First, Do No Harm: How Canadian Law Allows for Euthanasia and Assisted Suicide for Patients with Psychiatric Disorders (Dr Mark S. Komrad)

Canada recently passed a Bill, C-7, which responded to a Quebec Superior Court ruling that the previous Federal law introducing ‘Medical Aid in Dying’ (MAiD) – euthanasia and assisted suicide  (EAS) – into Canadian medical practice, violated the Canadian Charter of Rights and Freedoms by not including mental illness as an eligible condition for access to that practice. C-7 removed the existing limitation, and thereby joined the Benelux countries in having a legal framework allowing euthanasia to be accessed and applied to people suffering from psychological pathologies. Such an evolution in Canada’s euthanasia legislation has shocked that country’s professional mental health community, and led to alarm and strong objection from other parts of civil society, including among Canada’s First Peoples, the disability advocacy community (reflected in UN concerns about the effect of Canada’s euthanasia laws on persons with disabilities), and from the Canadian Catholic Bishops. It is however wholly unsurprising the logical ‘slippery slope’ implications of accepting doctor-involvement in the death of patients as an acceptable response to suffering or as constitutionally-guaranteed liberty or right.

This represents a remarkable shift in the deep ethos of psychiatry, in which psychiatrists would have to decide which suicides should be prevented and which should be abetted. It also has a severe effect on psychiatric patients now have much longer than that in Canada to get psychiatric consultation, treatment, and other resources in Canada, which of course affects less privileged patients who have greater difficulty in accessing needed care.

Canada and the European jurisdictions it has emulated show that the principles on which legalised euthanasia and assisted suicide are founded have clear negative implications for social justice and the welfare of the vulnerable.

Canada just passed a law that radically changes the boundary between acceptable and unacceptable medical practice and has opened a path to euthanasia for patients with psychiatric illness who find their conditions unbearable.

Unfortunately, this is not a new phenomenon. Several countries allow psychiatric patients who are suicidal to voluntarily receive death by lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide) from physicians. In Belgium, the Netherlands, and Luxembourg (collectively known as the Benelux nations) these practices first emerged in 2002, after laws were passed permitting medically assisted death for patients whose physical or psychological suffering was unbearable and could not be effectively treated by acceptable means. [1] A terminal condition was not a necessary criterion. This opened the door for some psychiatric patients in those countries to have suicide provided for them rather than prevented. It is documented that between 100 and 200 psychiatric patients are euthanised upon request annually between Belgium and the Netherlands (see Table 1 and Table 2). [2,3]

TABLE 1[**]. Belgian Patients Euthanised for Primary Psychiatric Disorders [2].

TABLE 2. Patients Euthanised in the Netherlands for Primary Psychiatric Disorders [3].

In concerned response to these developments, the American Psychiatric Association issued a position statement in 2016: “A psychiatrist should not prescribe or administer any intervention to a non–terminally ill person for the purpose of causing death”. [4]

In 2016, Canada passed Bill C-14, a law permitting medical euthanasia and physician-assisted suicide, together known as Medical Aid In Dying (MAID). [5] By November 2020, more than 13,000 individuals nearing the end of life had been voluntarily euthanised as a result of this bill. [6,7]

TABLE 3. Euthanasia Numbers in Canada [7]

To be eligible, a patient’s natural death must be predicted to be reasonably foreseeable. This uniquely Canadian term was not statutorily defined, but it was understood to be associated with the end of life – how close was undetermined. Because death from mental disorders was not considered to be strongly predictable, mental illnesses were not eligible conditions. This feature of the law essentially prevented the kind of psychiatric euthanasia practiced in the Benelux countries. [8]

Then, in 2019, a Quebec Superior Court ruling challenged the constitutionality of the reasonably foreseeable restriction. [9] As a result, a new federal bill was introduced to extend euthanasia eligibility, without the previous restriction. This new initiative, Bill C-7, followed the Benelux model; it removed the prior exclusion of those who have with nonterminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable. [10]

Initially, Bill C-7 clearly excluded psychiatric disorders, which was at least implicit in the original C-14 law. However, there was ambiguity in this proscription, because psychological suffering (which is not defined in either legislation) continued to be a criterion for eligibility. In addition, many protested that C-14’s scope discriminated against those with mental illnesses. Ironically, in its efforts to promote parity, the Canadian Psychiatric Association was such a voice. As an organisation, it declared: “Patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAID as available to all patients”. [11]

This led to a dramatic turn of events in the Canadian Senate, which considered Bill C-7 this February. In an unprecedented move, Senator Stan Kutcher, MD, who is also a psychiatrist, declared that the exclusion of individuals with psychiatric disabilities would be discriminatory. He introduced an amendment allowing MAID for mental illness available within 18 months of the bill passing. [12] When the modified legislation was returned to the House of Commons, the discussion was quickly shut down by a liberal coalition and the bloc party from Quebec (a province that promotes euthanasia and aims to restrict conscientious objection to euthanasia by health care professionals). A vote was forced, and on March 17, 2021, the C-7 expansion of euthanasia in Canada became law, complete with the last-minute amendment to sunset the mental illness exclusion after 2 years. [13]

This 2-year interval is to be used to create an expert panel to establish standards for evaluating patients and procedures to distinguish between patients with psychiatric disorders whose suicide should be prevented from those whose for whom it could be provided. However, as Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, noted in response to a query, “There isn’t a prosecutor in the land who would prosecute someone for doing euthanasia for mental illness before the 24-month time frame has passed because it is technically legal”.

This is a profound change in the trajectory of the euthanasia law, and the practice of psychiatry for Canada, which is now the largest nation that will soon allow MAID for psychiatric conditions. It has rocked the professional mental health  community in Canada, which fought to forestall the inclusion of psychiatric disorders for euthanasia.

The latest law is disappointing but unsurprising considering the huge pushes for parity and nondiscrimination at all costs. Unlike in the United States, health care in Canada is considered a charter (constitutional) right. Thus, once MAID became a medical procedure, excluding patients with psychiatric illness from this right was nearly impossible.

Countries that have allowed MAID in a limited number of cases have quickly found themselves descending a slippery slope. Prominent critic Wesley J. Smith, JD, noted [14]:

Once society embraces doctor-prescribed death as an acceptable answer to human suffering or as some kind of fundamental liberty right, there are no brakes. We need only look at European countries that have gone down the Euthanasia Highway to see how society is impacted deleteriously by accepting killing as a suitable answer to the problem of human suffering.

Indeed, Belgium and the Netherlands are now debating the extension of euthanasia beyond medical conditions to include those who feel they have a completed life [15] or are tired of living. [16] There is even discussion of de-medicalising euthanasia by providing lethal over-the-counter pills. [17] Pegasos, a self-proclaimed “voluntary assisted dying association” based in Basel, Switzerland, currently provides euthanasia for non-medical “suicide tourists”. [18]

Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of C-7, the psychiatrist editor of the Journal of Ethics in Mental Health reported [19]:

A few days ago, a 30-year-old patient with very treatable mental illness asked me to end her life. Her distraught parents came to the appointment with her because they were afraid that I might support her request and that they would be helpless to do anything about it. It’s horrific they have to worry that by going to a psychiatrist, their daughter might be killed by that very psychiatrist.

Similar significant objection comes from the disability advocacy community. [20] They are concerned that permitting euthanasia for nonterminal, disabled individuals implies that their lives may be not worth living. Furthermore, they recognise that individuals with disabilities may not have adequate access to state-of-the-art treatment, and that euthanasia could become a cost-saving alternative to suffering when adequate solutions are not available or affordable.

An evaluation by the United Nations also  expressed strong worry about how Bill C-7 impacts individuals with chronic disabilities [21]:

We are deeply concerned that the eligibility criteria set out in Bill C-7 to access medical assistance in dying may be of a discriminatory nature, or have a discriminatory impact. By singling out the suffering associated with disabilities being of a different quality and kind than any other suffering, they potentially subject persons with disability to discrimination on account of such a disability.

There is also strong objection among Canada’s First Peoples, due to conflicts with cultural values, their limited access to state-of-the-art treatments, and staggering suicide rates in that population. [22] Similarly, the Canadian Catholic Bishops, who are always opposed to euthanasia, have been left particularly aghast. [23]

Bill C-7 also sets up a 2-tier system, abolishing some of the original C-14 safeguards. For instance, patients who are terminally ill can be evaluated for euthanasia and possibly receive it on the same day, with no waiting period, unlike the 10-day waiting period in the previous C-14 law. However, patients who are not terminally ill must wait 90 days. Ironically, it is not unusual to have to wait much longer than that in Canada to get psychiatric consultation, treatment, and other resources.

Moreover, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration. Even Belgium, which is known for its liberal approach, recently added guidelines that individuals applying for euthanasia for a mental disorder should not have refused any evidenced-based treatments. [24]

A group of experts in Canadian law and medicine wrote [25]:

C-7 will allow physicians to end the life of people with disabilities or chronic illnesses at their request and will require the system to ensure it happens even when physicians are convinced, based on their expert knowledge, that medicine offers options and even when the patient may have years or decades to live with a good quality of life if other options are explored and tried first.

The American Medical Association has concluded that MAID practices are “fundamentally incompatible with the physician’s role as a healer”, [26] and the World Medical Association “is firmly opposed to euthanasia and assisted suicide”. [27] Nevertheless, these types of laws have been adopted around the world, most recently in New Zealand, Spain, Portugal, and several states in Australia. In US states, as in Canada, attempts have been made to expand initially strict practices. [28] The justifications made in debate for euthanasia and assisted suicide (e.g., autonomy, self-determination, and intolerable suffering) are now being applied to psychiatric disorders, despite lack of any agreement that treatment for psychiatric disorders are ever futile or that suffering is truly irremediable. [29]

Bill C-7 and similar laws would represent a remarkable shift in the deep ethos of psychiatry, in which psychiatrists would have to decide which suicides should be prevented and which should be abetted.

Karandeep Sonu Gaind, MD, past president of the Canadian Psychiatric Association and a fierce critic of the MAID expansion to psychiatric patients, noted that less privileged patients have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a poetic cri de  coeur [30]:

So thank you Canada, powers that be,

For ensuring that our smooth passings

Will reflect the privilege of our life trappings.

I will soon be free, without anxiety, knowing

That with ease I can choose the time of my going.

And any poor souls sacrificed on this altar

Of my choice, my voice,

There will be no way of knowing.

[*] This article originally appeared as First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders in the Psychiatric Times, Vol 38, Issue 6, 07th June 2021: https://www.psychiatrictimes.com/view/first-do-no-harm. Dr Komrad also recorded a video to accompany his article, which can be watched on the Psychiatric Times website, here: https://www.psychiatrictimes.com/view/new-agent-for-mdd-ppd-takes-a-step-closer-to-approval

The picture on the title page is ‘Headache Touching Forehead’ by Jose Navarro, retrieved 20th October 2021: http://bit.ly/HeadacheTouchingForehead-JoseNavarro

[**] Note: Table 1 is based on both reference number [2] and the author’s analysis of previous reports from the European Institute of Bioethics.

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[1] Komrad MS. A psychiatrist visits Belgium: the epicenter of psychiatric euthanasia. Psychiatric Times. 21st June 2018. Accessed 28th April 2021. https://www.psychiatrictimes.com/view/psychiatrist-visits-belgium-epicenter-psychiatric-euthanasia

[2] du Bus C. Euthanasia in Belgium: analysis of the 2020 Commission Report. European Institute of Bioethics. 16th November 2020. Accessed 28th April 2021. https://www.ieb-eib.org/en/news/end-of-life/euthanasia-and-assisted-suicide/euthanasia-in-belgium-analysis-of-the-2020-commission-report-1921.html

[3] Annual Report 2019. Regional Euthanasia Review Committees. April 2020. Accessed 28th April 2021. https://www.euthanasiecommissie.nl/binaries/euthanasiecommissie/documenten/jaarverslagen/2019/april/17/index/RTE_jv2019_ENGELS_gecorrigeerd.pdf

[4] Komrad MS. APA position on medical euthanasia. Psychiatric Times. 25th February 2017. Accessed 28th April 2021. https://www.psychiatrictimes.com/view/apa-position-medical-euthanasia

[5] Komrad MS. Medical euthanasia in Canada: current issues and potential future expansion. Psychiatric Times. 29th June 2018. Accessed 28th April 2021. https://www.psychiatrictimes.com/view/medical-euthanasia-canada-current-issues-and-potential-future-expansion

[6] Schadenberg A. There have been approximately 19,000 euthanasia deaths in Canada. Euthanasia Prevention Coalition. 20th October 2020. Accessed 28th April 2021. http://alexschadenberg.blogspot.com/2020/10/there-have-been-approximately-19000.html

[7] Health Canada. First annual report on medical assistance in dying in Canada, 2019. July 2020. Accessed 10th May 2021. https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html

[8] Rousseau S, Turner S, Chochinov HM, et al. A national survey of Canadian psychiatrists’ attitudes toward medical assistance in death. Can J Psychiatry. 2017;62(11):787-794.

[9] Marin S. Quebec court invalidates parts of medical aid in dying laws as too restrictive. Toronto Star. 11th September 2019. Accessed 28th April 2021. https://www.thestar.com/news/canada/2019/09/11/quebec-court-invalidates-portions-of-medical-aid-in-dying-laws-as-too-restrictive.html

[10] First session, forty-third Parliament, House of Commons of Canada. Bill C-7: an act to amend the Criminal Code (medical assistance in dying). first reading 24th February 2020. Parliament of Canada. Accessed 28th April 2021. https://parl.ca/DocumentViewer/en/43-1/bill/C-7/first-reading

[11] Chaimowitz G, Freeland A, Neilson GE, et al. Medical assistance in dying. Canadian Psychiatric Association. 10th February 2020. Accessed 28th April 2021. https://www.cpa-apc.org/wp-content/uploads/2020-CPA-Position-Statement-MAID-EN-web-Final.pdf

[12] Bryden J. Senators amend MAID bill to put 18-month time limit on mental illness exclusion. CTV News. 09th February 2021. Accessed 28th April 2021. https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151

[13] Bryden J. Canadian Senate passes Bill C-7, expanding assisted dying to include mental illness. Global News. 17th March 2021. Updated 19th March 2021. Accessed 28th April 2021. https://globalnews.ca/news/7703262/canada-senate-passes-bill-c-7/

[14] Smith W. Euthanasia spreads in Europe: several nations find themselves far down the slippery slope. National Review. 26th October 2011. Accessed 28th April 2021. https://www.nationalreview.com/2011/10/euthanasia-spreads-europe-wesley-j-smith/

[15] Boztas S. Euthanasia law proposed for healthy over-75s who feel their lives are complete. Dutch News.nl. 19th July 2020. Accessed 28th April 2021. https://www.dutchnews.nl/news/2020/07/euthanasia-law-proposed-for-healthy-over-75s-who-feel-their-lives-are-complete/ 

[16] Cohen-Almagor R. Euthanizing people who are “tired of life”. In: Jones DA, Gastmans C, MacKellar C, eds. Euthanasia and Assisted Suicide: Lessons from Belgium. Cambridge University Press; 2017:188-201.

[17] Clusky P. Euthanasia debate in Netherlands takes an unwelcome twist. The Irish Times. 10th September 2019. Accessed 28th April 2021. https://www.irishtimes.com/news/world/europe/euthanasia-debate-in-netherlands-takes-an-unwelcome-twist-1.4013718

[18] Cook M. A new Swiss group caters for Dutch who are eligible for euthanasia. BioEdge. 24th January 2021. Accessed 28th April 2021. https://www.bioedge.org/mobile/view/a-new-swiss-group-caters-for-dutch-who-are-not-eligible-for-euthanasia/13673

[19] Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canadian Broadcasting Corporation. 11th February 2020. Accessed 28th April 2021. https://www.cbc.ca/news/opinion/opinion-assisted-dying-maid-legislation-mental-health-1.5452676

[20] Neves P. Disability is not a fate worse than death. The Chronicle Herald. 24th March 2021. Updated 27th March 2021. Accessed 28th April 2021. https://www.thechronicleherald.ca/opinion/local-perspectives/patricia-neves-disability-is-not-a-fate-worse-than-death-567935/

[21] Quinn G, Mahler C, De Schutter O. Mandates of the Special Rapporteur on the rights of persons with disabilities; the Independent Expert on the enjoyment of all human rights by older persons; and the Special Rapporteur on extreme poverty and human rights. United Nations Human Rights: Office of the High Commissioner. 03rd February 2021. Accessed 28th April 2021. https://spcommreports.ohchr.org/TMResultsBase/DownLoadPublicCommunicationFile?gId=26002

[22] Ruck A. First Nations leaders say Bill C7 goes against their beliefs and values. Canadian Catholic News. 12th February 2021. Accessed 28th April 2021. https://grandinmedia.ca/first-nations-leaders-say-bill-c7-goes-against-their-beliefs-and-values/

[23] Ruck A. Canadian Conference of Catholic Bishops denounces assisted suicide law. The Dialog. 09th April 2021. Accessed 10th May 2021. https://thedialog.org/respect-life/canadian-conference-catholic-bishops-denounces-assisted-suicide-law/

[24] Verhofstadt M, Van Assche K, Sterckx S, et al. Psychiatric patients requesting euthanasia: guidelines for sound clinical and ethical decision making. Int J Law Psychiatry. 2019;64(May-Jun):150-161.

[25] Lemmens T, Shariff M, Herx L. How Bill C-7 will sacrifice the medical profession’s standard of care. Policy Options. 11th February 2021. Accessed 28th April 2021. https://policyoptions.irpp.org/magazines/february-2021/how-bill-c7-will-sacrifice-the-medical-professions-standard-of-care/

[26] Ethics: euthanasia. code of medical ethics opinion 5.8. American Medical Association. Accessed 28th April 2021. https://www.ama-assn.org/delivering-care/ethics/euthanasia

[27] WMA declaration on euthanasia and physician-assisted suicide. World Medical Association. 13th November 2019. Accessed 28th April 2021. https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide/

[28] Schadenberg A. Washington State debates bill to expand assisted suicide law. say no to same day death. Euthanasia Prevention Coalition. 11th January 2021. Accessed 28th April 2021. https://alexschadenberg.blogspot.com/2021/01/washington-state-debates-expansion-of.html

[29] Gaind KS. What does “irremediability” in mental illness mean? Can J Psychiatry. 2020;65(9):604-606.

[30] Gaind KS. Last rights. Karandeep Sonu Gaind. 11th March 2021. Accessed 28th April 2021. https://static1.squarespace.com/static/5387fe39e4b095eb4a02b4ac/t/604bcc0f49c07e3e0e1e5afd/1615580176126/LAST+RIGHTS+-+FIN.pdf