Death on Demand: Cautionary Tales from Canada
Canada’s Medical Assistance in Dying program, once reserved for the terminally ill, is increasingly attracting applicants experiencing poverty and depression.
Two years ago, a dear friend asked my husband and me to act as witnesses to his request for medically assisted death. We agreed without hesitation. Canada’s Medical Assistance in Dying (MAiD) law had been conceived for cases just like his. He was dying of respiratory failure and cancer. He was out of medical options, and his suffering was acute. The end was not far off. Through MAiD, he could either self-administer lethal medications, or have them administered intravenously by a medical professional. In either case, he could expect to drift into an unconscious state, from which he would never emerge.
We signed the form as his wife looked on, and tried not to cry. A few weeks later, he died in his sleep. Our friend never did use MAiD. But he was grateful and relieved that he had the choice of doing so. So were we.
In its original form, which was written into law in 2016, MAiD had widespread support from the general Canadian public. After all, we believe in personal autonomy. We do not believe in pointless suffering—including our own. Canada is, by now, a mostly secular country, unbeholden to religious ideas about the sanctity of each God-given soul. And so when Justin Trudeau’s government enacted MAiD seven years ago, it was presented as a progressive moral victory over regressive conservative medical hang-ups.
MAiD eligibility was restricted to Canadians with a “grievous and irremediable” medical condition, for whom “natural death has become reasonably foreseeable.” Applicants required two independent medical or nurse practitioners to sign off on their eligibility. Typical recipients were terminal cancer patients in their late 70s or older, whose dignified obits announced them as having died on their own terms, surrounded by loved ones.
The public was assured that the process was bioethically solid. Guardrails were in place to prevent abuse. Some Canadians warned of slippery slopes, but they were generally dismissed as doomsayers. Leading MAiD doctors such as Jean Marmoreo, widely celebrated in the media for their compassion and humanity, were quick to correct anyone who referred to their work as “assisted suicide.” Instead, we were told that this was a “medical procedure,” much like any other procedure (except to such extent that it’s guaranteed to be your last).
According to a government report published in July 2022, MAiD deaths represented about 3 percent of total Canadian deaths in 2021, up from about 0.3 percent in 2016. By now, a majority of my friends know someone who has died by MAiD, and many others who plan to do so when the time comes. For the most part, the availability of state-assisted suicide has become an accepted part of the Canadian social contract.
But thanks to recent legislative changes, MAiD has expanded in a way that many original supporters didn’t expect—or want. In 2021, following a successful court challenge by right-to-die litigants, the law was broadened to include patients with illnesses such as Parkinson’s disease or multiple sclerosis, who might live on with various degrees of impairment for many years. Specifically, the government removed the original eligibility requirement that a person’s natural death be “reasonably foreseeable.” (Such MAiD deaths are now tagged in the literature as “non-RFND”—i.e., no reasonably foreseeable natural death.) Aside from being over the age of 18 and of sound mind, applicants need only show that they are someone who has “a serious and incurable illness, disease, or disability, who is in an advanced state of irreversible decline in capability, who is experiencing enduring and intolerable suffering that cannot be relieved under conditions acceptable to them.”
It now turns out that some of the original doomsayers weren’t quite wrong when they warned of the slippery slope that MAiD would lead us to, as even many MAiD advocates are now acknowledging. “Tired-of-life cases in Canada are happening,” says Madeline Li, a Toronto-based psychiatrist specializing in palliative care for cancer patients, who has assisted in numerous MAiD deaths. “We’ve made MAiD so open you can request it for basically any reason.” It turns out you don’t even have to leave your home to get a doctor to sign off on MAiD: You can do it over Zoom.
And the eligibility conditions are set to expand further: As of March 17th, MAiD is slated to become available to Canadians with a mental illness as their sole medical condition (though, as discussed below, that date is in flux). And yes, depression counts. In one reported case, a 31 year-old Toronto woman who claims to suffer from a dubious psychosomatic condition called “Multiple Chemical Sensitivities” (more on this below) applied for MAiD because she couldn’t find proper housing.
The law stipulates that patients will be ineligible for MAiD if they are being pressured to kill themselves by third parties. But some of the people whom the government trusts to provide support to sick and disabled Canadians don’t seem to have received that memo. In one case, a federal employee working with Canadian military veterans was allegedly encouraging several of them to consider MAiD—i.e., to kill themselves. That employee was immediately terminated, and the government suggested it was an isolated case. But then another veteran named Christine Gauthier, a five-time Paralympic champion with a spinal-cord injury, testified before a parliamentary committee that she, too, had been encouraged to pursue MAiD by two separate government workers.
Gauthier had asked for a wheelchair lift for her house so that she wouldn’t have to crawl up and down the stairs. Her request for the lift was denied. But, by her account, she was told that if life was too awful to endure under these circumstances, she was welcome to apply for medically assisted death instead.
In recent months, Canadian news has featured numerous stories of people who were approved for MAiD on nominally medical grounds, but whose real reason for applying was apparently their belief that they lacked sufficient social supports. Sathya Dhara Kovac, 44, had ALS, a degenerative disease also known as Lou Gehrig’s disease. She didn’t actually want to die, friends said, at least not yet. But she wasn’t getting the level of free home care she needed. To get it, she would have had to move from her pleasant apartment into an assisted-living facility. She decided she’d rather die than move, so she applied for MAiD, and was approved. “It was not a genetic disease that took me out, it was a system,” she wrote just before her life ended.
It’s impossible not to feel compassion for Ms. Kovac. But it’s also impossible not to feel deeply unsettled by a Canadian assisted-suicide system (yes, that term fits, even if some advocates don’t like the way it sounds) that seems to be dispatching people because of what amounts to emotional distress and hopelessness.
Les Landry is a former truck driver with multiple disabilities, including diabetes and epilepsy, which confine him to a wheelchair. He lives in a rented house in Medicine Hat, Alberta, with his beloved German Shepherd. Last year, when he turned 65, his benefits were cut, and now the rent is going up. Soon he won’t be able to afford a place to live. So he applied for MAiD, and had no trouble getting a doctor to sign off. At the time he was interviewed by a British newspaper last month, Landry hadn’t yet found a second doctor to provide approval. He told a reporter that he’d simply keep shopping around till be found one.
Far from raising questions about the ethics of MAiD, Canada’s poverty and disability advocates seem mostly interested in weaponizing these examples as part of their campaign for more generous social services. No one, including me, doubts that even Canada’s relatively generous social-assistance policies leave a lot to be desired. But two points are worth making here. First, it’s highly unlikely that Mr. Landry and others like him will be cast out into the streets against their will. Somewhere in the system, there will be a place for him, even though he probably won’t like it, and it probably won’t take his dog (which, as any loving dog owner can attest, is no trivial consideration). Second, no system under the sun, no matter how well-funded and conscientiously administered, will ever be able to meet everybody’s needs. The shock Canadians are experiencing when they read these stories isn’t from learning that the social safety net has holes. The shock is from learning that if you don’t like your options, and have some kind of significant diagnosed medical condition, you might well be able to find a doctor who will help kill you. It’s just a matter of checking off the right boxes on a form.
Consider the case of Sophia, a 51-year-old Ontario woman who claimed to suffer from—again—the psychosomatic condition that’s been labelled as “Multiple Chemical Sensitivities,” or MCS. (Her last name had been withheld by the television network that broke the story.) Sophia lived in an apartment provided by the Salvation Army, which had a sealed-off bedroom to protect her from the environmental toxins that, Sophia had come to believe, were poisoning her system. But she believed that she was still being poisoned, and her efforts to find ultra-sterile accommodations proved futile. So last year she applied for MAiD and got it. A few days before Sophia died, she made a video in which she said, “the government sees me as expendable trash, a complainer, useless and a pain in the ass.”
It’s worth noting that her case was widely publicized by the MCS lobby, which provided the video to journalists. MCS, also called environmental illness, is what is diplomatically described as a “disputed” diagnosis. Studies have shown that claimed MCS sufferers who report a negative reaction in the presence of a given chemical will typically report an equally negative reaction when presented with a placebo that is labelled as the chemical in question. MCS is not recognized by leading medical associations, and there are no proven treatments (although antidepressants are sometimes recommended). Yet Canadian reporters who’ve broken stories about Sophia and other claimed MCS sufferers rarely mention any of this, and instead treat the claimed condition as if it were as real as cancer or ALS. By doing so, they ensure that medical fine points won’t complicate their narrative—which is that the real scandal here lies with social policy, rather than the fact that the state is helping to end the life of a mentally unwell individual suffering from an imaginary condition.
All of this is happening despite the fact that mental-health illnesses alone aren’t supposed to be sufficient to trigger MAiD eligibility in Canada until March 17th (at the earliest). And so many MAiD advocates, including psychiatric professionals whose patients are at greatest risk, have been fretting loudly about what will happen when the eligibility floodgates are really opened up. In response, the federal Justice Minister, David Lametti, recently declared that he plans to postpone the new policy on mental-health cases till some undisclosed date while specialists perform a further “expert review.”
“Further time is required to increase awareness of this [legislative] change and establish guidelines and standards to which clinicians, patients and the public can turn to for more education and information,” is how the Association of Chairs of Psychiatry in Canada put it last year. But the real problem with the amended MAiD law can’t be solved with technical fixes. Simply put, mental illness is different from, say, an untreatable, highly aggressive form of terminal cancer. The latter will kill you whether you like it or not. But the same isn’t true of many of the medical conditions now covered by MAiD, including mental illnesses.
It’s true that mental illness, much like cancer, causes great suffering. But it’s also true that a lot of mentally unwell people who really, really want to die because they think life is hopeless eventually manage to lead tolerable or even happy lives, at least some of the time. Indeed, the story of the now-successful artist, celebrity, activist, or entrepreneur who once was so down and out that he or she considered (or even attempted) suicide is a common feature of the autobiographical literary genre (especially in cases of former addicts who’ve kicked their addictions). And psychiatrists have a limited ability to tell which of their patients might get better and which ones won’t.
Advocacy groups for the mentally ill also are wary of the expanded MAiD policy. But their concerns typically have been couched in the language of social justice, alongside demands for greater funding and services, rather than as principled objections to the law itself. The Canadian Mental Health Association, for instance, declared that
Universal mental health care entails integrating mental health programs and supports into our public universal healthcare system and making them all available free of charge, including recovery-oriented approaches and new, life-saving treatments to which only some people currently have access. It means ensuring such services are culturally safe and trauma-informed and rooted in the principles of health equity. It also means centering the social determinants that are prerequisites for good mental health by providing housing, and income and food supports that help keep people well, safe and out of poverty, and which create conditions that may mitigate requests for MAiD.
But this line of argument—similar to the one offered by anti-poverty activists in response to stories of impoverished individuals using MAiD out of a fear of destitution—also misses the point. Yes, the Canadian mental-health treatment system is terrible in many respects. But even if ours were the best system that humans could devise, there would still be mentally ill people who’d want to kill themselves. The real issue is whether the state should ever help them.
My younger sister thinks not. She was first institutionalized with mental illness as a 14-year-old, 40 years ago. She’s had more hospitalizations and suicide attempts than either of us can count. She has stocked her various apartments with razor blades and poisons, and used them. She has been on countless medications, and overdosed on many. She has holes in her memory from years of electroconvulsive therapy. She has often believed that her life was utterly hopeless. She spent many years in the care of a psychiatrist who specialized in high-risk cases. He warned that my sister was at the top of his suicide-risk list.
These days, my sister is—on many days, though certainly not all—a reasonably happy, healthy, functioning human being. I asked her if she would have applied for assisted death during the bad times, had it been available. “Absolutely yes,” she told me. She’s glad it wasn’t an option.
Unfortunately, the vanguard of progressive thinking doesn’t reflect my sister’s views. Until recently, suicidal ideation among the mentally ill was widely considered as a form of distorted thinking that should be treated with therapy and medication. But today, an increasing number of doctors regard a patient’s wish to die as rational and even valid. If life makes them so miserable, they reason, why shouldn’t they have the same rights as Canada’s terminally ill?
Justine Dembo is one of these doctors. She assesses Canadians who apply for assisted dying, and sits on the federal government’s Expert Panel on MAID and Mental Illness. Dembo argues that there’s no meaningful distinction between physical and mental illness. “Suffering is suffering,” she contends. “Don’t we render people more vulnerable still, and more stigmatized, by denying them the same rights afforded to individuals without mental illness?”
As Dr. Dembo and like-minded journalistic observers present the issue, death for severe mental illness should be regarded as another form of harm reduction, somewhat like providing supervised injection sites for drug addicts (something Canada is also very big on, though the preferred term is now “supervised consumption”). They draw inspiration from the Netherlands and Belgium, which pioneered assisted death for psychiatric patients; though both countries supply their own cautionary tales. One 29-year-old Dutch woman was euthanized because she had been miserable since the age of 12. Last year in Belgium, a 23- year-old woman was euthanized because she was suffering from emotional trauma after witnessing the Brussels terrorist attacks of 2016. Perhaps her suffering really would have endured forever. But given her age—she was barely an adult—you can’t help but wonder if the doctors might have acted prematurely.
Canadians were once assured that health practitioners would not bring up the subject of MAiD at all unless their patients did. But that has now changed. According to the Canadian Association of MAiD Assessors and Providers (CAMAP), an association of nurse practitioners and physicians who administer MAiD services and perform eligibility checks on patients, doctors should now be obliged to discuss MAiD with any patient deemed eligible—even though the eligibility standards are morally fraught and subject to different interpretations. “Full disclosure of all treatment options is required to fulfill informed-consent criteria,” the group writes. Moreover, CAMAP informs us, if a doctor has a problem with MAiD, he or she should refer patients to a doctor who doesn’t. All of this is grounded in what CAMAP refers to as “the ethical principle of respect for patient autonomy”:
To respect a patient’s autonomy, healthcare professionals are commonly required to provide all of the medically effective and legally available treatments as options for patients, even if they are at odds with their personal values, so that the patient can make a considered choice among those treatment options (including provision, withholding, or withdrawal of treatment) and provide informed consent. By meeting the consent requirements discussed above, clinicians will fulfill their professional obligations as part of their inherent role as gatekeepers to the healthcare system … Patients, in most cases, do not have the same level of knowledge as the clinician … Patients cannot be expected to know whether they would be eligible for MAiD, a legal treatment option for their consideration, or how they would access it … Without being adequately informed of their treatment options in a timely manner, patients may not be able to access MAiD, may lose decision-making capacity and become ineligible for MAiD, suffer intolerably for longer, or have an end-of-life experience which may be unacceptable to them. When a patient is potentially eligible, not providing them with information about MAiD can create a significant risk of harm to them and their family.
In a 2022 document, “Bringing up Medical Assistance In Dying (MAiD) as a clinical care option,” CAMAP emphasized that doctors should not be guided by their expectation that MAiD-eligible patients will discuss “intolerable suffering.” Rather, CAMAP urges doctors to look for other, more intangible, signs of possible MAiD eligibility, such as distress, loss of autonomy, and decreased participation in enjoyable activities. CAMAP also alerts doctors to be on guard for “slippery slope arguments [that] may influence clinicians to avoid bringing up MAiD to patients with disabilities,” as well as spurious fears “that bringing up MAiD may lead to a complaint being lodged with a regulatory body.” Just the opposite, CAMAP counsels:
Not disclosing the option of MAiD may also pose a risk of a complaint being made if a patient missed the opportunity to avail themselves of this option. Given the therapeutic benefit of MAiD availability, and association of MAiD with increased palliative care consultation, it could be a double therapeutic miss not to bring up MAiD in conversation about clinical care options. Furthermore, not bringing up MAiD can also lead to harm by prolongment of unwanted, unnecessary suffering and missed therapeutic reduction in existential anxiety. (My emphasis.)
How morally normalized has MAiD become in Canada? Normalized enough that the government has funded an assisted suicide “activity book” for children. Normalized enough that a leading clothing retailer, Simons, produced (then deleted) a gauzy video featuring assisted suicide as a form of self- actualization. That short film was not a commercial per se, but what a Simons official called a public- spirited gesture that would help “build the communities that we want to live in tomorrow.” It starred an attractive woman named Jennyfer Hatch and her friends on a beach at sunset, singing and dancing as they celebrated her life, which she ended by lethal injection a few days later. All Is Beauty was the title, which was posted to YouTube as well as to the company’s shopping website. “I think people are ready for it,” enthused Dr. Stefanie Green, a co-founder of CAMAP. “It’s what they hope MAiD can be.”
As it turns out, people were most definitely not ready for it. The video backfired, with one New York Times writer aptly describing it as propaganda urging Canadians to “believe in the holiness of euthanasia.” What’s more, a CTV News journalist in Vancouver disclosed that Hatch’s story had already been told in the media, albeit under a pseudonym, and that the Simons art-film version of her life had left out important off-script details—specifically, her “struggles accessing support” from her local health care provider. “Our [health-care] system is very broken and part of what Jennyfer wanted to do is get people talking,” said one friend—suggesting that the celebratory tone of the Simons video was in fact quite at odds with Hatch’s own political message.
MAiD is generating plenty of other collateral damage, too. Some relatives are anguished when they learn that their parents, siblings, or even adult children had requested or received MAiD, and no one ever told them. (Authorities say that privacy laws prevent them from disclosing this information.) We also know that some people who have received approval for MAiD end up torturing themselves about whether to go through with it, scheduling and de-scheduling death dates as they weigh the misery of their existence against the prospect of personal annihilation. For many of these people, their primary form of suffering isn’t physical. It’s social and psychological: feelings of loneliness, boredom, helplessness, and depression. Are those sufficient reasons to indulge a wish for state-assisted death?
The implications of loosening the MAiD regime’s eligibility rules frighten me profoundly. Canada, like the rest of the world, is full of people who are sad, isolated, and/or disabled. Sooner or later, you and I may well be among their ranks (if you aren’t already), along with many of the people we love.
Of course, we want to control our fates. But there is something unsettlingly overeager about those stepping forward to expand the reach of this ghoulish (to many) form of medical therapy. Do we really want to be treated—and to treat others—as if humans were disposable? What happens when passing bouts of loneliness and sadness really are all that are formally required for a state-assisted death, with care providers casually offering to sign a depressed patient’s death warrant after he or she has completed a short form on a clipboard?
I for one, do not wish to find out.
