
- Vol 38, Issue 6
First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders
Dr Komrad has made a video to accompany this article. You can watch the video
COMMENTARY
Canada just passed a law that radically changes the boundary between acceptable and unacceptable medical practice and has opened a path to euthanasia for patients with psychiatric illness who find their conditions unbearable.
Unfortunately, this is not a new phenomenon. Several countries allow psychiatric patients who are suicidal to voluntarily receive death by lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide) from physicians. In Belgium, the Netherlands, and Luxembourg (collectively known as the Benelux nations) these practices first emerged in 2002, after laws were passed permitting medically assisted death for patients whose physical or psychological suffering was unbearable and
In concerned response to these developments, the American Psychiatric Association issued a
The Evolution of Canada’s Bill
In 2016, Canada passed Bill C-14, a law
To be eligible, a patient’s natural death must be predicted to be reasonably foreseeable. This uniquely Canadian term was not statutorily defined, but it was understood to be associated with the end of life—how close was undetermined. Because death from mental disorders was not considered to be strongly predictable, mental illnesses were not eligible conditions. This feature of the law essentially prevented the kind of psychiatric euthanasia practiced in the Benelux countries.8
Then, in 2019, a
Initially, Bill C-7 clearly excluded psychiatric disorders, which was at least implicit 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 C-14’s scope discriminated against those with mental illnesses. Ironically, in its efforts to promote parity, the Canadian Psychiatric Association was such a voice. As an organization, it declared: “Patients with a psychiatric illness
This led to a dramatic turn of events in the (unelected) Canadian Senate, which considered Bill C-7 this February. 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
This 2-year interval is to be used to create an expert panel to establish standards for evaluating patients and procedures to distinguish between patients with psychiatric disorders whose suicide should be prevented from those whose for whom it could be provided. However, as Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, noted 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, which fought to forestall the inclusion of psychiatric disorders for euthanasia.
The latest law is disappointing but unsurprising considering the huge pushes for parity and nondiscrimination at all costs. Unlike the in United States, health care in Canada is considered a charter (constitutional) right. Thus, once MAID became a medical procedure, excluding patients with psychiatric illness from this right was nearly impossible.
Countries that have allowed MAID in a limited number of cases have quickly found themselves descending a slippery slope. Prominent critic Wesley J. Smith, JD, noted, “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
Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of C-7, the psychiatrist editor of the Journal of Ethics in Mental Health
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.
Similar significant objection comes from the
An
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
Bill C-7 also sets up a 2-tier system, abolishing some of the original 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. Ironically, it is not unusual to have to wait much longer than that in Canada to get psychiatric consultation, treatment, and other resources.
Moreover, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration. Even Belgium, which is known for its liberal approach, recently added guidelines that individuals applying for euthanasia for a mental disorder should not have refused any evidenced-based treatments.24
A group of
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
Concluding Thoughts
Bill C-7 and similar laws would represent a remarkable shift in the deep ethos of psychiatry, in which psychiatrists would have to decide which suicides should be prevented and which should be abetted.
Karandeep Sonu Gaind, MD, past president of the Canadian Psychiatric Association and a fierce critic of the MAID expansion to psychiatric patients, noted that less privileged patients have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a
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 on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana.
References
1. Komrad MS. A psychiatrist visits Belgium: the epicenter of psychiatric euthanasia. Psychiatric Times. June 21, 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. Annual Report 2019. Regional Euthanasia Review Committees. April 2020. Accessed April 28, 2021.
4. Komrad MS. APA position on medical euthanasia. Psychiatric Times. February 25, 2017. Accessed April 28, 2021.
5. Komrad MS. 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. Health Canada. First annual report on medical assistance in dying in Canada, 2019. July 2020. Accessed May 10, 2021.
8. Rousseau S, Turner S, Chochinov HM, et al. A national survey of Canadian psychiatrists’ attitudes toward medical assistance in death. Can J Psychiatry. 2017;62(11):787-794.
9. Marin S. Quebec court invalidates parts of medical aid in dying laws as too restrictive. Toronto Star. September 11, 2019. Accessed April 28, 2021.
10. First session, forty-third Parliament, House of Commons of Canada. Bill C-7: an act to amend the Criminal Code (medical assistance in dying). first reading February 24, 2020. Parliament of Canada. Accessed April 28, 2021.
11. Chaimowitz G, Freeland A, Neilson GE, et al. Medical assistance in dying. Canadian Psychiatric Association. February 10, 2020. Accessed April 28, 2021.
12. 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.
13. Bryden J. Canadian Senate passes Bill C-7, expanding assisted dying to include mental illness. Global News. March 17, 2021. Updated March 19, 2021. Accessed April 28, 2021.
14. Smith W. Euthanasia spreads in Europe: several nations find themselves far down the slippery slope. National Review. October 26, 2011. Accessed April 28, 2021.
15. Boztas S. Euthanasia law proposed for healthy over-75s who feel their lives are complete. Dutch News.nl. July 19, 2020. Accessed April 28, 2021.
16. Cohen-Almagor R. Euthanizing people who are “tired of life.” In: Jones DA, Gastmans C, MacKellar C, eds. Euthanasia and Assisted Suicide: Lessons from Belgium. Cambridge University Press; 2017:188-201.
17. Clusky P. Euthanasia debate in Netherlands takes an unwelcome twist. The Irish Times. September 10, 2019. Accessed April 28, 2021.
18. Cook M. A new Swiss group caters for Dutch who are eligible for euthanasia. BioEdge. January 24, 2021. Accessed April 28, 2021.
19. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canadian Broadcasting Corporation. February 11, 2020. Accessed April 28, 2021.
20. Neves P. Disability is not a fate worse than death. The Chronicle Herald. March 24, 2021. Updated March 27, 2021. Accessed April 28, 2021.
21. 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. United Nations Human Rights: Office of the High Commissioner. February 3, 2021. Accessed April 28, 2021.
22. Ruck A. First Nations leaders say Bill C7 goes against their beliefs and values. Canadian Catholic News. February 12, 2021. Accessed April 28, 2021.
23. Ruck A. Canadian Conference of Catholic Bishops denounces assisted suicide law. The Dialog. April 9, 2021. Accessed May 10, 2021.
24. 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(May-Jun):150-161.
25. 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.
26. Ethics: euthanasia. code of medical ethics opinion 5.8. American Medical Association. Accessed April 28, 2021.
27. WMA declaration on euthanasia and physician-assisted suicide. World Medical Association. November 13, 2019. Accessed April 28, 2021.
28. 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.
29. Gaind KS. What does “irremediability” in mental illness mean? Can J Psychiatry. 2020;65(9):604-606.
30. Gaind KS. Last rights. Karandeep Sonu Gaind. March 11, 2021. Accessed April 28, 2021.
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