In my previous post on Canada’s system known as MAID (Medical Assistance in Dying), there was an issue that I did not properly address and thought worth exploring in more depth, and that is the question of when a patient’s request for assistance in dying should be honored. The criteria have been getting steadily looser over time, which is not surprising. Once the threshold has been crossed that it is acceptable for medical professionals to end the life of a patient, the line as how much it should be limited becomes difficult to draw.
In 2014, when the question of medically assisted death had come before Canada’s supreme court, Etienne Montero, a civil-law professor and at the time the president of the European Institute of Bioethics, warned in testimony that the practice of euthanasia, once legal, was impossible to control. Montero had been retained by the attorney general of Canada to discuss the experience of assisted death in Belgium—how a regime that had begun with “extremely strict” criteria had steadily evolved, through loose interpretations and lax enforcement, to accommodate many of the very patients it had once pledged to protect. When a patient’s autonomy is paramount, Montero argued, expansion is inevitable: “Sooner or later, a patient’s repeated wish will take precedence over strict statutory conditions.”
As the size of the aging population gets larger and we see many cases of painful and protracted end of life, and as more and more people become comfortable with the idea of assisted dying and know of people who have taken the route and died peacefully, they are likely to want greater access, and that has happened in Canada with the expansion occurring at a faster rate than in Belgium
It is too soon to call euthanasia a lifestyle option in Canada, but from the outset it has proved a case study in momentum. MAID began as a practice limited to gravely ill patients who were already at the end of life. The law was then expanded to include people who were suffering from serious medical conditions but not facing imminent death. In two years, MAID will be made available to those suffering only from mental illness. Parliament has also recommended granting access to minors.
Once you remove the requirement of imminent death, then under what circumstances would a medical professional agree to end someone’s life? In certain cases, like ALS or Alzheimers, there is no cure and even though death may not be imminent, the final stages of life are almost guaranteed to be extremely difficult and one can understand a person wanting to avoid it and not wait, risking that they might pass the time when they can give informed consent. I know that I would fear that. Canada has put patient autonomy as the top priority but does that mean that pretty much anybody’s wish should be granted?
The new law [that was originally passed in 2016] approved medical assistance in dying for adults who had a “grievous and irremediable medical condition” causing them “intolerable suffering,” and who faced a “reasonably foreseeable” natural death. To qualify, patients needed two clinicians to sign off on their application, and the law required a 10-day “reflection period” before the procedure could take place. Patients could choose to die either by euthanasia—having a clinician administer the drugs directly—or, alternatively, by assisted suicide, in which a patient self-administers a lethal prescription orally. (Virtually all MAID deaths in Canada have been by euthanasia.) When the procedure was set to begin, patients were required to give final consent.
The law, in other words, was premised on the concept of patient autonomy, but within narrow boundaries. Rather than force someone with, say, late-stage cancer to suffer to the very end, MAID would allow patients to depart on their own terms: to experience a “dignified death,” as proponents called it.
But a new law passed in 2021 made the requirements less stringent, because the meaning of what it meant to have an ‘incurable’ became much less clear.
Canada’s MAID law defines a “grievous and irremediable medical condition” in part as a “serious and incurable illness, disease, or disability.” As for what constitutes incurability, however, the law says nothing—and of the various textual ambiguities that caused anxiety for clinicians early on, this one ranked near the top. Did “incurable” mean a lack of any available treatment? Did it mean the likelihood of an available treatment not working? Prominent MAID advocates put forth what soon became the predominant interpretation: A medical condition was incurable if it could not be cured by means acceptable to the patient. [My italic-MS]
Now decisions about what constituted incurability shifted from being exclusively the province of clinicians to also allowing a role for the patient. This led to the case of a 30-year old man with cancer who was told that there was 65% chance that he could be cured. But the man was adamant that he did not want to experience any pain at all, either from the cancer or from the treatments and so even if there was a 100% chance of a cure, he would not take it. This put his doctor in a quandary.
What was [Dr. Madeline] Li left with? According to prevailing standards, the man’s refusal to attempt treatment rendered his disease incurable and his natural death was reasonably foreseeable. He met the eligibility criteria as Li understood them. But the whole thing seemed wrong to her. Seeking advice, she described the basics of the case in a private email group for MAID practitioners under the heading “Eligible, but Reasonable?” “And what was very clear to me from the replies I got,” Li told me, “is that many people have no ethical or clinical qualms about this—that it’s all about a patient’s autonomy, and if a patient wants this, it’s not up to us to judge. We should provide.”
And so she did. She regretted her decision almost as soon as the man’s heart stopped beating. “What I’ve learned since is: Eligible doesn’t mean you should provide MAID,” Li told me. “You can be eligible because the law is so full of holes, but that doesn’t mean it clinically makes sense.” Li no longer interprets “incurable” as at the sole discretion of the patient. The problem, she feels, is that the law permits such a wide spectrum of interpretations to begin with. Many decisions about life and death turn on the personal values of practitioners and patients rather than on any objective medical criteria.
Old age is the ultimate incurable condition. As we age, we can be certain that our bodies will steadily fall apart, reducing our quality of life, sometimes suddenly due to a fall. Should the fear of getting old and frail be sufficient to access MAID?
By 2020, Li had overseen hundreds of MAID cases, about 95 percent of which were “very straightforward,” she said. They involved people who had terminal conditions and wanted the same control in death as they’d enjoyed in life. It was the 5 percent that worried her—not just the young man, but vulnerable people more generally, whom the safeguards had possibly failed. Patients whose only “terminal condition,” really, was age. Li recalled an especially divisive early case for her team involving an elderly woman who’d fractured her hip. She understood that the rest of her life would mean becoming only weaker and enduring more falls, and she “just wasn’t going to have it.” The woman was approved for MAID on the basis of frailty.
Li had tried to understand the assessor’s reasoning. According to an actuarial table, the woman, given her age and medical circumstances, had a life expectancy of five or six more years. But what if the woman had been slightly younger and the number was closer to eight years—would the clinician have approved her then? “And they said, well, they weren’t sure, and that’s my point,” Li explained. “There’s no standard here; it’s just kind of up to you.” The concept of a “completed life, or being tired of life,” as sufficient for MAID is “controversial in Europe and theoretically not legal in Canada,” Li said. “But the truth is, it is legal in Canada. It always has been, and it’s happening in these frailty cases.”
This seems to be putting physicians in a very uncomfortable position. There is the option for people to self-administer the drugs but most people seem to be wary of doing so, perhaps fearing that they might botch it.
The trend seems to be towards allowing pretty much anyone to choose to have a medically assisted death. But this raises the problem of people who go through a difficult period or depression and feel they want to end it all, even though their situation may prove to be transitory and they could emerge feeling hopeful of life again. Pretty much everyone goes through dark periods even if they do not reach the stage of becoming suicidal. Perhaps people who are not experiencing a diagnosed condition of terminal illness may be required to have a waiting period so that they do not make too hasty a decision. Deciding on the length will be yet another matter for debate
Medically assisted deaths create situations fraught with ethical and moral issues for everyone involved. But those should not prevent people from having the right to choose it. We just have to grapple with those issues on a case-by-case basis.
Here is an interesting theoretical example.
Most Americans have either diabetes or pre-diabetes, even if they don’t know about it. Left untreated, it seems to be inevitable that the patient will have rising blood sugar and blood pressure and weight, and eventually kidney failure or liver failure or a heart problem and death.
So, as with all humans, death is inevitable. But that doesn’t say if it will be in one year or fifty years more. So, first, there should be standards, such as the mean time between dialysis treatments.
But also, what if some doctors report success with unconventional treatments? What should be the standard if the patient is assessed that standard treatment predicts only say five or ten years of more life? And what if an unconventional doctor says that the disease can be put into complete remission by just a simple change in diet, for example? (Like stop eating sugar and carbs). Is a patient legally obligated to try the unconventional diet, in case it cures them? Of can a suicidal patient just declare that they don’t want to try to live without sugar, so they might as well die today? What is an appropriate standard for what society should be able to demand of a patient before permitting suicide?
These are hard questions, but key ones!
I feel like a lot of us (Americans? Anglospheres? Westerners? …) are looking at this from a really flawed perspective.
There’s a whole lot going on about gatekeeping dignity and suffering, and I think I understand the concerns there, but maybe we should be considering trying to change things so we don’t have a society that only values people for their potential labor output, and can do something to meet the social and emotional needs of people, without regard to their personal or familial wealth.
We have the technological capability and resources to make so many people’s lives easier, but we refuse to, because we (collectively as a society) think it’s more important to raise a billionaire’s net worth by a couple percentabge points.
it’s shameful
I thought yesterday’s topic was fraught and hard to answer…you upped the stakes today, Mano.
Here’s something I was thinking of: people who want to end their lives often can, by themselves. A joke in a tv show had a regular character take a job in a grocery store. Another character comes across him as he’s using a price gun (the show is set in the early 1990s) to attach prices on cans of vegetables. The first character notes that he had to work in the store for a month before they trusted him to use the price gun. “But--this being Texas--I could go out and buy a real gun on my lunch break!”
That is to say, a person who is otherwise healthy enough to get around but going through a bad or depressive patch could easily go out and buy a gun in the USA. They could avoid the 24-hour waiting period by buying a $10 ticket to a gun show and buying a gun directly there, no questions asked, or get it by less legal means. A co-pay to see a doctor about mental health might be $50 or more and involve a 2-month wait.
And, obviously, there are lots of other ways someone can end their lives so long as they’re physically capable of moving around. If there’s no sanctioned way to end their lives, they’ll find an unsanctioned way.
I’m sure a decision to end someone’s life is very hard on physicians, which is why I suggested a talk with veterinarians, who are asked to end a life far more often than a physician.
Before long, we’ll probably have AIs that can interact with a person for a while and present a somewhat-plausible simulation of that person, from audio/video (as in a Zoom call) to matching answers on a psychological test. If both personas then agree they share an identity, and that the meat-based avatar is obsolete and redundant, do the doctors need to add a techno-philosopher to their euthanasia advisory board?
While it is true that in the US it is easy to get a gun and thus theoretically easy to kill oneself, and many people do choose that option, that does not solve the problem. That type of end is not what people who seek death with dignity envisage. Shooting oneself leaves a terrible mess for others to clean up, not to mention the trauma it causes them.
What people want, for themselves and for their pets, is to die peacefully in one’s ‘sleep’, even if that sleep is medically induced.
@1
Citation needed.
Running a quick search, I find the CDC website (yes, I know) says this about US diabetes prevalence: “About 38 million people have diabetes, and 1 in 5 don’t know they have it.” Seems very far from “most.”
That’s a very revealing choice of language. I want the right to MAID for myself (I live in Scotland, where a bill allowing it is likely to be passed next year) to protect me from having to live or die in agony, or lose myself to dementia; and to protect those I love from the vicarious suffering of seeing these outcomes. While “accommodate” has the suggestion of something done merely for the accommodatee’s convenience or even whim.
Mano, the message I meant to convey is that people who are suffering enough and in good enough shape to do so will find ways to kill themselves. Guns or drugs or death-by-cop. I’m all in favor of a humane, stress-free death for people as well as beloved pets. I understand that in some cases the justification can be uncertain. I also think the USA with its weird religious fundagelical obsessions is going to be last in the first-world countries to implement it.
As we age, our abilities will inevitably decline. At a certain point, life changes from something to enjoy into something to be borne. At that point I think it is valid to say “I’m done”, even if there is no acute illness.
Before I begin, I will state that my bestest friend took his own life four years ago. It was one of the worst things that has ever happened to me. I cannot imagine the effect on his still-living parents. That said: he made a plan, and followed through. I respect that. No fucking about with “attempts” for him. He was not physically ill (that I knew of). He had been in a bad place mentally, to the point that I’d encouraged him to see a doctor. He did, and got a couple of weeks off work with stress. I did try to probe further, but he seemed to get happier. Mental health first aid training I’ve had since his death taught me that that very improvement in his apparent mood was a red flag. Please do mental health first aid training. If you don’t, and you have ANY concerns about a friend’s mental state, just do this: talk to them. ASK them, straight out and using these words: “have you thought about suicide?”. Do NOT euphemise. Do NOT say things like “you’re not going to do anything stupid are you?”. Statistics show that simply asking straight out can prevent suicide. Ask. Please. I didn’t, because I didn’t know to, and he’s gone. Ask them.
That being said:
I’m on the page that if I’m compost mentis enough to ask a doctor to kill me, and they’re qualified to do so, then they’re as morally obligated to do that as they would be if I turned up and asked them to give me antibiotics for an infection. If you’re not up for the responsibility, take up dentistry or law or whatever. I’ve no time for people who want the pay and public respect that comes with being a doctor but don’t want to do bits of doctoring they don’t like the sound of. The day they decline to treat patients on grounds of their own personal morals is the day they should be struck off, in my opinion. Do the job, or don’t. Cherrypicking should not be an option.
@Katydid, 3:
I was going to say “citation needed”, but it’s more direct to say “you’re the opposite of correct”.
It’s an observed (and I thought quite well-known) fact that when a commonly-used method of suicide is removed (e.g. town gas poisoning), the overall suicide rate does go down. If a person’s chosen method of suicide is not available, they do NOT find another way to do it -- they don’t do it.
Citation: https://drexel.edu/~/media/Files/law/law%20review/V17-3/Gould%20919-969.ashx or just google “town gas suicide” and learn about this very well known phenomenon.
I wanted to be a vet. I was talked out of it. A good friend’s daughter wanted to be a vet. I and the vet she did work experience with talked her out of it. The evidence I used was based on things a couple of vets I know told me.
1. Vets get into being vets generally because they love and want to work with animals, then they find that a substantial portion of their professional life is spent killing animals… distressingly often healthy animals.
2. Vets spend a great deal of time and an even greater deal of money qualifying (longer than dentists and much longer than doctors) but find they don’t earn as much and don’t get as much public respect as either of those.
3. They have ready access to drugs that will painlessly end life… so in the UK at least they end up with one of the highest suicide rates among the professions.
Regarding self-administration and the risks of “botching it” -- I am not a doctor, I’m a chemical engineer. I design large, automated systems for handling highly hazardous chemicals and keeping the operators of the equipment from coming to any harm while using materials up to and including UN-monitored chemical weapons. I could with minimal difficulty design and managed the build of a system that a doctor could hook a patient up to, then leave, letting the patient choose the exact time at which they administer whatever they’re using to check out. Crucially, pretty much regardless of the patient’s level of physical infirmity, I could build a system that would give the patient AND ONLY THE PATIENT command authority. This is not a difficult task. I’m curious why these ethical dilemmas are exercising these doctors so much when the solution is there for the taking.
Further: there is no need for hazardous chemicals. I’ve referred to this before in the context of the backward and barbaric practice of cold-bloodedly murdering people whom society is already protected from by their incarceration. I believe the shithole countries where this practice is condoned call it “execution” or “the death penalty”, trying to give it a false patina of legitimacy by making it sound all legal-like. The countries that practice is do so with a sense of theatre, with methods including hanging, firing squad or lethal injection, and in recent years the supply of the approved lethal injection drugs has dried up because even evil capitalist corporations know it’s bad publicity to be seen to be collaborating with such barbarity. I’ve previously expressed bafflement that they don’t simply put people in a room full of nitrogen. Inert atmospheres regularly kill people in the process industries, because they’re a very common method of preventing explosions. Remove all the oxidant from a space, and even if it’s full of petrol and you get a spark or strike a match, no ignition is possible.
Those who’ve by luck survived near-death encounters with nitrogen atmospheres report no stress, they just faint, and if not retrieved from the inerted space, never wake up. It’s odourless, colourless and 78% of what you’re breathing right now. Strikes me it’d be an ideal method of suicide even for the clumsy or incompetent -- a simple pressure-swing adsorbtion system configured to draw in air in a small room, split it into oxygen and nitrogen, vent the oxygen outside the room and the nitrogen back inside it. Go in the room, switch it on, lie down, go to sleep, don’t wake up. Hard to botch, no doctor required.
Obviously you’d want to control access to such devices to try to keep the suicide rate from spiking… or would you? If someone wants to do it… who is anyone else to say they shouldn’t?
I go back to my friend. I was and am fucking angry at him for what he did. For not talking to me about it. But all of my feelings, that is about MY guilt, MY upset, MY grief at his having died. But it is not about me. How fucking narcissistic is it to make it about me? It was his choice. And like I said, for all the pain it caused -- I respect his choice. And the choice of anyone who chooses similarly.
The only caveat I’d accept is this: put obstacles in the way of impulsive action. But if someone’s made a plan -- respect it.
Currently 11 states and Washington DC have some version of Medical Assistance in Dying (see Assisted suicide in the United States ). And a few more states are on the way there.
@ 10 sonofrojblake
Given Mano’s current comment policy, I can only suggest there is a place where your opinion belongs, it is part of your anatomy, and not particularly well-illuminated. I think I can speak for anyone with a dear friend who may have attempted suicide, even more than once, and went on to live a long and happy life once the years of crisis passed.
The science is very clear: In the vast majority of people contemplating suicide the feeling is short-term and due to a temporary crisis, and the majority of people unsuccessful in completing suicide are glad of the failure.
Your opinion that lethal injections should be handed out like antibiotics, and doctors who refuse to kill patients should be “struck off” is one of the most morally reprehensible opinions I’ve ever seen on the blog (and that’s saying something).
Katydid is entirely correct that we can learn from vets. The reason is that there is so much religious baggage connected with human euthanasia that it muddies the waters in a way where the waters with animals is relatively clear. Vets are used to advising putting an animal down purely on the basis of whether the suffering otherwise accrued makes the relatively painless death merciful, or whether the animal will continue to enjoy life, albeit more impaired than previously. Of course with humans it’s different as the animal doesn’t get a say in it while the human must! Nevertheless, it should be possible to make some determination as to whether suffering/happiness will be greater or lesser if the life is ended which must be balanced against patients’ wishes -- given we know as an empirical fact most people who at one time wanted to end their lives ended up glad they didn’t.
P.S. As things stand, we can be thankful people people who rejected vet as too hard will certainly never be doctors! 😯
How nice for you that in your world, no suffering person has ever purposely overdosed on medication, knotted a rope, used a gun, jumped in front of a bus/train, or committed suicide-by-cop.
@ anat: The USA is a patchwork of states, and the usual suspects will find themselves too immersed in religious nonsense to allow people to make choices over their own bodies.
@Katydid -- how nice for you that in your world there’s no large body of data AN EXAMPLE OF WHICH I CITED that supports my position and contradicts yours.
I mean that seriously, not sarcastically. It really must be just so easy being you, never having to bother with learning facts or anything, just getting by on whatever you’ve decided is true. Much better to be happy than right, as Slartibartfast wisely observed. Oddly, you don’t come across as happy either, so I’m not sure how that’s working for you.
Katydid and sonofrojblake,
It seems both of you are arguing from extremes? Katydid is correct that at least some people do indeed die by suicide when refused medical assistance in dying, and sonofrojblake is correct that in general, most of those who cannot access their preferred method of suicide end up not using an alternative method.
It’s very unlikely that people wanting to die because sickness is causing them severe suffering, or they expect it to do so soon, are in any way representative of people with suicidal ideation in general. As I’ve seen it expressed: “I’m not choosing death over life. I’m choosing the kind of death I want.”