Parliament felt last summer that it had to follow the Supreme Court’s 2015 Carter vs. Canada decision by allowing Canadians access to assisted suicide. Although this feeling was incorrect, Parliament at least attempted to limit the applicability of the law by restricting it to the terminally ill and those approaching the end of their lives.
This restriction is, however, artificial and was immediately challenged by so-called “Dying with Dignity” on behalf of a woman who is not terminally ill but still wants access to assisted dying. The organization’s website states that many prominent legal scholars have called Bill C-14 unconstitutional and warned that it would be very vulnerable if challenged in court. The law discriminates against Canadians who do not fall within its scope but still wish to be assisted in committing suicide. As has happened in other jurisdictions, our Supreme Court will therefore doubtlessly find in the coming years that Parliament’s restrictions cannot be maintained.
Additional parliamentary action is therefore required to affirm the government’s support for all Canadian citizens, whether mentally ill, physically handicapped or terminally ill. We must not allow for a utilitarian view of human life to gain any foothold in our society, one that judges the viability of a life by the degree of autonomy a person has. Can and should our society uphold a double standard, where some people are judged worthy to receive counseling and treatment to prevent suicide and where the elderly and sick are instead abandoned, assisted in committing suicide without even trying to understand the reasons, address their needs and show them we appreciate their existence?
We need to affirm the value and dignity of all members of society and fully support those in need of assistance to live more dignified lives, including—and especially - at the end of their lives. Beyond reinforcing end-of-life care and expanding palliative services, Parliament now needs to do what the Liberal Party platform promised: base its approach on the evidence. The on-going review of Bill C-14 is actually wrongly aimed at widening the law’s scope (expanding it to minors and the mentally ill) when it could be an opportunity to improve the law and contain its negative impacts, minimizing the number of suicides in Canada.
A person’s desire to hasten death is a means of communication between the patient and the world - one that needs to be explored to best help the patient.1 Rather than callously granting a “right to die” without asking further questions (essentially saying we do not care about those who suffer but would rather end their lives than care for them compassionately), we need to understand that calls for assisted suicide are a cry for help, a cry for acknowledgement, for compassion, and for personalized care and support from relatives and medical personnel.
We must not ignore the strong link between mental disorders and the expressed wishes for assisted suicide. Researchers have concluded that suicidal thoughts appear linked exclusively to mental disorder.2 Chochinov and Breitbart found a statistically significant association between clinical depression and the desire for hastened death.3,4
Social support for a patient is another strong factor in a wish for an assisted death. Kelly found that perceiving oneself as a burden to others, having poor family cohesion, and having both a small number and a poor quality of social supports were all correlated with a desire for a hastened death.5 Similar results were obtained by Breitbart.4 In other words, many who have been abandoned by their families are now also being abandoned by our society and being offered assisted suicide instead of social support.
The majority of patients who receive treatment and counseling will revoke their wish to be killed. “Many WTD [wish to die] statements do not imply a desire to hasten death.. Terminally ill persons’ WTD statements differ in their intention, and deeper knowledge about these differences is ethically relevant.”6 In a survey of terminally ill patients, more than half had changed their minds about asking for assisted suicide after six months. In-depth evaluation found many meanings and uses of the expression of desire for hastened death, ranging from a manifestation of the will to live and a gesture of altruism to a despairing cry depicting the misery of the current situation and to a manifestation of the last control the dying can exert.7 “Requests to hasten death generally signal the presence of physical, psychological, or social stressors that can frequently be ameliorated. Understanding the nature of such requests allows physicians to ease suffering and reduce the desire for death in such patients.. there is strong evidence that psychological and social factors (e.g., comorbid depression, hopelessness, loss of dignity, and the impact of spiritual beliefs), rather than the physical ones (e.g., functional status and the level of pain control), are the chief determinants of the desire to hasten death.”8
These findings mean that it is unethical to simply grant a wish to die to patients. By doing so, we may end lives that could have lasted much longer if patients had had the time to reconsider. Had they been shown enough human kindness and support, they would have revoked their expressed desire. People with new disabilities frequently go through an initial period of depression and suicidal feelings but over time adapt to the new situation and rediscover meaning in their lives.9 In many cases, we would be killing people who have mental health problems and are therefore not qualified to make decisions of life and death and are in need of treatment, not of assisted suicide.
Although the law is tailored to relieve people with “enduring physical or psychological suffering”, the majority of people who have requested assistance to commit suicide in Oregon, the Netherlands and other jurisdictions, did so mainly claiming a “loss of dignity”. Whether human dignity can be lost or not is a matter of debate but it becomes clear that the loss of autonomy felt by patients and identified as this loss of dignity cannot be the main reason intended by the law for granting assistance in suicides. A loss of autonomy can be relieved by assistance through machines and other humans. It would be illogical to grant someone who has suffered a loss of autonomy, the remedy of a complete and irrevocable removal of any autonomy by administering death.
So, a situation that can be improved rather easily should not be taken as a reason for government to concede that a life is no longer worth living (else we should kill all our babies, who are anything but autonomous for many years). Some commons sense is required here, resulting in a clearer delimitation of who should be eligible according to the intent of the law. It is precisely because of the dangers of a loose definition of the scope of the law that Parliament needs to act now to clearly delimitate its applicability. Otherwise, courts will soon be misinterpreting its intent and will widen its scope to more and more Canadians with physical or mental illnesses and handicaps. The law must therefore be clarified and restricted to cases where suffering is indeed deemed objectively intolerable and cannot be mitigated.
The current version of the law does not include safeguards for patients with depression. Mandatory counseling should be prescribed for patients requesting assisted death and if diagnosed, treatment of depression should be part of end-of-life care and patients should not be allowed to receive suicide assistance as long as they are mentally ill.
Bill C-14 recognizes in its preamble that “suicide is a significant public health issue that can have lasting and harmful effects on individuals, families and communities.” So it would be a logical next step to attempt to reduce the number of assisted suicides in Canada, given this practice will undoubtedly motivate others to also seek assisted suicide or to commit unassisted suicide.
A recent Canadian study confirmed that “suicide contagion” is real.10 Oregon enacted assisted suicide laws in 1998 and beginning in 2000, its general suicide rate increased substantially. Today, its suicide rate is almost 50% above the national average. This trend coincides with a downward trend in divorce rates, which are traditionally correlated to suicides rates. Yet another study concludes, “Legalizing [assisted suicide] has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that [assisted suicide] does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.” The very high Flemish (unassisted) suicide rates have actually become lower among men since the legalization of euthanasia in Belgium in 2002. Yet, this goes in parallel with assisted suicides for the whole country skyrocketing to about 2000 cases per year, i.e, the Flemish number of assisted suicides is now higher than that of unassisted ones. Legalizing assisted suicide is not a practice that reduces overall suicide rates in the population (their number has been increasing since 2007 in the Netherlands) and the risk of suicide contagion is one more reason to keep their number as low as possible.
Another consideration is the effect if the law in making suicide socially more acceptable. State sanctioned assisted suicide increases the number of assisted suicides over time. As we may make a decision today whether cremation or burial might be the best option, the next generation of Canadians may consider the choice between suicide and natural death just as commonplace. As seen above, the number of assisted suicides in Belgium has increased strongly over the past decade. The same was observed in the Netherlands: over 1,800 euthanasia cases were reported in 2003, rising to over 5,500 in 2015.This represents almost 4% of all deaths the Netherlands—and those are only the reported cases.
Parliament should work to minimize the number of suicides in Canada, whether assisted or non-assisted. A Canadian “evidence-based” approach would have to tackle suicidal tendencies on several levels:
1. Since a doctor’s lack of experience in dealing with terminally ill patients can also foster their desire to die,8 it is necessary that Parliament require on-going training of palliative care practitioners. We need to put our money where our (parliamentary) mouths are. MP Marilyn Gladu’s proposed Bill C-277 on improving palliative care should be supported by the federal government. Nurses employed in palliative care centres should receive adequate support, enough time off and the centres be well staffed to avoid “compassion fatigue” related to long working hours and constant exposure to the demands and needs of patients who are approaching the end of their lives. By funding palliative care adequately, our governments can send a clear message that the assisted suicide bill is not meant to be a way to reduce spending in this sector. By offering more attractive end-of-life choices, government can actively discourage people from committing suicide.
2. There should be longer waiting periods (months, not weeks) for patients who ask for euthanasia. Evidence suggests that people don’t ask to be killed because of excessive pain (which can be well controlled in almost all cases) but because of hopelessness, loneliness, loss of autonomy and because they feel they are a burden to society or their relatives.8 This longer waiting period will provide room for counseling, a psychological evaluation to exclude mental problems, and provide room for a change of mind. It is also warranted given it is impossible to predict the life expectancy of the terminally ill well, apart from certain cancer cases.12
3. Mandatory counseling should be part of the decision-making process. People are very vulnerable especially at the end of their lives and when they are terminally ill. This is not a good context for making life and death decisions. Counseling should aim at understanding the real reasons for the wish to accelerate death, and offer the human and technical resources to alleviate suffering.
4. In this context, advance decisions made by people in wills specifying a wish for assisted suicide should be taken with much caution, given the evidence that many people will change their minds later on. Counseling should be the basis of such decisions, not ideas expressed by a patient years before a situation actually occurs.
5. Provincial governments should create “safe spaces”, i.e. hospitals where no euthanasia is offered. It is known from other countries that authorizing doctors to both cure and kill destroys the trust relationship between doctor and patient (some Dutch elderly people set up guards at their beds or ask to be transferred to Germany, where euthanasia remains illegal). Quebec’s Bill 52 allows palliative care centres to not offer euthanasia to their patients; this practice should be adopted by all provinces.
6. Government should also put renewed emphasis on supervising assisted dying practices in Canada, and prosecute any medical personnel found to be in breach of the law. This is necessary to maintain current limits and discourage doctors from taking license, as has been the case in the Benelux countries in Europe, where doctors have for years euthanised patients without their consent, and where this is still current practice today even though it is illegal. That such crimes have not been prosecuted or punishments have not been applied in other jurisdictions warrants the establishment of a Canadian assisted suicide “watchdog” organization that reports to Parliament annually to monitor malpractice and infractions, and should also monitor elder abuse in our country. Such an organization should have the means to investigate complaints by family members and other parties about specific cases of assisted suicide. Documentation on positive and negative decisions about requests for assisted suicide, signed documents and psychiatric evaluation results must remain available for third-party review, research, and criminal investigations. Doctors should be required to document the time to death, any suffering observed and notably, cases where the supposedly lethal drug did not lead to death and what happened to the patient in these instances (about 16% of assisted suicides are unsuccessful in Oregon13 and the Netherlands14). Video recordings of the dying process and previous conversations with the patient would make this process more transparent. Interviews should be conducted with clinical personnel, families and family doctors in order to gather data on suicidal tendencies and improve preventative programs based on the results obtained. It cannot be the will of the Canadian government to condone the killing of (some of) its citizens without implementing a very strict mechanism for supervision and accountability. Such a mechanism is crucial in setting Canada thoroughly and intentionally apart from some of the most horrid precedents in recent history in terms of state-sanctioned euthanasia.
7. Finally, the purpose of the law should be clarified. The preamble needs to clearly state that the government’s intent is to minimize the number of suicides, in order to justify the clauses limiting the law’s applicability. The latter should be further limited to extreme physical suffering that cannot be relieved with current medical means. Since the notion of “loss of dignity” is philosophically questionable and highly subjective, and since the situation underlying such a perceived loss is simply a loss of autonomy that can be addressed by human and technological assistance, the law should be clear that in such situations, assisted suicide will not be granted.
Without a clear strategy that has suicide prevention (whether assisted or not) as its goal, Canada will undoubtedly follow the path of other jurisdictions where both assisted and unassisted suicides are on the rise. We can and must do better. Our government must affirm life, not providing a “good death” but a good life to the very end. Rather than avoiding suffering by ending lives, we must mitigate suffering by supporting Canadians through improved palliative care. And rather than agreeing with the suffering that their lives are no longer worth living, we should do what we can as compassionate human beings and as a loving community to address the needs of our citizens and show them that we value their lives and that suicide should never be the preferred option to end one’s life.
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