Law expanding access to medical aid in dying divides Canadians

Halifax, Canada – Changes to Canada’s assisted dying regime have divided the country, with advocates hailing “a momentous day for end-of-life rights” and critics warning of heightened risks for the most vulnerable citizens.

The passage this month of Bill C-7 means that medical assistance in dying (MAID), previously restricted only to those with a “reasonable foreseeability of natural death”, will be more widely accessible in Canada.

The law expands the country’s MAID regime – also referred to as voluntary euthanasia – to people who might not be facing imminent death but have reached a state of “intolerable physical or psychological suffering” due to an incurable disease or disability.

The revised law comes in the wake of a 2019 Quebec Superior Court decision, which struck down as unconstitutional the “reasonable foreseeability” clause. But advocates for mentally ill and disabled people say their concerns have been shunted aside in the government’s rush to pass the legislation.

“We’re shocked, we’re appalled – we’re completely caught off guard,” John Maher, an Ontario-based psychiatrist and ethicist who specialises in treating severe mental illnesses, told Al Jazeera.

“We now have patients who are asking us to stop treatment – patients who will get better – because they don’t have to keep trying any more … This is an inducement to suicide.”

Several criteria

Canadians seeking to access MAID must meet a number of criteria, including being 18 or older, making the request voluntarily, and being in an advanced state of irreversible decline that causes extreme suffering. Those seeking assisted death solely on the basis of a psychiatric disorder will not be eligible until March 2023, allowing the government two years to explore appropriate safeguards.

In the meantime, an expert panel will be tasked with suggesting guidance and protocols.

Justice Minister David Lametti said the government consulted widely with medical professionals, legal experts and community groups before revising the law. In a statement to Al Jazeera, he noted that anyone seeking MAID must undergo two independent medical assessments. There will be heightened safeguards for those whose natural death is not reasonably foreseeable, including a requirement that they are informed of all possible support services and care options.

“These safeguards are designed to protect against abuses and were developed specifically to respond to concerns raised during the consultations,” Lametti said.

But Jewelles Smith, communications coordinator for the Council of Canadians with Disabilities, said the government’s consultation process was woefully inadequate, effectively ignoring the input of people with disabilities.

“We’re really, really concerned. I mean beyond concerned,” Smith told Al Jazeera. “I’ve fielded a lot of late-night conversations with members of my community who are panicking.”

‘Risk of coercion’

The inclusion of disability as a specific category in the MAID law has sown fear among community members, as has the condition requiring only one signature from an independent witness on assisted-dying requests, she said.

“The requirement of only one signature, to us, is definitely putting people at risk of coercion,” Smith said. While people whose death is not imminent will have to wait 90 days for an eligibility assessment – during which time they can be referred to alternative resources and supports – it can often take many months longer to actually obtain such resources, she said.

“It’s discriminatory to offer people the opportunity to die when you don’t offer the opportunity to live … I have heard so much fear from folks who now are afraid to go to the hospital, they’re afraid to reach out.”

We now have patients who are asking us to stop treatment - patients who will get better - because they don't have to keep trying any more ... This is an inducement to suicide

by John Maher, Ontario-based psychiatrist and ethicist

UN human rights experts have highlighted similar concerns, noting that older people with disabilities “may feel subtly pressured to end their lives prematurely due to attitudinal barriers as well as the lack of appropriate services and support”.

Maher called C-7 “an unabashedly ableist policy masquerading as compassion”. Clients with mental health issues are often impoverished, stigmatised and pushed to the margins of society, he noted: “The suffering is profound, but a large, large chunk of it can be responded to literally with social supports, with care, with housing, with food, with social connection.”

About 7,000 requests in 2019

According to a Health Canada report published last year, 5,631 cases of MAID were reported in 2019, up 26 percent from the previous year. The average age of those receiving MAID was 75, with cancer the most commonly cited underlying medical condition.

Of 7,336 written requests for MAID reported in 2019, slightly more than a quarter did not move forward, either because the patient died naturally, was deemed ineligible or withdrew the request.

Stefanie Green, president of the Canadian Association of MAID Assessors and Providers, called the passage of Bill C-7 “a significant step in the right direction” towards allowing all Canadians to be able to consider their end-of-life options.

“I don’t think that because they’re suffering from a non-terminal illness, that should exclude them from that opportunity,” Green told Al Jazeera.

Today is a momentous day for end-of-life rights in Canada. After mths of parliamentary debate, @SenateCA has passed #BillC7!

We thank all parliamentarians who listened to the voices of Cdns, and passed this compassionate bill. Final step ➡ Royal Assent. https://t.co/P5yHiEYTy5 pic.twitter.com/P3NsuhASYN

— Dying With Dignity Canada (@DWDCanada) March 17, 2021

Responding to the concern that disabled people or those experiencing mental health issues may be pushed towards assisted death, Green said that has never been the case in the hundreds of consultations she has carried out. “Marginalised communities are much more fearful of lack of access to this care than they are of fearing being coerced into this care,” she said.

Helen Long, the chief executive of Dying with Dignity Canada, pointed to a recent Ipsos poll showing that seven in 10 Canadians agreed with removing the “reasonably foreseeable” requirement from the country’s MAID legislation.

“This access is very important for those who suffer from chronic conditions. It gives Canadians choice and autonomy for their own healthcare,” Long told Al Jazeera, noting that her organisation hears regularly from people “who feel a great deal of relief knowing that MAID is now more accessible, people living in pain and those who want to know this is an option should they need it”.

Parliamentary review

A parliamentary review of Canada’s MAID legislation is due to start by mid-April. Among other things, it will explore the eligibility of “mature minors”, and how to handle advance requests from patients who do not currently meet the eligibility criteria, but fear losing the capacity to apply later.

“Those are two very serious debates that need to happen,” Green said.

Meanwhile, Smith said members of the disability community were planning to take legal action against the “fundamentally flawed” legislation – even as she acknowledged it could take 10 years to complete a challenge under the Canadian Charter of Rights and Freedoms.

“A decade from now,” she said, “this could be so ingrained in our society – the assumptions about whose life is worth living – that it could change the very fabric of our community.”