Medical assistance in dying: Who and when?

How far should our governments go in expanding medical assistance in dying (MAID) to Canadians who suffer from a grievous and irremediable medical condition?

Although because of the pandemic there is no firm date, Members of Parliament are to debate amendments to the four-year-old assisted dying law, removing the requirement that the person’s natural death be “reasonably foreseeable” before a medical professional can help them die.

However, and somewhat controversially, this does not include cases where mental illness is the sole underlying medical condition.

The amendments are to be studied in detail in a committee format that has yet to be determined. There also will be a review of the original legislation and status of palliative care in Canada. Issues expected to be examined include whether advance request for assisted dying should be permitted, whether psychiatric conditions should be grounds for assisted death, and whether the procedure should be extended to “mature minors” – people under age 18 considered by doctors to be capable of directing their own care. Quebec also is consulting on whether to extend access to the procedure to those with mental disorders.

The amendments were introduced following a Quebec Superior Court ruling that invalidated aspects of federal and Quebec medical aid in dying laws. Justice Christine Baudoin found the requirement that death be “reasonably foreseeable” infringed on the “life, liberty and security of the person” provision of the Canadian Charter of Rights and Freedoms.

Baudoin gave Quebec and Ottawa six months to respond to her ruling, and granted an exemption to the two plaintiffs, Nicole Gladu and Jean Truchon, so they could apply for medically assisted death immediately. In early spring, wheelchair-bound Truchon, who had cerebral palsy and lost the use of four limbs, received medical assistance in dying at a Montreal area long-term care facility. Quebec let the problematic sections drop and Ottawa moved to amend the law.

The bill in Ottawa would remove requirements of a 10-day reflection period after being approved for assisted death before the procedure is carried out and final consent is given a second time immediately prior to the procedure. It would reduce the number of witnesses required from two to one.

What has not changed is the necessity to have a condition that causes intolerable suffering and be in an advanced state of decline due to an incurable condition.

There are, however, more restrictive requirements for those whose natural deaths are not judged to be reasonably foreseeable.

Dr. Stefanie Green, president of the Canadian Association of MAID Assessors and Providers, said from B.C., the group will work within the law as it is amended.

Speaking as a provider, Green praised the “many positive changes in the legislation.”

Green said she expected those who meet the criteria for natural death that is not imminent include those with such complicated conditions as chronic pain syndrome, and “people with ill-defined illnesses that we don’t know how to deal with well.”

“They will probably require significant time to assess properly, and we will want the input of expertise on these cases.”

What does not change, she said, is that people who have a diagnosis that puts them on a trajectory toward death, such as those diagnosed with ALS or Parkinson’s disease, already meet the criteria for a reasonably foreseeable death.

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“I feel very strongly about that, and the majority of assessors and providers in Canada feel that way,” Green said.

Some religious groups oppose all forms of assisted death, notably is the Conference of Catholic Bishops, which says it is “contrary to the most profound natural inclination of each human being to live and preserve life.”

Dying With Dignity Canada, which supports Canadians through end-of-life choice and care, and advocates for legislative changes, is pleased with the proposed changes. It campaigned to remove the late-stage consent rule from the law, since it could lead to some patients, fearing they may lose capacity, ending their lives before they’re ready.

The group, however, questions the 90-day assessment period for patients (unless the loss of capacity is imminent) who do not meet the “reasonably foreseeable” natural death criterion.

“Potentially the 90-day assessment period is too long, and prolongs intolerable suffering for some people,” the group’s chief executive, Helen Long, said in an interview. Other critics have noted that period may indeed be too short for some patients who might benefit from a “cooling-off” period. Long suggested that 30 days would be reasonable.

To qualify for assisted death if natural death is not reasonably foreseeable would require approval by two medical practitioners, one of which would need to have expertise in the person’s medical condition.

Long says her group is concerned that “in some cases, if you’re in a really remote, or rural area, or somewhere where that practitioner is not available, having an assessor with a specific expertise could be a barrier.”

Though “fairly satisfied,” Long said her group joins other critics in questioning the legislation specifically excluding those with mental health as the sole underlying condition.

“We think that is stigmatizing and discriminatory,” Long said.

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