Ethical controversy has erupted over Canada’s expansion of eligibility criteria for medical assistance in dying (MAiD).
When MAiD became legal in 2016, there was a requirement that death was reasonably foreseeable. In 2022, eligibility expanded to include people with disabilities or those suffering from pain, even if those people were not close to death.1 The law is set to expand again to allow MAiD in cases when a mental health disorder is the sole underlying condition.2
Kerry Bowman, PhD, a bioethicist at the University of Toronto, has been involved in many MAiD cases, but is concerned about how the law has evolved. “A lot of people thought in 2016 that this was really quite straightforward — that MAiD was a societal change. But just as with gay marriage, people would realize it was the right thing, and adjust, and move on,” Bowman says.
In Bowman’s view, the COVID-19 pandemic brought to light the fact there were bigger concerns involving social determinants of health than people realized at the time MAiD was legalized. “We really underestimated how ethically challenging that would be,” Bowman notes.
If someone is living with chronic pain or other serious physical problems that meet the criteria for MAiD, but that person also is living in extreme poverty without adequate support for a disability, it is hard to separate those two issues. “We were ill-prepared for the ethical implications of the social determinants of health. With mental health, we will have even greater challenges,” Bowman predicts.
Many people with a mental health diagnosis also are living in poverty due to their inability to find employment and housing. “Their safety net is gone, and they are living on the streets,” Bowman laments. Therefore, it is nearly impossible to be certain as to what is driving their request for MAiD.
Advocates of adding the mental health criterion point out people need decision-making capacity to consent to MAiD. For example, someone who is psychotic and dissociated from reality would not be a candidate. The same is true for someone in an acute depressive state.
However, there are gray areas, such as someone who has struggled with depression and tried multiple therapies over a long period, who is not currently in an acute depressive state, and wants to pursue MAiD. It is possible this person would change her mind if a new treatment became available or something alleviated the depression. On the other hand, says Bowman, “we run the risk of being paternalistic to say that someone with depression is never capable of choosing MAiD.”
Bowman says a central ethical concern is whether Canadians will look at a person with a disability or mental health condition and wonder why they do not apply for MAiD. It raises the ethical concern that people would view some lives as worth less than other lives. “These are very vulnerable people,” Bowman observes. “I do support MAiD, but we are moving too fast, and need to slow down and reflect.”
Udo Schüklenk, PhD, has co-authored papers about this specific issue.3,4 According to Schüklenk, the ethical justification for including treatment-resistant major depressive disorder as the sole underlying condition to permit access to MAID “is the same as for any other disease or disability.”
Schüklenk says just societies should respect and support the end-of-life choices of patients with decisional capacity, who suffer from an irremediable condition (at the time of decision-making), and who consider their quality of life sufficiently bad enough that they do not wish to continue living. “It’s clearly a combination of respect for patient autonomy, and the recognition that we are the best judges of our own quality of life. We do not frivolously ask that our lives be ended,” says Schüklenk, professor of philosophy at Queen’s University. Safeguards may be reasonable to ensure the wish to end one’s life is stable over a reasonable period, Schüklenk says.
In comparison with Canada, only 10 U.S. states and Washington, DC, currently allow some form of MAiD.5 Unlike Canada, where MAiD is accessible for anyone with a “grievous and irremediable medical condition,” the U.S. states require people to have been diagnosed with a terminal illness that includes a prognosis of six months or less to live. “If death to avoid suffering is a good thing, then why is living with that suffering for two years worse than living with it for just six months?” asks Paul T. Menzel, PhD, professor of philosophy emeritus at Pacific Lutheran University in Tacoma, WA.
If someone suffers from a disease that will lead to death in several years as opposed to six months, the person does not meet criteria to access MAiD in states where it is legal. Determining who should be able to access MAiD is a difficult ethical balance, Menzel admits. “We don’t want to draw the line so liberally that people would not have chosen MAID had they gotten better care, especially palliative care, or seen more clearly their prospects,” Menzel shares. “We also don’t want to draw it too tight, so that the benefits of aid in dying are deprived to people unduly.”
Menzel says that in the United States, a pressing ethical concern is MAiD is restricted to self-administration. Canadian physicians can administer lethal medications. “From an ethical perspective, what is the difference in prescribing a lethal agent with full instructions on how to self-administer and injecting the drug?” Menzel asks.
There is ongoing litigation centered on the requirement of self-administration. Plaintiffs argue this is discriminatory against the physically disabled who cannot swallow the medication adequately or raise an arm to ingest it.6 “Regardless of the outcome of the lawsuit — ethically, it’s not defensible to say that MAiD is accessible to those who can self-administer and not to those who can’t. That line has to fall,” Menzel says.
If physicians are allowed to administer lethal medication for disabled patients, it raises the question why anyone is forced to self-administer. Safety is a valid ethical concern.
“There are many ways that self-administrating lethal medications can go wrong. Inadequate self-administration could result not in death, but in a more compromised existence,” Menzel notes.
As the inadequacies of self-administration are realized, Menzel believes it is possible some states will move toward the Canadian model. “The restrictions in the U.S. that MAID be self-administered cannot last,” says Menzel, adding he believes the same is true for the requirement of a terminal illness with a prognosis of six months or less.
John D. Banja, PhD, a medical ethicist at the Center for Ethics at Emory University in Atlanta, views the expanded Canadian criteria as ethically problematic, mainly because of the socioeconomic implications. “Possibly, this law is not strict or detailed enough to allow the healthcare providers to properly assess the motives of the patient, as well as the patient’s quality of life and living conditions,” Banja explains.
A substantive discussion of the ethical implications of euthanasia is needed, argues Banja, with ethicists, clinicians, disability risks activists, economists, and public health experts all weighing in.
In the case of persons with serious disability, social stigma also is a factor. “The attitudes of so many Americans are ‘I wouldn’t want to live like that,’” Banja observes.
The concern over whether some people who choose euthanasia are only doing so because of socioeconomic circumstances, or lack of resources, is not a new one. Banja points to a case from more than 30 years ago. A man with a serious disability went to court to argue he should be allowed to withdraw from a ventilator and die.7 The court ruled in his favor; however, by that time, the man had received additional support and chose to continue the life-sustaining intervention. The decades-old case is relevant to the current controversy, according to Banja. “It’s a very interesting cultural lesson there. There is much to what the disability advocates say: That a more compassionate society would want to help people feel that their life has value,” he says.
In Canada, the concern is people are requesting euthanasia when additional support or different circumstances might change their decision. “It is very easy to imagine someone becoming depressed and requesting the end of life,” Banja offers.
It is possible that depression, although severe, is temporary. “We are pointing the finger in the wrong direction when we point it at the quality of their decision-making and whether they are rational,” Banja argues. “We need to point it at the socioeconomic dimensions in our society, and whether these people are being abandoned by not getting the resources they need to live in a quality way.”
Economic troubles can push people to despair, raising ethical concerns that those people might request euthanasia. “These are really socioeconomic variables that societies ought to be looking at if they pass euthanasia laws,” Banja suggests.
In the United States, physician aid-in-dying is only allowed if someone is suffering in a grave manner and has exhausted all the clinical interventions that might ameliorate the suffering. “Physician aid-in-dying, in the U.S., is really a last resort. In Canada, it doesn’t seem like an issue of last resort,” Banja observes.
The overarching concern is people can ask clinicians to sign off on requests for euthanasia too lightly, without examining the full set of circumstances. “We need to make it hard for people to have euthanasia. By that I don’t mean we need to burden them,” Banja says. “But we need to make the system accountable. We need a detailed, thoughtful consideration of what’s going on.”
REFERENCES
1. Pesut B, Thorne S, Wright DK, et al. Navigating medical assistance in dying from Bill C-14 to Bill C-7: A qualitative study. BMC Health Serv Res 2021;21:1195.
2. Bains C. Delay assisted dying for people with mental disorders: Psychiatric association. The Canadian Press. Dec. 1, 2022.
3. Schüklenk U, van de Vathorst S. Treatment-resistant major depressive disorder and assisted dying. J Med Ethics 2015;41:577-583.
4. Rooney W, Schüklenk U, van de Vathorst S. Are concerns about irremediableness, vulnerability, or competence sufficient to justify excluding all psychiatric patients from medical aid in dying? Health Care Anal 2018;26:326-343.
5. Compassion & Choices. States where medical aid in dying is authorized.
6. Dinzeo M. Judge: California aid-in-dying law doesn’t discriminate against the disabled. Courthouse News Service. June 22, 2022.
7. Georgia. Supreme Court. State v. McAfee. Wests South East Report 1989;385:651-653.
Ethical controversy has erupted over Canada’s expansion of eligibility criteria for medical assistance in dying.
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