28 Jan 2019 CCA report leaves Parliament with many warnings about expanding euthanasia
In December 2018, the Council of Canadian Academies completed a massive report on assisted suicide, and its possible expansion in Canada. Requested by the Ministers of Justice and Health and tabled in Parliament, this report was written “in order to inform a national dialogue among the Canadian public, and between the public and decision makers.”
It’s helpful to define terms used in this article. The CCA reports makes consistent reference to “MAID”, which stands for “Medical Assistance in Dying”. We strongly object to this euphemistic term, since it intentionally blurs the line between ethical end-of-life palliative medicine and the intentional killing of a patient. Therefore, throughout this article, we replace the acronym MAID with either “assisted suicide” or “euthanasia”. At some points, we use these terms interchangeably when referencing the unethical death of a patient with the involvement of a medical professional. However, assisted suicide is distinct from euthanasia in that assisted suicide also involves the patient’s willful act or involvement to end their own life (more likely in cases of mental disorders and mature minors), whereas euthanasia is solely the act of another in killing the patient (more common with advance directives).
How the CCA report came about
Since the summer of 2017, some 75 experts from Canada and around the world have been working on this report about the expansion of euthanasia in Canada. The Council of Canadian Academies (the CCA) was tasked with going on a fact-finding mission to report on “the state of knowledge on medical assistance in dying for mature minors, advance requests, and where mental disorder is the sole underlying medical condition”. The CCA assembled the “Expert Panel on Medical Assistance in Dying” to undertake this project. This panel was split into three working groups: one focused on assisted suicide for mature minors, one on advance requests for euthanasia, and one on requests for assisted suicide where mental disorder is the sole underlying medical condition.
Simply talking about the expansion of euthanasia makes expansion a topic of reasonable discussion
After 18 months of research and writing, the 750-page report landed in Parliament. The report does not make any recommendations for or against the expansion of euthanasia; it merely records “the state of knowledge” on these topics. In this way, the report is not all that controversial. Advocates on either side of the issue will be able to point to parts of the report as supporting their arguments for or against expansion.
The one inherent danger in the CCA report
Thankfully, the CCA report does not push for greater access to euthanasia or assisted suicide for teens, people with dementia, or people with a mental disorder. Still, tabling this massive report comes with an inherent danger. Even though it never recommends expanding euthanasia, it does talkabout it. Simply talking about the expansion of euthanasia makes expansion a topic of reasonable discussion. This is an example of the “Overton Window” at work: shifting an issue from unthinkable, toward acceptable, toward policy. Just a few short years ago, a doctor killing their patient was a crime worthy of the harshest penalty in the Criminal Code: life in prison with no eligibility of parole for a minimum of 25 years. Three years later, prestigious academics from across the country are encouraging Canadians to have a public dialogue about killing teens with mental disorders on request.
Our obligation as committed Christians who love our neighbours is to push back, not just against this expansion of euthanasia, but against all euthanasia
Now, the thing about the Overton Window is that it can, with persistent engagement, slide in either direction – toward more acceptability on a topic, or away from acceptability of a topic. The direction of the shift usually depends on the loudest, or most engaging, or most winsome arguments presented. And so, in the face of a report that makes it reasonable to discuss expanding assisted suicide, our obligation as committed Christians who love our neighbours is to push back, not just against this expansion of euthanasia, but against all euthanasia. We need to push back by pointing out how weak the safeguards are in our current law, and how eligibility requirements are too vague. We need to emphasize over and over again how euthanasia devalues all human life, and puts the lives of all vulnerable people at increased risk.
Let’s take a look at the three areas of concern that the report investigates (page numbers below reference the executive summary). Inside these pages are warnings against the expansion of euthanasia that are worth highlighting.
The executive summarynotes that whether or not we should apply the current law regarding mature minors’ consent for healthcare treatment (as it applies to chemotherapy or surgery, for example) “depends, in part, on whether one views withholding or withdrawing treatment as ethically distinct from [assisted suicide] (pg. 9).” Herein lies a fundamental difference in belief between euthanasia advocates and opponents: those who value all life view killing your patient as morally wrong and bad medicine, and ethically distinct in substance from withdrawing medical treatment. If this moral line is blurred, then euthanasia continues to expand and spread.
The report gives a few clear warnings as they relate to euthanasia for minors. One is that “there is a lack of detailed guidelines describing capacity testing for [assisted suicide] in Canada.” (pg. 10). In other words, no one really knows whether or not a teenager, asking for assisted suicide, actually has the capacity to do so.
The report also cautions that an “unintended consequence might be that some terminally ill minors may feel pressure to request [assisted suicide] as a means of protecting their families from continued financial and/or emotional stress,” and that “allowing mature minors to request [assisted suicide] might normalize suicide among young people, especially those who struggle with mental disorders and may be considered vulnerable” (pg. 11).
Allowing mature minors to request assisted suicide might normalize suicide among young people, especially those who struggle with mental disorders and may be considered vulnerable
Furthermore, the report notes that doctors in pediatric medicine “indicate a greater unease about the prospect of providing [assisted suicide] to mature minors” (pg. 12). This should not surprise us; virtually all doctors working with kids do not want to kill their patients. Yet, if Canada expands the “right” to assisted suicide to mature minors, we can expect that doctors will have to fight for their Charter-guaranteed freedom of conscience to not be forced to kill a teenage patient on request.
The summary report on assisted suicide for minors includes a number of safeguards that should be considered if the practice was expanded in Canada. The list includes parental consent (as exists in Belgium and Netherlands), and increased palliative care, made available in a timely manner at hospital or home.
Many advocates in favour of expanding euthanasia particularly want it expanded for dementia patients. The basic argument is that a healthy person, knowing they’ve been diagnosed with a degenerative disease like dementia, should be able to consent to their own death months ahead of time so that consent at the time of lethal injection can be waived. This prior consent is based on the assumption that one would not want to live that way and, lacking the mental capacity to be aware of their state as the disease progresses, should be killed by their doctor when they reach that stage.
Obviously, this raises all kinds of concerns. The report notes, “Interpreting suffering in others is difficult since it is a personal, subjective experience” (pg. 18). The report later states, “An AR (Advanced Request) for [euthanasia] 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 do not reflect the lived experience of the person when they reach those circumstances. Uncertainty about how to approach an AR for [euthanasia] increases if the person who has lost capacity appears indifferent to receiving [euthanasia], expresses a desire to continue living, or physically or verbally resists the [euthanasia] procedure” (pg. 21).
Consider that last sentence again:
“Uncertainty about how to approach an advance directive for [euthanasia] increases if the person who has lost capacity… expresses a desire to continue living, or physically or verbally resists the [euthanasia] procedure.
So, if a dementia patient expresses a desire to continue to live, a doctor with an advance directive in their hand would seriously wonder whether or not to still kill the patient? This is absolutely ludicrous. And if the patient physically resists the assisted suicide, it should be absolutely crystal clear that you DO. NOT. KILL. THIS. PATIENT! And yet, this exact scenario has played out in the Netherlands, where a doctor was reprimanded (though never sanctioned) for telling a husband and daughter to pin down a resisting elderly woman so that he could kill her. In any other jurisdiction, that would be first-degree murder, with the husband and daughter being charged as accomplices. Yet Canada poses the scenario in the hypothetical as a topic for discussion, an area of “uncertainty” for how to proceed.
If the patient physically resists the assisted suicide, it should be absolutely crystal clear that you do not kill this patient!
The report also “recognizes that some people are concerned that allowing ARs for [assisted suicide] might have an impact on the way society values people with capacity loss, increasing stigma and signaling that it is acceptable to consider a life with capacity loss as one not worth living” (pg. 23). We completely agree: it is an inevitable result. Moreover, “some have expressed concern that allowing ARs for [assisted suicide] would create a society in which [assisted suicide] was an appropriate alternative to providing quality and accessible care to those with capacity loss, opening the door to cost of care, bed clearing, or other considerations to explicitly or subtly enter the treatment decision-making process” (pg. 23).
The report lists more risks involved in expanding euthanasia to dementia patients. “The primary risk involved in ARs for [euthanasia] is the risk that a person will receive an assisted death against their wishes. This risk is influenced by systemic and societal pressures… stigma associated with a loss of decision-making capacity, or biased assumptions about quality of life” (pg. 23).
No safeguard can remove a risk entirely
This part of the report wraps up with this summary of findings on safeguards: “Safeguards can respond to risks by reducing potential impact and/or likelihood, though none can remove a risk entirely” (pg. 23). That last phrase is incredibly important: no safeguard can remove a risk entirely.We must ask, a risk of what exactly? The risk of killing someone who didn’t want to be killed, the risk of an unsuspecting person being executed by an employee of the state. That’s the risk, and it needs to be stated clearly and unequivocally.
The third part of the report on euthanasia and assisted suicide expansion looked at mental disorders. In this section, the division between experts was most clearly seen. Page 28 has a long chart of all the areas of fundamental disagreement between the two sides, disagreements that cannot be sorted out with more facts or better arguments. These disagreements go to the foundation of a person’s ultimate view of a suffering human: how do you love them and give them what’s best for them? Depending on assumptions, the answers can be radically different.
Having a mental disorder is one of the most strongly associated risk factors for suicide
The biggest issue noted in this section of the report is this: “A particular challenge for some people who request [assisted suicide for a medical disorder] 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” (pg. 29). Later, the report notes that, “Having a mental disorder is one of the most strongly associated risk factors for suicide”(pg. 30).
And yet, Canada is seriously discussing the possibility of making assisted suicide available to people with mental disorders.
So where to from here?
The executive summary of the CCA report concludes by noting a fundamental tension facing the experts studying the expansion of euthanasia. It says, “what is a safeguard to some people might be a barrier to others” (pg. 37).
Indeed. Some people really do see access to doctor-assisted death as a fundamentally good thing. They see nearly every safeguard as an unnecessary inconvenience and an affront to their “right” to die at a time, place and in a manner of their own choosing. This is where autonomy of the individual trumps all. There is little concern about the value of protecting the vulnerable and ensuring the care of other Canadians who want to live.
We know euthanasia advocates won’t stop. Neither should we. The Overton Window has been pushed in one direction with the tabling of this report; we need to slide it the other way. We need to engage in the dialogue, not by dancing around the parameters of the debate framed by the report, but by pushing back against the new “status quo”, by advocating for much stricter safeguards rather than expansion, by telling the stories of people who want to live, but whose legal protections are carelessly thrown under the bus to satisfy the extreme voices of a few who want access to death on their own terms.
We know euthanasia advocates won’t stop. Neither should we.
The euthanasia law, passed in June 2016, included a legal requirement for a formal review five years after its passage. That review is still coming – this CCA report is merely an additional report for Parliament’s consideration. The legislative review may very well include changes to the law. We need to keep the pressure on to make sure the changes made are in the right direction. This issue will not go away, and our vulnerable friends and neighbours are counting on us all to add our voices to theirs, to stand up for life.