Canadian report discusses expanding eligibility for euthanasia

A long-awaited discussion paper on three controversial extensions to Canada’s euthanasia law has been released. It was only two-and a-half years ago, in June 2016, that Bill C-14 was passed amending the Criminal Code to legalise both euthanasia and physician-assisted suicide. Now the government is already considering expanding eligibility.

Three important and contentious issues were passed over at the time. This report, by the Council of Canadian Academies, a government advisory board, reviews the pros and cons without making any recommendations.

The three areas are requests for euthanasia by mature minors, advance requests, and requests where mental illness is the sole underlying medical condition – all highly controversial issues which have surfaced in the media. Each has generated a long well-documented report (available on the CCA website). There is also a summary of all three.

While the CCA’s brief was simply to outline the issues – which it did quite well – it is easy to discern which of the proposals was most controversial amongst the authors.

Euthanasia for mature minors. Only the Netherlands and Belgium permit this at the moment and there are only 16 documented cases – which do not include the experiences of the families of the “mature minors”. The nub of the issue (given that euthanasia has already been legalised) is balancing the autonomy of persons under 18, their maturity in dealing with life-and-death issues, and the need to protect them from undue pressure. The working group “concludes that there are many gaps in knowledge that make it difficult to arrive at definitive answers”.

However, as Alex Schadenberg, of the Euthanasia Prevention Coalition, points out, the CCA report declined to define euthanasia as simply part of a continuum of options for end-of-life care.

Advance requests (or advance directives.) ARs for Medical Aid In Dying (MAID) are currently not legal. Media publicity has been given to cases in which a person who wanted MAID feared that they could lose decision-making capacity and thus become ineligible for MAID. Their solution was to choose euthanasia early. However, an AR creates a difficult situation for doctors; they would be ending the life of person who cannot consent to their own death.

Critics allege that ARs would subtly stigmatize disability and dementia and signal “that it is acceptable to consider a life with capacity loss as one not worth living”. The report dismisses such concerns: “little evidence exists as to the likelihood of potential impacts, positive or negative; they are plausible but conjectural”. The report calls for further research.

Requests where mental illness is the sole underlying medical condition (MD-SUMC). This was clearly an area on which the authors were divided. “The Working Group disagrees about how to balance two risks: ending the life of a person with a mental disorder whose condition would have improved and who would have regained the desire to live, and denying MAID MD-SUMC to a person whose condition would not have improved and who would continue to live with intolerable suffering.”

Furthermore, there are intractable problems with distinguishing between a request for MAID stemming from the pathology of a mental illness and one which is autonomous and realistic. In other words, some people might use MAID as a way to commit suicide, not to end intolerable suffering.     

And a very serious problem is the definition of “intolerable”. Canada is the only country in the world which defines this in subjective terms. Ominously the report notes that “If Canada were to expand MAID MD-SUMC using this criterion, it could become the most permissive jurisdiction in the world with respect to how relief of suffering is evaluated.”

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