Canada Considers Bill to Euthanize People Who Cannot Make Rational Decisions

The Canadian government on Tuesday introduced a bill that would allow Medical Assistance in Dying (MAID), Canada’s preferred euphemism for euthanasia, to be conducted on people who have lost the mental capacity to give informed consent for the procedure.

According to Justice Minister Sean Fraser, the idea is to give Canadians a way to authorize euthanasia in advance, when they are of sound mind, “so their wishes could be respected if ⁠they are diagnosed with an incurable illness that could take ​away the ability to make this decision.”

Fraser promised there would be “rigorous safeguards to protect people and ensure the decision remains voluntary and free from external pressure.” He said, for example, that MAID would not be conducted automatically based on pre-authorization, but only for patients who are undergoing “intolerable suffering” and have lost the mental capacity to ask doctors to end their lives.

Fraser said the bill was drafted after a “rigorous study” by parliament demonstrated it was necessary, so that people in an “advanced state of irreversible decline in capability” would not be denied the life-ending services they had previously requested, based on existing rules against euthanizing people who have lost their mental competence.

The justice minister said individual provinces would “determine the extent to which they wish to embrace the next frontier on Medical Assistance in Dying.”

“From my point of view, this is going to be the start of a national conversation that will largely play out at the provincial level around the extent to access,” he said.

The concept of requesting euthanasia in advance is not unknown among nations that have embraced physician-assisted suicide. Belgium, the Netherlands, and Spain have provisions similar to what Canada is contemplating, and Canada’s province of Quebec already allows advance requests.

Canada has been criticized, both from within and abroad, for expanding MAID too quickly and pushing it too aggressively on patients who are not terminally ill. The Liberal government acknowledged some of this criticism earlier this month by halting its plans to provide MAID for patients who are suffering from purely mental illnesses.

Fraser and other Canadian officials said on Tuesday that the rules have been bent to authorize euthanasia for the mentally ill, a “gap” in the laws that would be closed by the same bill that allowed advance requests for MAID. The two issues were deliberately paired because blocking MAID for the mentally ill would prevent people with reduced mental capacity from requesting the procedure even if they met other criteria that would normally make them eligible.

“Advocates have long argued that people diagnosed with conditions like dementia and Alzheimer’s disease are forced to choose to end their lives early for fear that they will lose the capacity to provide final consent,” the National Post noted.

One of the more difficult regulatory questions facing Canadian lawmakers and doctors is how to handle a patient with diminished mental capacity who indicates they do not want euthanasia — a scenario that has already occurred in some high-profile MAID cases. A recent example was 83-year-old Brigitte Stegemann, whose family said she was railroaded into euthanasia by aggressive doctors despite failing cognitive tests. Stegemann clearly changed her mind before the end, but she was euthanized anyway in a botched procedure that left her covered in blood.

Dementia Justice Canada founder Heather Campbell Pope told the National Post that the “safeguards don’t go far enough” to protect patients with cognitive difficulties.

“Our question is, when the doctors, the nurses, the social worker, and the family members are around the table discussing whether to carry out MAID, who is in the seat representing the patient?” she said.

“A law that allows MAID on the basis of advance requests clearly crosses further the line between voluntary and involuntary euthanasia,” said University of Toronto health law professor Trudo Lemmens.

Dying with Dignity Canada CEO Helen Long took the opposite view, saying the new rules made it too easy for a patient’s written consent, supplied in advance, to be ignored if their mental condition deteriorates.

“Individuals should be allowed to define what they consider to be physical and psychological intolerable suffering, as part of the advance request, and medical practitioners should base their decision on that objective standard,” Long said.

CTV News noted there is “persisting disagreement among experts over whether practitioners can safely assess an individuals’ circumstances when seeking MAID on the basis of a mental illness.”

The protocols for recognizing refusal or resistance to MAID from a patient with cognitive decline have been hotly debated — for example, whether body language and hand gestures should be accepted as refusal from patients who have lost the ability to speak.

Both advocates and critics of MAID have suggested the issues of advance requests and mental illness should be separated, because the latter is far more contentious than the former.

“If you are a member of Parliament who is concerned, as I am concerned, you have to concede which issue matters more to you, and the fact that they’re unwilling to separate these is major cause for concern,” said author Alicia Duncan, whose mother Donna was euthanized in British Columbia in 2022 despite suffering mental impairment from a concussion — and in defiance of a court injunction obtained by her panicked daughters.