Delays will provide time to find right basis for use of MAID

On Feb. 29, Bill C-62, received Royal Assent. The bill serves to pause until 2027 consideration of expanding our laws to allow medical euthanasia to include those whose sole underlying medical condition is mental illness.

This has been a difficult issue for parliamentarians, as evidenced by first introducing legislation enabling what we call MAID, then expanding eligibility, and now reversing based on evidence and public concern. Volumes have been written about MAID, making evident the complexity of the issue, far more so than was anticipated by both its advocates and the legislators.

Not long ago, the Report of the Special Joint Committee on Medical Assistance in Dying was released. Its recommendation was an indefinite delay in the implementation of MAID for mental illness as the sole criterion. In response, the government introduced this legislation to delay implementation until 2027. There were sharply dissenting voices in the Senate, but Parliament’s protection of core principles of law-making, including basing decisions on evidence over blind ideology, and the safety of all, especially the vulnerable, stood firm.

The delay saved lives. We are all the beneficiaries. I come to this discussion as a cancer physician, long involved in patient care, cancer care systems, and the evolution of palliative care in Canada and around the world. As one who has been deeply involved in sensitive public policy matters here and abroad for decades, I understand that it is politicians and legislators, who must come to terms with the consequences of these decisions. In that context, I want to credit them for having considered four questions:

1. The success rate for rigorously developed and evaluated medical procedures rarely exceeds 90 per cent. Errors in diagnosis and treatment have adverse consequences, including death. The direct consequence in MAID is wrongful death. Given that Canada has the most permissive MAID structure in the world, with an approaching 60,000 deaths to date without a mental illness as sole criterion provision, were politicians and legislators prepared to publicly acknowledge and be accountable for the between 2,000 and 4,000 wrongful deaths that may have already occurred? (In a parallel historical analogy from the days before we abolished capital punishment, consider the degree of scrutiny exercised by the requirement for unanimity at juried trials, and the extensive appeal processes. Despite that, there is clear data that the wrong conclusion was made in as many as 30 per cent of cases).

2. Given the widely acknowledged inability of mentalhealth experts to accurately predict the irremediability of those with mental illness (predicting if someone would not recover), were parliamentarians prepared to publicly acknowledge and be accountable for an error rate of as much as 50 per cent, with the attendant unintended death rate of similar proportions, should MAID for mental illness as a sole criterion go forward?

3. The motivation for MAID has been the relief of suffering in the eyes of the sufferer. The balance in the Charter Section 1 vs. Section 7 has been interpreted in this way. Perhaps parliamentarians considered the plausible and testable hypothesis that, from a societal perspective, suffering has paradoxically increased rather than decreased. It may be the almost unanimous input of the disability community, those without supports and services saying they are driven to MAID for lack of options or even those who have developed a tormenting fixation on getting MAID, which one might call maidism. Perhaps politicians and legislators considered the need to publicly acknowledge and be accountable for an increase in societal suffering as a consequence of their actions?

4. MAID is not a new technology. It is old medicines repurposed. In every other circumstance where a new treatment or technology has been introduced, there has been a rigorous evaluation process, coupled with careful selection, training, supervision and evaluation of providers. (This extends to many technology innovations, including aircraft safety) With MAID this has not been the case. The explicit provisions of C-14 for detailed independent review after five years would have been circumvented. The selection and training programs as exist have been designed and administered only by advocates without independent oversight. Politicians and legislators were aware of this, and it must have weighed heavily that they would need to publicly acknowledge and be accountable for this significant exception to the standards of care that have been developed over the last century.

This is not a screed in opposition to MAID. Rather it is a grateful acknowledgment that direct clinical consequences among the many other complex and possibly irresolvable issues were deeply considered. This is a vital starting point in our struggle to find — with time and experience — a culturally, morally, legally and medically acceptable place for MAID.

I am grateful parliamentarians did not race headlong in ideological flight, ignoring the evidence and uncertainty, only to invite deep and enduring regret.