In just six years, Canada has risen to the top of the world ranking in the practice of euthanasia. Some believe it’s because the procedure is granted too easily for those requesting it, including patients who are not offered effective alternatives.
Euthanasia, or “medical assistance in dying” (MAID) as it is officially known, has been legal in Canada since 2016. The spike in cases in the North American country since then is dizzying. California approved euthanasia the same year as its northern neighbor and its population is about the same (40 million). But in 2021, while California recorded 486 cases of euthanasia, that number was 10,064 in Canada. The following year, that figure rose 31%, to 13,241.
The 2022 data represents 4.1% of total deaths in the country, almost double that of Belgium (2.3%), which legalized euthanasia in 2002. Canada has not yet bested the Netherlands’ 4.8%, which was the first nation to allow euthanasia, informally in 1994 and by law since 2002. Except in one case: the province of Quebec holds the world record, with euthanasia accounting for 6.8% of total deaths there, according to the latest official report which covers April 2022-March 2023.
With such a rapid rate increase, the New York Times posed the question last year of whether perhaps it is too easy to choose medically assisted death in Canada.
Ineffective safeguards
In principle, it shouldn’t be. The Canadian Supreme Court’s 2015 ruling which declared the ban on assisted suicide unconstitutional, noted at the same time that it would only be admissible for “adults who consent and are capable, well informed and seriously and irremediably ill.” The justices also ruled the procedure would have to be performed “in accordance with the patient’s wishes and in their best interests, and with the aim of alleviating suffering.” They added that a law with “well-thought-out and applied precautions is capable of protecting vulnerable people from abuse and errors.”
“Canada has the least safeguards of all of the countries that allow euthanasia” (Trudo Lemmens, professor of law)
The law passed the following year stipulated that a request for euthanasia could only be processed if the patient had a short life expectancy, and had to be evaluated by a medical or nursing professional, called a “MAID advisor.” In 2021, in light of another ruling by the Supreme Court of Quebec, the High Court eliminated the terminal illness requirement, opening the doors for the practice of euthanasia among those with disabilities. And now, Parliament is considering a new reform which would include mental illness among the legal reasons for euthanasia.
The fact is that the safeguards included in the law do not seem effective. The official commission responsible for the review of the application of euthanasia law in Quebec warned that, in the province, “many of the cases of euthanasia barely meet the legal requirements for it and many do not comply with them.”
But, according to some, the problem lies in the law itself. “Canada has the least safeguards of all of the countries that allow it,” Trudo Lemmens, law professor at the University of Toronto, told the New York Times.
A cheap solution
Dr. Madeline Li also argues that “crucial safeguards for patients are missing from [Canadian] law.” Li, a specialist in oncological psychiatry, supports legal euthanasia and intervenes in its administration. But she is concerned about the way it is regulated and applied in her country, as she shares in a testimony published in Maclean’s magazine.
According to Li, the law does not safeguard that the patient be provided effective treatments against their illness or pain first, making euthanasia the last resort. The doctor makes her point with the case of a person who had requested MAID after being admitted for chronic pain. Li was not the patient’s advisor, but they asked her opinion. “This person told me,” she says, “that if they didn’t feel quite as lonely, if they felt that anyone cared about them at all, they probably could tolerate their pain better.” The doctor responded that it would be a shame for her to die so early and expressed caring, “which seemed to mean everything to this person.” The patient decided to instead look into a therapeutic alternative, but the thousands of dollars it meant was financially impossible for her to take on. So euthanasia was back on the table. Li does not know what became of the patient; but the case weighs on her.
This example also shows that, as Li says, euthanasia request reviews are generally superficial. “Right now,” Li says, “MAID assessment is a checklist of legal requirements. (…) More than that, MAID assessors typically parachute into a patient’s life: they don’t typically have a long-term relationship with them.” Instead, Li says, they need to spend much more time and attention getting to know and listening to them.
The fear of some that euthanasia is administered flippantly because it is the least laborious option for doctors and hospitals, and also the cheapest for the health system, seems justified. In fact, a 2017 study published in the Canadian Medical Association Journal estimated that euthanasia would translate to a net saving of C$33 million to C$124 million dollars annually for the country’s healthcare system.
Mental illness and euthanasia
Given the current panorama, resorting to euthanasia is especially dangerous when it comes to those who suffer from mental illness, who could be the next group included in a potential modification of the law. Li is opposed to extending it to this group, and the previous reform’s elimination of the terminal condition requirement: “We shouldn’t be providing MAID for mental disorders—and more broadly than that, for chronic illness.” And she illustrates her position with another case.
Some believe that assisted suicide in Canada is becoming an almost routine medical option, rather than an extraordinary measure for exceptional cases
“I recently had a patient with chronic depression who was planning to apply for MAID until we finally found an effective treatment. They asked me how requests in patients with depression would eventually be assessed. I said we’d have to distinguish a rational desire to die from one driven by depression, and they replied, ‘But why would I want to die if it wasn’t because of the depression?’ That gave me pause. At the very least, I think we need to prompt clinicians to exercise clinical judgment—both the clinician and the patient should feel that there have been reasonable attempts at treatment. And rather than just checking boxes, we should have to sit down and have a meaningful conversation [with the patient] about the desire for death.”
To the detriment of palliative care
All this in mind, some believe that assisted suicide in Canada is becoming an almost routine medical option, instead of an extraordinary measure for exceptional cases. Which, on the other hand, is to the detriment of palliative care, as expert Neil Hilliard said in 2017. According to him, the inclusion of MAID in hospitals is line “a cancer growing within the palliative care programs.”
Two years ago, in an appearance before the parliamentary committee on MAID, Dr. Leonie Herx, former president of the Canadian Society of Palliative Care Physicians, recalled that only 25-30% of patients who need them had access to them. And she warned: “When palliative care needs are not met, the resulting physical, emotional and spiritual suffering of patients can lead them to feel depressed and hopeless, and to consider themselves a burden to others: that is, several of the most frequent reasons cited in MAID requests.”
Herz summarized, on the same occasion, the “deleterious effects” euthanasia has on palliative care: fewer resources are dedicated to it; loss of staff due to palliative professionals leaving, feeling dissatisfied or discouraged; patients who resist receiving palliative care for fear of being euthanized.
Ultraliberal freedom
It’s clear that, despite the claim that euthanasia is simply part of the “complete package” of services offered, along with palliative care, so that everyone can choose what care they want, the two options can hardly coexist. Furthermore, there’s a problem when it comes to choosing between the two.
Canadian journalist Jeremy Appel was in favor of euthanasia, but changed his mind. He explains this ideological shift to the magazine Jacobin, whose very name indicates its political tendency.
“The problem with my previous perspective,” Appel says, “was that it held individual choices as sacrosanct. But people don’t make individual decisions in a vacuum. They’re the product of social circumstances, which are often out of their control. (…) The cavalier way in which MAID has been implemented in Canada serves as a form of eugenics, where only the able-bodied survive.”
What Appel says is somewhat reminiscent of Marxism, and perhaps helps shed light on why the Portuguese Communist Party opposed the approval of euthanasia in Parliament. Also worth noting is the fact that arguments in favor of upholding euthanasia often dovetail with an ultra-liberal concept of freedom, which may be fine and well for the able-bodied and sound of mind, but far more detrimental to those in dire or helpless situations.
Translated from Spanish by Lucia K. Maher