Potential issues that may have arisen when expanding “death with dignity” (assisted suicide/euthanasia) to more people, particularly in Canada

Great Debates
1

I’m been reading about things that have been happening with regards to MAiD (medical assistance in dying) in Canada. There has been some controversy with regards to it. According to some, MAiD is becoming an alternative to benefits etc for poor (disabled) people. These articles argue that it’s, to say the least, deeply problematic to offer (in some cases, maybe even strongly encourage or worse) MAiD to individuals when they would very well like to continue living if they simply had the necessary support to do so.

Of course, from one point of view it would be much cheaper, efficient and cost effective to simply have sufficiently disabled or elderly individuals die to free up resources (and even human organs) to more (potentially) productive members of society. Indeed, some advocates for “death with dignity” would like to completely demidicalize euthanasia. Should death be freely (or cheaply) available to anyone who wants it over the counter? Is the “problem” of disabled (and any other qualified) people who feel like they can’t live a dignified life, make ends meet or are just “tired of living” solved by offering them death instead of the care and resources that will often make their lives worth living?

I highly recommend watching this talk by psychiatrist and ethicist Mark Komrad. For relevant reading from him go here.

A quote from Meghan Nicholls, The Mississauga Food Bank CEO:

Some #FoodBank users are telling us they can’t go on living in poverty, & are considering ending their lives or seeking #MAiD. We tell you this because we must collectively act to end #poverty we have to do it now. #AidNotMAiD

More from her here.

If current guidelines don’t change, it’ll be possible to get MAiD for psychiatric conditions without having exhausted all available treatments. This is (or at least used to be) also the case in the Netherlands. Belgium (source, p88) used to be the same but even they apparently changed their minds:

Moreover, [in Canada,] 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.

Something about the prognosis for mental disorders, from here:

Furthermore, there is no validated empirical method or agreed-upon standard for determining that any psychiatric illness is irremediable; or when it would be reasonable to so conclude. There is tremendous controversy over futility in psychiatry and prognostication regarding psychiatric illness is highly unreliable. An absence of response to treatments already provided is in no sense, and by no stretch of logic, a demonstration that the patient’s condition is irremediable.

A quote from a Canadian disability activist:

Fix Poverty before bring Suicide Booths into our Country. The Booths are a slight humor even crude humor… The point is if we can’t even feed, shelter and clothe are most vulnerable people, then why we offering them a death a free pass to death? Everything I said above would qualify for MAID and one simple thing changed the persons life for the better… Yet we rather let them kill themselves as it’s cheaper for society? Where is the sense in that? Humans are meant to adapt, and grow and better the human race… Why we only bettering a few lives?

A “brilliant” solution to poverty: instead of amelioration, why not (pseudo) voluntary extermination? And after that, offering or encouraging MAiD as the first line of “treatment” to all the other “undesirables”.

There are other potential issues with MAiD, for example insufficient oversight or safeguards (especially compared to equivalents in Europe), mistakes from doctors in terms of diagnosis, treatment and prognosis and not allowing conscientious objectors, whether it’s a good thing that medical professionals are allowed to tell patients unprompted that it might be an option for them (not the case anywhere except Canada to my knowledge) or whether they should even be the ones to administer it.

I am not against assisted suicide or euthanasia in principle, but it seems like there are several unresolved issues with it in many places where it happens. I certainly am not very comfortable with it under these conditions, in particular for bare psychiatric illnesses, especially if refusing any offered evidence-based treatment options doesn’t exclude someone from getting it.

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It’s a bit more complicated than that, because when exactly have you truly exhausted all available treatments? At the end of the day, that’s always going to be something a psychiatrist decides together with the patient. (But have you tried magnesium? Have you tried a daily walk in the sun? No but have you really tried to just be happy? Have you tried Jesus? How about Pele? How do you know you’ve exhausted all treatment options?)

In the Netherlands, 3 psychiatrists must look at the request. The following is a translation from the guidelines for psychiatrists on the specific part about further treatment:

[quote]You investigate which treatments and interventions have already taken place and with what result.

You investigate and discuss with the patient which treatments are still available and what the chance of success is. In consultation with the patient, you weigh up the reasonableness of the treatment: the relationship between the chance of the expected improvement and the burden for the patient. In consultation with the patient, you weigh up the foreseeability of the period in which the treatment can have an effect.

When the patient refuses treatment, you and the patient investigate the reasonableness of this; if after consultation you are not convinced of the reasonableness, you reject the request for termination of life for the time being.[/quote]

The question of further treatment options is just one of the four questions that must be assessed, again a translation from the physician guidelines:

[quote]In the assessment phase, the physician must initially come to the conclusion that the first four due care criteria have been met. He must therefore answer the question whether there is:

  1. a voluntary and well-considered request

  2. hopeless and unbearable suffering

  3. the patient is thoroughly informed about their situation and prospects

  4. no reasonable alternative [/quote]

(Excuse the bad translation, I popped it in Google Translate and couldn’t be bothered to change much, it’s about the gist of it.)

So “further treatment options” falls under question 4: no reasonable alternative. Once you’re looking into the section about further treatment, the guidelines go off into the question of when a treatment could be considered adequate.

Part of that consideration is supposed to be biological, psychological, social and spiritual interventions. So I would say that social questions such as poverty are addressed in that part.

Anyway, a very long-winded explanation to say that in The Netherlands it is indeed possible to proceed with euthanasie without having exhausted all available treatments options, [i]if you can convince three psychiatrists of the reasonableness of not trying those options.[i] And, I suspect, that alleviation of poverty as a cause of the unbearable suffering, would be considered under the “social interventions.”

I hope I’m representing this accurately, it’s a complicated process to go through and I’m not a psychiatrist or in any way an expert. I do believe there is a Doper who is a Dutch psychiatrist, they’ll know all this much better.

I find it quite difficult to relate this to your question. I do think tangible circumstances that can be changed can make a difference in quality of life, but they didn’t seem a factor in any of the cases that have lately been in the media - and there have been quite a few.

As to your final paragraph: there are definitely unresolved issues with euthanasie in The Netherlands. It’s constantly evolving and has changed a lot. As is true of legislation in general, or all of society, even. “The story so far:
In the beginning the Universe was created.
This has made a lot of people very angry and been widely regarded as a bad move.” We’re just sorta trying to improve from that point on. It’s taking longer than we thought?

3

Thank you for your reply. Yes, not every available “treatment” under the sun should be considered, therefore I think “exhausted all available treatments” should be amended to be “all available evidence based treatments”. Of course, then the problem becomes what “evidence based” actually means. One would hope it’s based on the best available scientific evidence. So, no to crystal healing or reiki, yes to ECT and MAOIs.

The guidelines you quote don’t seem terrible, I admit, but at least according to Komrad, what happens in practice can be different from what (at least a cursory reading of) the guidelines would suggest (unless they were inadequate at the time or not adhered to well enough). According to a study cited by him (slide 39), during the period 2011-2014 in the Netherlands, 28% of patients euthanized with a personality disorder had no prior history of any psychotherapy. Also, even when independent consultants disagreed with it, in 24% of those cases the patient was euthanized anyway.

Maybe the situation has improved since then (or was actually not as bad as it seems to me), I certainly would hope so. For example, I find it hard to believe not needing to have gone through a relevant, scientifically validated time period of psychotherapy before euthanizing someone for a bare personality disorder should be okay. But that’s just me I guess.

4

Right, but it’s still unclear where you draw the line. There’s evidence for magnesium, probably evidence for finding Jesus, I’d imagine. If you’ve tried several SSRIs but not all, should you continue through all of them if coming off-and-on the SSRIs exacerbates the unbearable suffering? Personally, I’m satisfied that if three doctors agree that it is reasonable that a patient doesn’t want to try ECT, for x, y and z reasons, that they can proceed. I don’t think I want to force ECT on anyone over allowing them to choose euthanasia. It’s more important that it has been discussed as an option.

This I don’t know, I feel like I’m missing something. Some nuance? It just seems unlikely that the patients had no therapy at all? How do they even get into that system without going through therapists? Just knowing the Dutch medical system, I have no idea how this could happen at all. I’m struggling with long covid myself and every single tiny step there are about twenty steps they want me to take first, before we proceed to the next test or whatever. Maybe the Dutch psychiatrist on the boards can shed light on this, if she’s still around.

But, again, if it is the case as described, then apparently three doctors agreed that it was reasonable for the patient to refuse to try therapy.

The last datum of 24% of cases having the consultant disagree, I don’t think is possible. All three (one is a consultant and not the patient’s personal physician) must agree. Doctors are sometimes prosecuted if there is reason to believe that procedures were not adequately followed and this is a very real fear for doctors. They are extremely hesitant in cases of Alzheimers, for example, because it can be difficult to determine the 4 questions (post above) if left too late.

Could it be about cases where at first a consultant has disagreed, then further treatment is tried, then the patient goes through the process again? It just seems odd to me, because it would open doctors up to prosecution if it’s true exactly as written. The guidelines I quoted above say quite clearly that if one of the doctors does not find it “reasonable” the request for euthanasia is denied “for the time being.”

The process takes years and 60% of psychiatrists refuse to engage requests because they feel under qualified to make the judgement (a small percentage are ideologically opposed). Usually, a doctor or psychiatrist sends a patient to a specialist centre for euthanasia. Well over half of patients referred there are denied euthanasia and only 9% have undergone euthanasia. The rest continue to try treatment through the centre. See why I think there’s more to the stats? How can you be a patient at that centre and have tried no therapy at all - it doesn’t add up?

I’m sure the system is imperfect in many ways, but there are quite a few cases in the media and they’re pretty clear on how thorough the process is and how much has been tried over many, many years.

Here is an example, a newspaper article in Dutch (I think you should be allowed to read a few articles for free). If you have Google Translate as a browser extension, you can read the article in translation to get an idea of the process. The psychiatrist also delves further into the question of knowing when all treatments have been tried, clarifying that it’s not about being evidence based. There’s always more treatment, it’s about what a patient is willing to try or reasonably rejects.
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