day, with no waiting period; unlike the 10-day waiting period in the previous C-14 law. However, patients who are not terminally ill must wait 90 days. Unfortunately, it is not unusual to wait much longer than 90 days to receive psychiatric consultation, treatment, and other resources.
Moreover, as with C-14, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration Yet, despite its liberal approach, Belgium recently established a requirement that individuals applying for euthanasia due to a mental disorder must not have refused any evidenced-based treatments.22
A group of experts in Canadian law and medicine wrote23:
C-7 will allow physicians to end the life of people with disabilities or chronic illnesses at their request and will require the system to ensure it happens even when physicians are convinced, based on their expert knowledge, that medicine offers options and even when the patient may have years or decades to live with a good quality of life if other options are explored and tried first.
The American Medical Association has repeatedly concluded that MAID practices are “fundamentally incompatible with the physician’s role as a healer,”24 and the World Medical Association “is firmly opposed to euthanasia and assisted suicide.”25 Nevertheless, these laws have been adopted around the world, most recently in Victoria Australia, New Zealand, Spain, and Portugal.26 In US states, there have been attempts to expand initially strict criteria and practices.27 The justifications for euthanasia and assisted suicide (eg, autonomy, self-determination, intolerable suffering, and irremediability) are now being applied to psychiatric disorders, despite lack of any widespread agreement that treatments for psychiatric disorders are ever futile.28
Bill C-7 and similar laws would represent a terrible shift in the deep ethos of psychiatry. Psychiatrists would have to decide which suicides should be prevented and which should be abetted. Karandeep Sonu Gaind, MD, past president of the CPA and a fierce critic of this bill, noted the less-privileged have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a poetic cri de couer29:
So thank you Canada, powers that be,
For ensuring that our smooth passings
Will reflect the privilege of our life trappings.
I will soon be free, without anxiety, knowing
That with ease I can choose the time of my going.
And any poor souls sacrificed on this altar
Of my choice, my voice,
There will be no way of knowing.
Dr Komrad is a psychiatrist at the Johns Hopkins Hospital in Baltimore, Maryland, clinical assistant professor of Psychiatry at the University of Maryland, and Teaching Faculty of Psychiatry at Tulane University in New Orleans
1. Komrad M. A psychiatrist visits Belgium: the epicenter of psychiatric euthanasia. Psychiatric Times. June 20, 2018. Accessed April 28, 2021.
2. Du Bus C. Euthanasia in Belgium: analysis of the 2020 Commission Report. European Institute of Bioethics. November 16, 2020. Accessed April 28, 2021.
3. Regional Euthanasia Review Committees. Annual Report 2019. April 2020. Accessed April 28, 2021.
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5. Komrad M. Medical euthanasia in Canada: current issues and potential future expansion. Psychiatric Times. June 29, 2018. Accessed April 28, 2021.
6. Schadenberg A. There have been approximately 19,000 euthanasia deaths in Canada. Euthanasia Prevention Coalition. October 20, 2020. Accessed April 28, 2021.
7. Marin S. Quebec court invalidates parts of medical aid in dying laws as too restrictive. Toronto Star. September 11, 2019. Accessed April 28, 2021.
8. Bill C-7: an act to amend the criminal code (medical assistance in dying). 1st reading February 24, 2021, 43rd Parliament, 1st session. Accessed April 28, 2021.
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10. Bryden J. Senators amend MAID bill to put 18-month time limit on mental illness exclusion. CTV News. February 9, 2021. Accessed April 28, 2021.
11. Bryden J. Canadian Senate passes Bill C-7, expanding assisted dying to include mental illness. Global News. Updated March 19, 2021. Accessed April 28, 2021.
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14. Cohen-Almagor R. Euthanizing People Who Are “Tired of Life.” In: Jones DA, Gastmans C, MacKellar C, eds. Euthanasia and Assisted Suicide: Lesson from Belgium. Cambridge University Press; 2017:188-201.
15. Clusky P. Euthanasia debate in Netherlands takes an unwelcome twist. The Irish Times. September 10, 2019. Accessed April 28, 2021.
16. Cook M. A new Swiss group caters for Dutch who are eligible for euthanasia. BioEdge. January 24, 2021. Accessed April 28, 2021.
17. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canada Broadcasting Corporation. February 11, 2020. Accessed April 28, 2021.
18. Neves P. Disability is not a fate worse than death. The Chronicle Herald. Updated March 27, 2021. Accessed April 28, 2021.
19. Quinn G, Mahler C, De Schutter O. Mandates of the Special Rapporteur on the rights of persons with disabilities; the Independent Expert on the enjoyment of all human rights by older persons; and the Special Rapporteur on extreme poverty and human rights. February 3, 2021. Accessed April 28, 2021.
20. Ruck A. First nations leaders say Bill C7 goes against their beliefs and values. Canadian Catholic News. February 12, 2021. Accessed April 28, 2021.
21. Ruck A. Canadian Conference of Catholic Bishops denounces assisted suicide law. The Dialog. April 9, 2021. Accessed May 10, 2021.
22. Verhofstadt M, Van Assche K, Sterckx S, et al. Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making. Int J Law Psychiatry. 2019;64:150-161.
23. Lemmens T, Shariff M, Herx L. How Bill C-7 will sacrifice the medical profession’s standard of care. Policy Options. February 11, 2021. Accessed April 28, 2021.
24. Euthanasia. Code of medical ethics opinion 5.8. American Medical Association. Accessed April 28, 2021.
25. World Medical Association. WMA declaration on euthanasia and physician-assisted suicide. October, 2019. Accessed April 28, 2021.
26. Euthanasia and physician-assisted suicide (PAS) around the world: legal status in 28 countries from Australia to Uruguay. ProCon.org. Updated December 3, 2020. Accessed May 10, 2021.
27. Schadenberg A. Washington State debates bill to expand assisted suicide law. Say no to same day death. Euthanasia Prevention Coalition. January 11, 2021. Accessed April 28, 2021.
28. Gaind KS. What Does "Irremediability" in Mental Illness Mean? Can J Psychiatry. 2020;65(9):604-606.
29. Gaind KS. Last rights. March 11, 2021. Accessed April 28, 2021.