First, Do No Harm – Except for Death
Canada’s expansion of physician-assisted dying to mental health patients
Aly Muhammad Ladak
Disclaimer: The following article contains sensitive language and political subject matter. Any opinions voiced by the author do not reflect those of Trinity Times as a publication, or those of the masthead.
In April 2022, a Toronto woman was injected with a sequence of two anaesthetics, propofol and rocuronium, which stopped her heart. She wasn’t suffering from a terminal illness nor was she in untreatable, debilitating pain. Instead, she had a set of environmental allergies known as Multiple Chemical Sensitivity — where smoke, fragrances, and other particles that entered through her apartment’s ventilation system caused excruciating pain. According to Toronto physician Dr. Riina Bray, this woman “just needed to be helped to find a suitable place to live, where there wasn’t smoke wafting in through the vents.” Her suffering could have been alleviated by moving to an apartment or house without shared ventilation, but instead our medical system allowed for and facilitated her death. This case reflects a broader change in policy: more and more Canadians are choosing to undergo Medical Assistance in Dying (MAiD), or physician-assisted suicide, despite having other options to reduce their suffering. The Canadian government plans to expand MAiD to patients struggling exclusively with mental health conditions, which will lead to more untimely, unnecessary, and tragic deaths.
As one of a dozen countries worldwide where assisted suicide is legal, the history of MAiD in Canada is filled with controversy. The saga has been marked by a back-and-forth between the Canadian government and courts. It began on February 6, 2015, when the Supreme Court of Canada ruled that the federal ban on euthanasia was unconstitutional. This set the ball rolling for Bill C-14 in 2016, which legalized MAiD for patients whose death was ‘reasonably foreseeable’.
But this wasn’t the end for MAiD laws in Canada. In 2019, the Superior Court of Quebec ruled that the limitation of MAiD to situations where death was imminent violated the Charter of Rights and Freedoms of Canada. Their core argument was that restricting access to MAiD is inconsistent with the Charter’s call for “equal protection” under the law and that those suffering from non-terminal conditions have the same right to MAiD as those suffering from terminal ones. Similar arguments rooted in the Charter have been widely used to push for broadening access to MAiD. Most recently, they have been used to expand MAiD access to patients with mental health conditions – for example, those with severe depression and suicidal ideation.
A ban on MAiD for mental health patients is set to be lifted in March 2023, and although the Federal Government has now agreed to delay this, they are still committed to eventually implementing the expansion. This has been pitched by advocacy organizations, such as Dying with Dignity, because they feel that removing “a gross violation of the Charter of Rights and Freedom” ignores how “suffering caused by a mental disorder is no less real than suffering caused by a physical illness, injury, or disability.” However, these arguments based on ‘equal protection’—while well-intentioned—ignore that many patients in these scenarios do not have the capacity to make free and informed judgements about ending their lives. Former Canadian Psychiatric Association president K. Sonu Gaind argues that “mental illness can affect how a person thinks… [sometimes] with emotional resilience lowered until mundane stresses seem overwhelming.” Limiting access to MAiD would constitute recognition of this fact, rather than ignoring these patients’ suffering. Furthermore, MAiD is prototypically meant for cases in which no other options are available for managing patients’ suffering, and many mental illness patients have a plethora of other treatment options available before considering euthanasia — including drugs, therapies, and operations. It is perhaps ironic that many advocacy groups are promoting MAiD for mental health patients, given that this legitimizes the view that suffering due to mental illness cannot be effectively alleviated. Allowing patients in mental distress the access to MAiD without supporting their exploration of other options is tantamount to abandoning their care.
“First, do no harm.” This core medical principle serves as a stark backdrop to MAiD, especially for patients who have other options. K. Sonu Gaind instead argues for a principle of “do the least harm” when considering MAiD – advocating for MAiD in cases where the choice is between continued suffering and death and when that suffering is unbearable.
To achieve this standard, I believe a few changes are needed in the process of accessing MAiD. First, we need to improve access to palliative care for patients. Of Canadians who died of MAiD in 2021, 12% of them did not have access to end-of-life services. People have the right to end their lives in dignity, and denying access to a comfortable and caring environment is a violation of this right. We can also keep the “do the least harm” principle in mind in terms of expanding MAiD to patients with mental health conditions. If the government goes ahead with this expansion – which it remains committed to doing – then there should be specific provisions limiting access from those with severe depression that limits their capacity to freely make these decisions. Furthermore, those with mental illness who are denied MAiD upon request should be offered the care they require as soon as possible. But the most critical component of regulating MAiD has nothing to do with the process of requesting it at all. Instead, I believe we need to uproot the systemic inequities within our society and prevent them from causing widespread harm. Think back to the Toronto woman with Multiple Chemical Sensitivities. Her suffering could have been alleviated by providing housing that did not let in irritating smoke and chemicals, and yet Canada’s social support systems failed her so deeply that she sought out MAiD. Sadly, suffering of people like her is further worsened by a busy healthcare system with long wait times and a lack of access to palliative care.
Faced with a society that inadequately addresses their suffering, a healthcare system whose limitations prolong their suffering, and a paucity of dignified end-of-life care, it is perhaps no surprise that some of those suffering take matters into their own hands – often in the most tragic way possible.