tag:theconversation.com,2011:/us/topics/maid-44443/articlesMAID – The Conversation2024-03-13T17:03:49Ztag:theconversation.com,2011:article/2245952024-03-13T17:03:49Z2024-03-13T17:03:49ZBereavement policies need to be updated to better support employees affected by MAID<figure><img src="https://images.theconversation.com/files/580777/original/file-20240308-16-mvo5i4.jpg?ixlib=rb-1.1.0&rect=20%2C30%2C6659%2C4436&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Current bereavement policies do not address the reality of employees with family members that have used, or are planning to use, medical assistance in dying (MAID) services.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine your elderly parent has just made the decision to use <a href="https://www.canada.ca/en/health-canada/services/health-services-benefits/medical-assistance-dying.html">medical assistance in dying (MAID) services</a>. Your parent, who has a terminal diagnosis and is suffering and in pain, made this choice after careful consideration, medical guidance and a heartfelt talk with family.</p>
<p>Your family members, who are spread across Canada, decide to gather a few days before MAID is performed — to visit, share stories, laugh and cry together, and say goodbyes. You want to be by your parent’s side, holding their hand, when the procedure is performed. There are plans for a funeral service two days after the procedure.</p>
<p>You call your employer to alert them that you need five days off due to an imminent death in the family. “I’m sorry,” your employer says. “Our official policy allows only three days of bereavement leave, please let us know which three days you will be absent.” </p>
<p>Which event would you be willing to miss? The goodbyes? The medical procedure itself? The funeral? And how much will it cost you emotionally to make that choice? </p>
<p>This is the situation many Canadians, including an Alberta HVAC technician named Arthur Newman (pseudonym), whom I interviewed for this story as part of ongoing research on the topic, currently find themselves in. </p>
<p>Most workplace bereavement policies were designed prior to MAID and very few employers have adjusted these policies in light of the new reality of living and dying in Canada.</p>
<h2>Bereavement policies in Canada</h2>
<p>Bereavement policies are <a href="https://www.benefitscanada.com/benefits/absence-management/a-look-at-current-provincial-policies-on-bereavement-leave/">inconsistent across Canada.</a> Federal employees are able to take up to <a href="https://www.canada.ca/en/employment-social-development/programs/laws-regulations/labour/interpretations-policies/compassionate-care.html">10 days</a> off (not required to be consecutive), while the minimum legal requirements in <a href="https://www2.gov.bc.ca/gov/content/employment-business/employment-standards-advice/employment-standards/forms-resources/igm/esa-part-6-section-53">British Columbia</a> and <a href="https://www.alberta.ca/bereavement-leave">Alberta</a> are only three days. </p>
<p>In <a href="https://www.ontario.ca/document/your-guide-employment-standards-act-0/bereavement-leave">Ontario</a> it is only two days, although employers can voluntarily offer more. <a href="https://www.canada.ca/en/services/benefits/ei/caregiving.html">Compassionate care leave</a> is available, but that requires going through Employment Insurance and is intended for people acting as a primary caregiver for an extended period, rendering it impractical for short leaves.</p>
<p>In addition, some employers strongly encourage employees to take their bereavement days consecutively, limiting flexibility. This current approach assumes the leave only begins after a death has occurred and is inadequate when a family member is using MAID. </p>
<figure class="align-center ">
<img alt="Close up of a pair of hands holding the hand of an older person with an oxygen saturation probe on their finger" src="https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580765/original/file-20240308-26-89qkk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being physically present for the procedure itself is also an important comfort for the person dying and their loved ones.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In the era of MAID, <a href="https://www.cfp.ca/content/64/9/e387.short">death rituals</a> that take place before someone passes away, like <a href="https://www.nytimes.com/2017/05/25/world/canada/euthanasia-bill-john-shields-death.html">living wakes</a> and other <a href="https://doi.org/10.1080/07481187.2021.1876790">traditions</a>, are becoming increasingly common. If a family member wishes to fully participate in all the end-of-life rituals of a loved one, they will need more than two or three days of leave.</p>
<p>Being physically present for the procedure itself is also an important comfort for the person dying and their loved ones, both of whom <a href="https://doi.org/10.1177/10497323231196827">psychologically benefit from a supportive and serene environment</a>. These new support needs and rituals generally supplement funerals, rather than replace them, which increases the overall time off that is required.</p>
<h2>Unintended complications</h2>
<p>Aside from death rituals and the MAID process itself, there are additional practical complications that can impact how many days of leave someone requires. For example, in Newman’s case, he travelled from Alberta to Ontario for his father’s MAID services. </p>
<p>After he arrived, his father decided to postpone his death a couple of weeks to address some unexpected legal complications related to his estate. Newman found himself in the impossible position of, having already taken a bereavement leave, being ineligible for another in the same year. </p>
<p>It was not an uncommon dilemma; the nurse practitioner scheduled to perform the service told him short postponements often happened due to things like estate management issues or parents giving their adult children more time to accept their decision. </p>
<p>Current bereavement policies do not address this reality. The outcome of that can be unintentionally cruel if employees are forced to choose between participating in death rituals (postponed or otherwise) or maintaining a positive relationship with their employer. </p>
<p>Some of these issues apply to non-MAID deaths as well. People with terminally ill loved ones who don’t choose MAID also want to be with them at the end, gather with loved ones, and have rituals, but the timing is even more difficult because they don’t have a specific death date.</p>
<h2>Supporting grieving employees</h2>
<p>Like most people who experience loss, employees who have a loved one going through MAID often require support <a href="https://doi.org/10.1177/0969733020921493">while they process a wide range of emotions</a>. They experience the usual emotions associated with grieving, including fear, anger, guilt, sadness and uncertainty. </p>
<p>In some cases, however, they also experience moral confusion or outrage if their personal or religious beliefs conflict with the practice of MAID. Family tension, arguing and alienation may emerge if some family members support the decision and others do not, heightening anxiety for everyone.</p>
<p>This creates significant stress. <a href="https://www.tandfonline.com/doi/abs/10.1080/08853134.1997.10754079">Work-family role conflict</a>, which is conflict experienced when our work roles interfere with our ability to meet family obligations, magnifies the negative impacts of stress. This can lead to emotional exhaustion, difficulties with empathy, the tendency to treat people like objects and diminished performance at work. </p>
<figure class="align-center ">
<img alt="A man with a tired, stressed look on his face, rests his head against his hand while sitting at a desk" src="https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580778/original/file-20240308-22-rdjshw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Employees who have a loved one going through MAID require extra time and support to process their grief.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>All of these outcomes are highly negative in the workplace. As such, it is beneficial for employers to minimize work-family conflict by providing compassionate and caring supports for all bereaved workers, including those whose family members use MAID. That could include an empathetic supervisor, provision of an employee assistance plan with free counselling or referrals to bereavement support groups. </p>
<p>It also includes allowing sufficient time for employees to help their loved ones die with dignity and celebrate the life that was lost — in rituals that occur both before and after MAID services. It is highly recommended that employers adjust bereavement policies to allow more time and flexibility. </p>
<p>The additional cost created is justified on moral and ethical grounds, but also on a direct cost basis. Employees who feel like they are treated fairly, with compassion, consistently <a href="https://doi.org/10.1093/jopart/mux028">perform better than employees who feel their needs are being overlooked</a> or neglected. As such they are better able to do their work and contribute to profitable operations.</p><img src="https://counter.theconversation.com/content/224595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine Breward does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most workplace bereavement policies were designed prior to MAID and very few employers have adjusted these policies in light of the new reality of living and dying in Canada.Katherine Breward, Associate Professor, Business and Administration, University of WinnipegLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2240572024-03-04T20:58:06Z2024-03-04T20:58:06ZMAID and mental health: Does ending the suffering of mental illness mean supporting death or supporting better lives?<p>Recent headlines have <a href="https://nationalpost.com/news/canada/psychiatrists-clash-deadline-maid-mental-illness">highlighted debates</a> among federal parties over the proposal to <a href="https://www.canada.ca/en/health-canada/news/2024/02/the-government-of-canada-introduces-legislation-to-delay-medical-assistance-in-dying-expansion-by-3-years.html">extend Medical Assistance in Dying</a> (MAID) to people suffering solely with mental illness. </p>
<p>Proponents of <a href="https://psychiatry.utoronto.ca/news/discussing-medical-assistance-dying-and-mental-illness-canada">expanding Bill C-7 to mental illness claim</a> that delays to do so are based on stigma and stereotypes promoting the belief that a mental disorder renders someone incapable of making a rational choice to die. Those that advocate for delaying an expansion suggest that more work is needed to <a href="https://doi.org/10.1097/yco.0000000000000298">ensure appropriate safeguards</a> are in place to distinguish requests for MAID from illness-induced suicidal ideation. </p>
<p>The recent announcement that including mental illness in MAID will be <a href="https://www.cbc.ca/news/politics/liberals-delay-expanding-maid-1.7101560">delayed until 2027</a> gives provincial and territorial health-care systems more time to prepare for implementation. </p>
<h2>Putting access to MAID in context</h2>
<p>People living with long-term mental illness should have the option to consider MAID, like others facing chronic, debilitating illnesses. However, access to MAID is a small part of a larger conversation we ought to be having about how the health-care system can provide supports and services that empower people with mental health disorders to navigate the long journey of mental illness with dignity and resilience. Extending support to the families that care for them should be considered key. </p>
<p><a href="https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics">As the Centre for Addiction and Mental Health (CAMH) reports</a>, mental illness is the leading cause of disability in Canada, and wait lists for services are far too long. For each person with a debilitating mental illness, there are family members — biological, legal or chosen — doing their best to provide support and care. But who supports these families as they navigate the challenges of persistent mental illness? </p>
<p>Despite decades of research demonstrating the <a href="https://doi.org/10.7870/cjcmh-2015-009">importance of family caregivers</a> for supporting people with severe mental illness, and the <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Caregiving_MHCC_Family_Caregivers_Guidelines_ENG_0.pdf">beneficial outcomes</a> for all family members when families are supported, vital support services have <a href="https://www.fraserinstitute.org/sites/default/files/mental-health-care-how-is-canada-doing.pdf">declined throughout Canada</a>. Families that are racialized, poor or newcomers are <a href="https://doi.org/10.1177/0840470420933911">getting even less support</a> in a depleted family support service system. </p>
<p>Examples of evidence-based family-focused supports that would help include <a href="https://doi.org/10.1111/j.1752-0606.2011.00256.x">family psychoeducation</a>, <a href="https://doi.org/10.1111/hsc.12689">peer support</a>, and <a href="https://doi.org/10.1177/07067437231197263">community-based, culturally-acceptable services</a> that focus on whole families.</p>
<h2>Supporting patients and families</h2>
<p>In addition to asking health-care systems to prepare to end the suffering of mental illness by facilitating death, we should be asking legislators and policymakers to build a health-care system that supports better lives for people with mental disorders and their families. </p>
<p>Families manage mental illness <a href="https://www.ctvnews.ca/health/relatives-of-people-with-serious-mental-illness-often-bear-brunt-of-stigma-study-1.6374892">out of sight</a> of these leaders and society at large; their suffering is seen as a <a href="https://tspace.library.utoronto.ca/bitstream/1807/94700/1/Caregiving%20under%20siege_Williams.pdf">personal matter</a> that is no one else’s business. But the numbers tell us that ending suffering from mental illness is everyone’s business. It requires <a href="https://cmha.ca/brochure/social-support/">networks of support</a> for those who have been diagnosed and caregivers. Ignoring the families that support individuals with mental illness has <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Caregiving_MHCC_Family_Caregivers_Guidelines_ENG_0.pdf">ramifications for everyone’s health</a>. </p>
<p>My research exploring the experiences of Ontario families affected by mental illness has shown there are <a href="http://familyguidetomentalhealth.com/port/harmful-practices/">gaps in the system</a> when it comes to family support. Conversations with families reveal that, whether one is a caregiver or someone who has been diagnosed, those living with mental illness often feel <a href="http://familyguidetomentalhealth.com/port/stigma-isolation/">isolated, alone and overwhelmed</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/bO_jmSo4VfA?wmode=transparent&start=8" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In a video from the Family Caregiving Project, family members describe difficult interactions with the health-care system.</span></figcaption>
</figure>
<p>Family members who <a href="https://tspace.library.utoronto.ca/bitstream/1807/94700/1/Caregiving%20under%20siege_Williams.pdf">don’t fall into the definition of “traditional family”</a> often report challenges throughout the care process. Families that are part of marginalized or lower-income groups face additional <a href="https://doi.org/10.1177/0840470420933911">challenges to getting help and support</a>, often due to financial barriers, language and cultural barriers, or other social determinants that correspond to inequities in access to health care. </p>
<p>The failure to build proper supports and services that meet the needs of families could worsen an already growing mental health crisis. If the family is stressed, that <a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=c8ae98f27c37c9ca253832a6f7a479f3d322b502">stress will impact everyone within it</a>, caregivers and people struggling with a mental illness alike. This is suffering that can last for decades. The well-being of whole families affected by mental illness must be recognized as an issue of urgent concern.</p>
<h2>Caring for people with long-term mental illness</h2>
<p>Education and training are needed to ensure health professionals have the information they need to better support families. At the same time, more work must be done to promote the general public’s understanding of mental illness and reduce stigma, so people don’t feel ashamed about asking for help. </p>
<p>My work with the Family Caregiving Project to develop <a href="http://familyguidetomentalhealth.com/family-caregiving-project/">free online educational resources</a> is a start. These resources help health-care professionals, educators and community groups better understand and discuss the experiences of families struggling with mental health issues. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medical-assistance-in-dying-for-mental-illness-ignores-safeguards-for-vulnerable-people-156012">Medical assistance in dying for mental illness ignores safeguards for vulnerable people</a>
</strong>
</em>
</p>
<hr>
<p>But Canada’s families require government support as well. We need to ensure that our health-care system provides necessary services for families. Last year, we called on the Ontario government to fund targeted support for families living with serious and persistent mental illnesses, <a href="https://www.change.org/p/family-day-includes-families-affected-by-mental-illness-they-need-your-help-0cc2c044-c4bf-4de2-a722-ef5eae4f2d05">collecting nearly 1,500 signatures from people who agree family support needs to be a priority</a>. </p>
<p>Living with a recurrent mental illness and having hopes rise and fall when treatments fail is a source of profound suffering for families all over Canada. People diagnosed with mental illness need to be part of the dialogue surrounding MAID eligibility because long-term mental illness can be devastating. At the same time, we have a health-care system that is focused on the short term of crisis and hospitalization, with little thought or investment for the months and years over which individuals and their families must find ways to carry on. </p>
<p>We need to offer more than assistance to death. We need to offer adequate resources and services that will get people help when needed, and support the mental health and well-being of all family members over the long term.</p><img src="https://counter.theconversation.com/content/224057/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charmaine C. Williams receives funding from the Social Sciences and Humanities Research Council (SSHRC). In the past she has received funding from the Canadian Institutes of Health Research (CIHR), the International Development Research Council (IDRC), the Ontario HIV Treatment Network, and the Ministry of Health and Long-Term Care.</span></em></p>In addition to asking health-care systems to prepare to end suffering of mental illness through Medical Assistance in Dying (MAID), we must ask policymakers to support better lives for families.Charmaine C. Williams, Dean and Professor of Social Work, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2218612024-01-30T23:08:05Z2024-01-30T23:08:05ZHere are some dos and don’ts to help tackle ableism<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/here-are-some-dos-and-donts-to-help-tackle-ableism" width="100%" height="400"></iframe>
<p>When we met each other in Grade 11 in Alberta, we were far from the typical high school success story. Heidi has cerebral palsy and was seen as too disabled for regular schools, and Michelle was a chronic truant and an activist. </p>
<p>Soon, we became friends and made a pact to get our doctorates, which we did. Over the past three decades, we have researched, taught classes and given talks on disability and ableism. </p>
<p>Throughout the course of our careers and lived experiences, we have seen the daily ableism people living with disabilities contend with. As professors of education and disability ethics, we have put together the following list of dos and don’ts. </p>
<h2>The dos</h2>
<p><strong>1. Listen to feedback even if you’d rather not.</strong>
Giving people feedback on <a href="https://www.talilalewis.com/blog/working-definition-of-ableism-january-2022-update">ableism</a> isn’t our idea of a good time, but we’d like a society that isn’t ableist. Try to be mindful and understanding when someone tells you that your <a href="https://theconversation.com/disability-and-dignity-4-things-to-think-about-if-you-want-to-help-198993">words or actions are not helpful</a>.</p>
<p><strong>2. Listen to how people identify themselves.</strong>
Some disabled people use <a href="https://doi.org/10.1111/j.1755-618X.2001.tb00967.x">identity-first language</a>: “I am disabled.” Others might use people-first language: “I am a person with disabilities.” This is a personal and political choice. The same goes for titles. When we teach, we use Dr. Janz instead of Heidi because it is often challenging for students and colleagues to see Dr. Janz as having academic expertise.</p>
<p><strong>3. Think about how often disability is used to denote something negative or as an insult.</strong>
Here are a few we’ve heard recently: blind to it, blindspot, deaf to it, schizo, manic, lame or when talking about a person who was challenging organizational norms as “definitely autistic.” </p>
<p><strong>4. Think about how you can be more inclusive of people with disabilities.</strong>
Excluding or minimizing the experiences of disabled individuals often leads to <a href="https://doi.org/10.1377/hlthaff.2022.00520">flawed research</a>, policy and <a href="https://www.c-q-l.org/resources/articles/most-disability-professionals-are-ableist/">education</a> of future professionals. It’s essential to integrate critical work by disability scholars for ethically sound, and socially relevant research and education.</p>
<p><strong>5. Commit to fair compensation.</strong>
We can’t tell you how many times it has been assumed that Michelle should be paid but that Heidi is happy as a clam to do work for free. Disabled people deserve compensation for their work like everyone else. </p>
<p>Their costs are often far higher than those of someone who does not travel with a personal care attendant and needs to use accessible transportation and accommodation — <a href="https://www.cbc.ca/news/canada/calgary/canadian-cities-accessibility-disabilities-research-calgary-ottawa-vancouver-1.7043923">when it is available</a>. But even if they didn’t need any of these things, the assumption disabled people should work for less or for free is downright insulting.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/working-from-home-has-worked-for-people-with-disability-the-back-to-the-office-push-could-wind-back-gains-209870">Working from home has worked for people with disability. The back-to-the-office push could wind back gains</a>
</strong>
</em>
</p>
<hr>
<p><strong>6. Challenge the notion that people are better off dead.</strong>
Despite the opposition of major disability rights groups in Canada and concerns expressed by <a href="https://spcommreports.ohchr.org/TMResultsBase/DownLoadPublicCommunicationFile?gId=26002">United Nations special rapporteurs on the rights of persons with disabilities</a>, Canada promised to expand Medical Assistance in Dying (MAID) to <a href="https://www.thestar.com/news/investigations/surge-in-medically-assisted-deaths-under-canada-s-maid-program-outpaces-every-other-country/article_29028f96-bc6b-11ee-8f67-03bf29ac7d34.html">people with mental health challenges</a>. </p>
<p>The expansion of MAID to include individuals with mental illness is <a href="https://www.cbc.ca/news/politics/medical-assistance-in-dying-mental-illness-delay-1.7098313">likely to be postponed</a> following more testimonies from mental health experts and advocates arguing that MAID as a solution for mental illness is problematic, especially considering the high number of people who are unhoused, living in poverty and unable to access supports including mental health and addiction treatment services. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/liks62ZcMK0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Heidi Janz providing expert testimony on MAID and ableism to Parliament’s Standing Committee on Justice and Human Rights in November 2020.</span></figcaption>
</figure>
<p><strong>7. Understand the impact of your government’s policies on disabled people.</strong>
The UN estimates that about <a href="https://www.youtube.com/watch?v=liks62ZcMK0">9.7 million</a> people with disabilities are displaced because of conflict and war. The late associate professor of English, <a href="https://www.penguinrandomhouse.ca/books/734125/landbridge-by-y-dang-troeung/9781039008762">Y-Dang Troeung</a>, and gender, race, sexuality and social justice professor <a href="https://www.dukeupress.edu/the-right-to-maim">Jasbir Puar</a> are two scholars who examine how ableism, racism and geopolitics connect.</p>
<p><strong>8. Think about who you see as leaders and why.</strong>
Democracy is founded on representation. <a href="https://www.ctvnews.ca/canada/statcan-8-million-people-27-of-canadians-have-at-least-1-disability-1.6675303">Twenty-seven per cent of Canadians identify as having a disability</a>. Consider what government, workplaces, health care, education and the justice system would look and feel like if a commitment to dismantling ableism was a priority.</p>
<h2>The don’ts</h2>
<p><strong>1. Don’t tell disabled people you are their voice.</strong>
Watch the power tripping that comes with assuming you are a voice for a group you are not a part of, including disability. Is it that you are speaking for the voiceless? Or for people with clear voices about what needs to change — based on their lived experience and expertise — who are being ignored? Voices come in many forms — text, story, art, music, screams of frustration, love and laughter. </p>
<p>Similarly, don’t ask a disabled person to speak for all disabled people. Not all disabled people will agree with each other, just as not all individuals in any group share the same opinions. Learn to listen. </p>
<p><strong>2. Don’t ask disabled people and other structurally marginalized groups to be patient.</strong>
Consider what it is like for disabled people asking for the basics of life, such as accessible housing, education, health care and food security, to constantly be told to be patient while others decide what they think is best for you. It’s important to clarify that the issue does not lie with frontline staff, who are often overstretched and underpaid, but rather with the fair distribution of public resources to include disabled people.</p>
<p><strong>3. Don’t assume disabled people aspire to be your inspiration.</strong>
Telling someone you don’t know how they do it or that you just wouldn’t cope if disabled might seem harmless, but consider how such comments might sound to a disabled person. How should a person, who might view their life as pretty enjoyable, respond to a comment that assumes it is actually pretty awful? </p>
<p><strong>4. Don’t assume you know what a person’s quality of life is.</strong>
Dr. Janz, for example, always needs an advocate with her when in the hospital because, too often, those paid to care for her assume she wants to be a DNR (do not resuscitate). <a href="https://www.telegraph.co.uk/news/2021/06/09/patients-mental-illness-learning-disabilities-given-do-not-resuscitate/">Ableism is life-threatening</a>.</p>
<p><strong>5. Don’t displace your discomfort onto disabled people.</strong>
It is okay to be uncomfortable when you can’t understand someone’s speech, or you don’t understand why they are twirling or rocking back and forth. What isn’t okay is to blame disabled people for your discomfort. </p>
<p>Ableism goes beyond individual fear or prejudice. It influences who we see as having a life worth living and who is seen as a burden. That, in turn, impacts our practices and policies. We all have a role to play in challenging ableism, which may sometimes leave us feeling awkward or unsure if we’re doing and saying the right things. But, to our knowledge being awkward isn’t deadly. Ableism too often is.</p><img src="https://counter.theconversation.com/content/221861/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People with disabilities contend with daily challenges and ableism. Here are some dos and don'ts to help you be more mindful of those living with a disability.Michelle Stack, Associate Professor, Department of Educational Studies, University of British ColumbiaHeidi L. Janz, Associate Adjunct Professor of Disability Ethics, John Dossetor Health Ethics Centre, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2052782023-05-17T18:04:19Z2023-05-17T18:04:19ZMAID’s evolving ethical tensions: Does it make dying with dignity easier than living with dignity?<figure><img src="https://images.theconversation.com/files/526437/original/file-20230516-17-xndwxx.jpg?ixlib=rb-1.1.0&rect=127%2C82%2C4446%2C3016&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is debate about whether a health-care worker can ethically participate in both palliative care and the MAID program. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical assistance in dying (MAID) has <a href="https://doi.org/10.1007/s10912-022-09764-z">received lots of media attention over the past few years</a>. This is especially true as the Canadian government considers expanding eligibility for people whose sole underlying condition is a mental illness. This has led to <a href="https://theconversation.com/canada-delays-expanding-medical-assistance-in-dying-to-include-mental-illness-but-its-still-a-policy-built-on-quicksand-196264">increased concerns about the ethics of MAID</a>.</p>
<p>Even in its present form, MAID is fraught with ethical tensions. As scholars <a href="https://doi.org/10.1016/j.jrurstud.2022.09.011">engaged in research on MAID</a>, we have heard about these tensions firsthand through interviews with physicians and nurses who provide MAID-related care, clinical ethicists who perform MAID-related consults, family members of patients who have received MAID and patients who have requested MAID. </p>
<p>From these conversations, we highlight three emerging tensions: </p>
<ol>
<li>Palliative care versus MAID provision; </li>
<li>Transparency versus privacy; and </li>
<li>Providing a dignified death versus a dignified life. </li>
</ol>
<p>These tensions can contribute to unpredictability in health service provision, strained relationships, moral distress, harm for prospective patients and the erosion of public trust.</p>
<h2>Palliative care vs. MAID provision</h2>
<p>There is debate about whether a health-care worker can participate in both palliative care and the MAID program. </p>
<p>Palliative care involves efforts to improve the <a href="https://www.virtualhospice.ca/Assets/MAiD_Report_Final_October_15_2018_20181218165246.pdf">quality of life of patients facing serious or life-threatening illness by preventing or relieving suffering through early identification, assessment and treatment of pain, including physical, psychosocial and spiritual pain</a>. MAID, on the other hand, provides patients experiencing intolerable suffering the option to end their lives with the assistance of a doctor or nurse practitioner.</p>
<p>Some people see the two services as <a href="https://healthydebate.ca/2020/06/topic/palliative-care-and-maid/">co-existing within end-of-life care</a>. Others view them as having <a href="https://www.chpca.ca/news/chpca-and-cspcp-joint-call-to-action/">incompatible intentions and goals</a>, and may see the two services as being in conflict. </p>
<figure class="align-center ">
<img alt="A man in a white coat, stethoscope and face mask sitting in a chair and looking upset" src="https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ethical conflicts can potentially place strain on professional relationships between MAID providers and palliative care teams or cause moral distress for palliative care providers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>For instance, as one medical professional informed us, pharmaceuticals that might be provided to relieve pain during palliative care could undermine cognitive capacity and limit a patient’s ability to provide consent to MAID:</p>
<blockquote>
<p>“It was brutal. I knew at that time we wouldn’t be able to do the provision because we would have to medicate her so much… then we’d have to reverse it to get consent, and that was really hard.”</p>
</blockquote>
<p>Examples like this reveal the tensions that medical professionals might face if they seek to provide both palliative care and MAID. We also heard that some palliative care professionals perceive MAID requests as a failure of their efforts to provide quality palliative care. </p>
<p>This can potentially place strain on professional relationships between MAID providers and palliative care teams, or cause moral distress for palliative care providers.</p>
<h2>Transparency vs. privacy</h2>
<p>The federal government notes the importance of <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">transparency for the improvement of MAID and maintenance of public trust</a>. However, patients and care providers sometimes have strict privacy concerns, wanting their participation in MAID kept confidential because of disapproving family, colleagues or community members. </p>
<figure class="align-center ">
<img alt="A man in a hospital bed and a woman with her arm around him, both looking at a man in a white coat seen from behind" src="https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients and care providers sometimes have strict privacy concerns, wanting their participation in MAID kept confidential because of disapproving family, colleagues or community members.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This is particularly true in smaller communities where privacy may be more limited, health-care professionals are <a href="https://doi.org/10.1111/nin.12308">highly visible</a> and people may be concerned about <a href="https://edmontonjournal.com/news/local-news/rural-alberta-faces-more-end-of-life-care-challenges-conference">MAID-related stigma</a>.</p>
<p>One patient in our study had family members insist on keeping their cause of death a secret. Another participant spoke about a patient’s request for the MAID team to do the provision at a long-term care home without letting the staff, family or other residents know. </p>
<p>When medical providers are asked to assist patients in such secrecy, transparency may become compromised.</p>
<blockquote>
<p>“Staff had to really balance transparency with confidentiality… One of those transparency pieces, very clearly from the government, was accurate recording, so that there was nothing secret… (But) we’ve had patients who have said, ‘I don’t want my family to know.’ But they’re going to find out what the cause of death was; the death certificate is very clear.”</p>
</blockquote>
<p>In cases like this, medical professionals are placed in the difficult position of not being able to accommodate privacy requests of patients or family members, as doing so could undermine ethical obligations of transparency and professional accountability.</p>
<h2>A dignified death vs. a dignified life</h2>
<p>MAID is often celebrated for supporting <a href="https://www.dyingwithdignity.ca/">suffering patients to exercise control and die with dignity</a>. </p>
<p>With the passage of <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7</a>, which removed the requirement of a reasonably foreseeable death, Canadians are now applying for MAID when suffering is impacted by socioeconomic factors such as inadequate housing, medical care, food security or income supports. </p>
<p>As a result, there has been growing concern about offering this service in a limited social welfare state <a href="https://www.thestar.com/opinion/contributors/2021/02/11/if-medically-assisted-death-becomes-more-accessible-for-canadians-we-have-a-moral-obligation-to-make-living-well-through-housing-mental-health-supports-accessible-too.html?rf">that does not provide the conditions for people with an illness or disability to live with dignity</a>.</p>
<p>There have been news reports of people being offered MAID when they just needed assistance to live. This has included a <a href="https://www.ctvnews.ca/politics/paralympian-trying-to-get-wheelchair-ramp-says-veterans-affairs-employee-offered-her-assisted-dying-1.6179325">veteran who merely required a wheelchair ramp</a>, individuals who did not have access to food or <a href="https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579">adequate housing</a> and <a href="https://www.ctvnews.ca/health/the-solution-is-assisted-life-offered-death-terminally-ill-ont-man-files-lawsuit-1.3845190">patients who needed home care</a>. </p>
<p>We have also recently seen <a href="https://www.ctvnews.ca/health/the-number-of-medically-assisted-deaths-in-canada-s-prisons-a-concern-for-some-experts-1.6380440">reports of prisoners who may be requesting MAID to escape the harsh conditions of prison life</a>.</p>
<p>In our research, a participant told us about an individual who had received MAID and might have otherwise benefited from existing programs:</p>
<blockquote>
<p>“There was a (patient) in our community who went through MAID… and his diagnosis was heart failure… (But) he never came to our program and I felt there were a lot of things that we can actually do with these heart failure patients to give them good quality of life.”</p>
</blockquote>
<p>Canadian legal scholar Trudo Lemmens has similarly noted <a href="https://www.cbc.ca/news/opinion/opinion-medical-assistance-in-dying-maid-legislation-1.5790710">that MAID may be quicker to access than certain medical and financial supports</a>, including, for instance, access to specialized long-term care, specialized pain clinics and the <a href="https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit.html">Canada Pension Plan Disability Benefits</a>.</p>
<p>“It is crucial that individuals are not placed in a position <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349713/">where MAID will be seen as the only alternative to suffering</a>.</p>
<p>Unfortunately, we heard from study participants that this issue may be further exacerbated in rural areas with limited access to palliative care. </p>
<blockquote>
<p>"I think some of those patients don’t get the same palliative care that somebody in town would and so maybe they’re opting to do MAID sooner than somebody else would… maybe they didn’t really want to do it but they kind of felt that it was their only option.”</p>
</blockquote>
<p>Another study has already corroborated this concern, noting there is an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302435/">inadequate provision of palliative care for those requesting MAID</a>. This is alarming as it signals the reality that MAID requests are sometimes made not out of necessity, but rather due to unmet needs.</p>
<h2>Moving forward</h2>
<p>These tensions surrounding MAID place staff in complex ethical predicaments and are deserving of greater attention. Current policy and legislation do not adequately address how they ought to navigate potential conflicts between palliative care and MAID, between transparency and privacy, or how to best handle MAID requests being made due to unmet socioeconomic or medical needs. </p>
<p>This situation is made worse by the fact that some of our participants felt ill-prepared to step into a MAID-related role due to limited training or support.</p>
<p>We encourage the federal government to reconsider its role in improving the quality of life of its citizens. In many situations, Bill C-7 has made “dying with dignity” easier than “living with dignity.” It is ethically problematic if a state is more willing to facilitate death than to provide the necessities of life.</p><img src="https://counter.theconversation.com/content/205278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julia Brassolotto receives funding from Alberta Innovates and the Social Sciences and Humanities Research Council (SSHRC). </span></em></p><p class="fine-print"><em><span>Alessandro Manduca-Barone and Monique Sedgwick do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Bill C-7 has created ethical tensions between MAID providers and palliative care, between transparency and patient privacy, and between offering a dignified death rather than a dignified life.Alessandro Manduca-Barone, Research Associate - Faculty of Health Sciences, University of LethbridgeJulia Brassolotto, Associate Professor, Public Health and Alberta Innovates Research Chair, University of LethbridgeMonique Sedgwick, Associate Professor of Nursing, University of LethbridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1983802023-01-31T20:22:43Z2023-01-31T20:22:43ZAs eligibility for MAID expands, the ethical implications of broad access to medically assisted death need a long, hard look<figure><img src="https://images.theconversation.com/files/507293/original/file-20230131-12-n9up99.jpg?ixlib=rb-1.1.0&rect=1086%2C1267%2C5211%2C3199&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Given how quickly MAID eligibility has changed in Canada in the past six years, it is time we take a step back to ask whether current MAID practice is still something we want to support. </span> <span class="attribution"><span class="source">(Pexels/Karolina Grabowska)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/as-eligibility-for-maid-expands--the-ethical-implications-of-broad-access-to-medically-assisted-death-need-a-long--hard-look" width="100%" height="400"></iframe>
<p>As a philosophy professor and researcher of end-of-life ethics, I ask the students in my ethics class who should be eligible to receive Medical Assistance in Dying (MAID). Should it be open only to people actively dying from a terminal illness? To anyone with any medical condition that causes them unendurable suffering? To anyone who asks for it for any reason, as long as their request is truly voluntary? </p>
<p>Student responses generally align with the <a href="https://www.parl.ca/Content/Bills/421/Government/C-14/C-14_4/C-14_4.PDF">original 2016 MAID legislation</a>, which required that the patient’s death be reasonably foreseeable and that they have a grievous and irremediable illness causing enduring and intolerable suffering.</p>
<p>Since 2016, Canada’s practice of offering MAID has followed a trajectory of ever-expanding eligibility. <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/docs/MAID_Infographic_EN.pdf">As of March 17, 2021</a>, to receive MAID a person no longer has to be dying anytime soon. </p>
<p>If their death <em>is</em> reasonably foreseeable, they no longer need to undergo the 10-day reflection period to ensure that this is really what they want. Nor do they have to give final consent to the procedure immediately before it is administered, which allows for individuals who lose the ability to consent to have their lives ended despite that. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/canada-delays-expanding-medical-assistance-in-dying-to-include-mental-illness-but-its-still-a-policy-built-on-quicksand-196264">Canada delays expanding medical assistance in dying to include mental illness, but it's still a policy built on quicksand</a>
</strong>
</em>
</p>
<hr>
<p>Although the federal government has put implementation on hold after concerns were raised, the 2021 legislation also opens MAID for persons who do not have a physical illness; a grievous and irremediable mental illness will also make one eligible. </p>
<h2>Eligibility and expansion</h2>
<figure class="align-center ">
<img alt="A sign in the foreground reading Supreme Court of Canada with a building in the background" src="https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=355&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=355&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=355&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=446&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=446&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507296/original/file-20230131-14-8nj0xi.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=446&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The original MAID legislation in 2016 required that natural death be reasonably foreseeable.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<p>What eligibility criteria remain? A person must be at least 18 years of age. This condition has been and continues to be challenged, with <a href="https://www.dyingwithdignity.ca/blog/pr_mature_minors/">alternative minimum ages as low as 12 being suggested</a>. Requests for MAID must also be voluntary, though it is often possible to question how voluntary MAID requests are <a href="https://theconversation.com/why-is-access-to-medically-assisted-death-a-legislated-right-but-access-to-palliative-care-isnt-161994">when people don’t understand or have access to good palliative care</a> and social supports. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-is-access-to-medically-assisted-death-a-legislated-right-but-access-to-palliative-care-isnt-161994">Why is access to medically assisted death a legislated right, but access to palliative care isn’t?</a>
</strong>
</em>
</p>
<hr>
<p>The issue of whether MAID is voluntary can also conflict with requests for MAID by advance directive, when a person’s condition has made it impossible for them to give final consent. This was illustrated when a <a href="https://www.theguardian.com/world/2019/aug/26/doctor-on-trial-landmark-euthanasia-case-netherlands-dementia">Dutch physician used a sedative to pacify a woman with dementia</a> who had previously requested assisted death. </p>
<p>The ultimate expansion of eligibility would make MAID available to anyone who wanted it, for any reason. This might seem absurd, but it follows the sort of <a href="https://sencanada.ca/en/senators/kutcher-stan/interventions/553870/11">logic articulated by Senator Stan Kutcher</a> before the vote on Bill C-7 to expand MAID to cases of suffering from mental illness: </p>
<blockquote>
<p>“Intolerable suffering is a subjective personal experience. It cannot be negated or delegitimized by anyone else’s valuation of that suffering.” </p>
</blockquote>
<p>If a person’s claim to intolerable and enduring suffering must always be accepted at face value, why limit MAID eligibility to physical or mental illnesses? Many things besides illness cause suffering: the break-up of a personal relationship, loss of a job, low self-esteem, boredom, loneliness, a sense of meaninglessness. </p>
<p>If it’s <a href="https://www.psychiatrictimes.com/view/first-do-no-harm">discriminatory to discount suffering from mental illness</a>, how can we avoid discriminating if we refuse to put suffering from other forms of hardship on an equal par? Indeed, it seemed to make good sense to at least one doctor recently to <a href="https://toronto.citynews.ca/2022/10/13/medical-assistance-death-maid-canada/">approve the application of a man whose MAID request was based not on his chronic pain issues but on his risk of becoming homeless</a>. </p>
<p>In the Netherlands, a bill has been in the works for some time to provide access to <a href="https://nltimes.nl/2022/05/20/completed-life-euthanasia-proposal-needs-safeguards-misuse-council-state">physician-assisted death for anyone over the age of 75</a> who feels that their life is “complete,” even if they have no physical or mental illness.</p>
<h2>Ethical implications and questions</h2>
<p>Part of the reason it made sense to allow MAID for people already actively dying was that doing so <a href="https://doi.org/10.7202/1084448ar">seemed equivalent to accepted practices such as withdrawing life-sustaining treatment</a> or palliative sedation. </p>
<p>This equivalence fails when we broaden the scope of MAID to those who aren’t dying, and all the more when we countenance offering it for non-terminal mental illness, <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2021.html#a4.3">or loneliness, or loss of ability to engage in meaningful activities</a>. </p>
<p>Given how quickly things have changed in Canada over the past six years, and the further expansions in other jurisdictions who’ve had MAID longer than we have, it is time we took a step back to ask whether current MAID practice is still something we want to support. </p>
<p>Those who raised slippery slope concerns in the past might reasonably claim we’ve slid halfway down the slope already. How do we put the brakes on to make sure we don’t slip any further? What kind of a society are we if we sanction doctors to end the lives of suffering people while not doing our best to ensure they have the support that would make their lives worth living? </p>
<p>Maybe, tragically, death was the best we could offer for those initially eligible for MAID. But the broader the category of MAID-eligible individuals becomes, the more empty this sort of reasoning feels.</p><img src="https://counter.theconversation.com/content/198380/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Stumpf receives funding from Social Sciences and Humanities Research Council of Canada.</span></em></p>Since 2016, Canada’s practice of offering MAID has followed a trajectory of ever-expanding eligibility. The ultimate expansion would make MAID available to anyone who wanted it, for any reason.Andrew Stumpf, Assistant Professor of Philosophy, University of WaterlooLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1962642022-12-15T15:50:34Z2022-12-15T15:50:34ZCanada delays expanding medical assistance in dying to include mental illness, but it’s still a policy built on quicksand<figure><img src="https://images.theconversation.com/files/500879/original/file-20221213-14-4j61be.jpeg?ixlib=rb-1.1.0&rect=506%2C191%2C5867%2C4242&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The planned expansion of Canada's medical assistance in dying (MAID) law to include people with mental illnesses whose death is not imminent has been delayed, but not cancelled.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The federal government admitted Thursday it needs more time before expanding Canada’s controversial medical assistance in dying (MAID) policy to enable MAID solely for mental illness.</p>
<p>Although the government had recently announced its intention to proceed with expanding MAID for those with mental health disorders by next March, <a href="https://www.ctvnews.ca/politics/feds-seeking-to-delay-expansion-of-medical-assistance-in-dying-laws-1.6196668">Justice Minister David Lametti said he had heard from medical experts that the health-care system wasn’t prepared to deal with patients who want to end their lives for mental health reasons</a>. He did not commit to a new deadline. </p>
<p>But the justice minister said Ottawa was only seeking to delay implementation of the MAID changes — it’s still clear the government remains intent on <a href="https://www.theglobeandmail.com/canada/article-maid-canada-mental-health-law/">further expanding its legislation to include mentally ill people who are suicidal and could get better</a>.</p>
<p>It’s one of many controversial elements of the proposed changes to the MAID legislation, and remains cause for concern.</p>
<p>Canada’s federal minister of disability inclusion recently expressed feeling devastated about Canadians being driven to <a href="https://www.cbc.ca/news/politics/assisted-dying-carla-qualtrough-1.6625412">seek assisted death through MAID — medical assistance in dying — due to lack of social supports</a>.</p>
<p>Some are pushing for <a href="https://nationalpost.com/news/quebec-college-of-physicians-slammed-for-suggesting-maid-for-severely-ill-newborns">MAID for infants</a>, while others think <a href="https://www.theglobeandmail.com/canada/article-maid-canada-mental-health-law/">non-dying disabled people on wait lists</a> should receive MAID. When <a href="https://www.thestar.com/politics/provincial/2022/11/29/justice-minister-david-lametti-under-fire-for-unbelievable-comparisons-between-euthanasia-and-suicide.html?rf">the minister of justice suggests we should make it easier for those ambivalent about suicide to die</a>, that is bone chilling.</p>
<p>When Canada embarked on this journey years ago, I cautioned about the importance of ensuring we <a href="https://www.theglobeandmail.com/opinion/how-mental-illness-complicates-assisted-dying/article30193498/">“do the least harm” with our expanding laws</a>. As physician chair of my hospital MAID team, I have seen the myths and realities that have fuelled our MAID expansion. </p>
<h2>False autonomy and false compassion</h2>
<p>As a society, we take comfort that MAID is provided for compassionate relief from suffering. Individually, MAID has been sold to Canadians as an autonomous choice, and framed as a right. When MAID was introduced in 2016, for those whose deaths were reasonably foreseeable, these principles may have been true. In contrast, our MAID expansion to non-dying disabled people has been misled by the fallacies of false autonomy and false compassion.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-is-access-to-medically-assisted-death-a-legislated-right-but-access-to-palliative-care-isnt-161994">Why is access to medically assisted death a legislated right, but access to palliative care isn’t?</a>
</strong>
</em>
</p>
<hr>
<p>True autonomy requires true choice. For those of us fortunate enough to live lives with privilege, choosing “death with dignity” can be sold as an autonomous choice. Yet we have now had marginalized Canadians living in poverty be given state-supported suicide who have openly said they chose MAID not to avoid suffering from illness, but because <a href="https://www.cbc.ca/news/canada/manitoba/sathya-dharma-kovac-als-medical-assistance-in-death-1.6605754">society had failed to provide them a chance to live with dignity</a>. </p>
<figure class="align-right ">
<img alt="A woman in a navy jacket" src="https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500681/original/file-20221213-14387-fa7efg.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Minister of Employment, Workforce Development and Disability Inclusion Carla Qualtrough, pictured in the House of Commons on Dec. 8, recently described MAID requests driven by lack of social supports as devastating.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>Most would be hard-pressed to argue it reflects true autonomy with a range of choices when the marginalized poor are enticed toward “painless” death to escape a painful life of poverty.</p>
<p>Canadians have rationalized that non-dying disabled people are being provided MAID in the name of compassion. However, it is not compassionate to provide death for one reason while pretending it is for another. We have reassured ourselves that MAID is for medical conditions that will not improve, or are irremediable. In the court cases that originally established MAID — which involved conditions like <a href="https://bccla.org/2012/10/in-memory-of-gloria/">ALS</a> and <a href="https://www.cbc.ca/news/canada/montreal/medically-assisted-dying-law-overturned-quebec-1.5280702">spinal stenosis</a> — or for medical conditions like cancers, that can be true.</p>
<p>However, evidence shows it is <a href="https://www.eagmaid.org/report">impossible to predict that a mental illness will not improve in any individual</a>. Yet expansion activists mistakenly believe they can make such predictions. Science tells us their chance of being right amounts to chance or less, with <a href="https://doi.org/10.1017/s0033291722002951">precision modelling showing only 47 per cent of “irremediability” predictions end up being correct</a> — which is worse than flipping a coin.</p>
<h2>False safety</h2>
<p>Perhaps most tragically, the twin pillars of false autonomy and false compassion fuelling the expansion agenda have been propped up by the third myth of false safety.</p>
<p>Until now, expansion activists have reassured that “<a href="https://www.suicideinfo.ca/local_resource/suicide-physician-assisted-death/">MAID is not suicide</a>.” When provided to help avoid a painful death for those who are dying, we can distinguish MAID from suicide. Yet when expanded to those seeking death for mental illness, evidence shows MAID becomes indistinguishable from suicide. <a href="https://cca-reports.ca/reports/medical-assistance-in-dying/">We cannot differentiate those seeking psychiatric euthanasia from suicidal individuals</a> who resume fulfilling lives after being provided suicide prevention, rather than facilitated death. </p>
<figure class="align-center ">
<img alt="A woman sitting a table looking pensive" src="https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500851/original/file-20221213-26864-o5h4ft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Until now, expansion activists have reassured that ‘MAID is not suicide.’</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>All this sobering evidence is sadly borne out by our <a href="https://globalnews.ca/news/9176485/poverty-canadians-disabilities-medically-assisted-death/">now common headlines</a> of assisted suicide <a href="https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579">being provided</a> to <a href="https://www.ctvnews.ca/health/woman-with-disabilities-nears-medically-assisted-death-after-futile-bid-for-affordable-housing-1.5882202">marginalized Canadians</a> seeking <a href="https://www.chatelaine.com/health/maid-assisted-death-poverty/">escape from life suffering</a> and <a href="https://toronto.citynews.ca/2022/10/13/medical-assistance-death-maid-canada/">poverty</a>. </p>
<p>The government-appointed federal panel, <a href="https://policyoptions.irpp.org/magazines/missing-the-mark-on-a-profound-social-change-with-maid-for-mental-illness/">chaired by an expansionist in favour of MAID for mental illness</a>, was responsible for providing safeguards, standards and guidelines for how to implement MAID for mental illness. Instead, the panel recommended that <a href="https://www.canada.ca/en/health-canada/news/2022/05/final-report-of-the-expert-panel-on-maid-and-mental-illness.html">no further legislative safeguards be required before providing death for mental illness, and did not provide any specific standards</a> for the length, type or number of treatments that should be tried before providing MAID. Its report even suggested society had made an “ethical choice” that MAID should be provided even if suicide and MAID were the same.</p>
<p>Two members of the initial 12-member panel resigned, including the <a href="https://www.hilltimes.com/story/2022/06/16/maid-expert-panel-recommendations-are-inadequate-contends-panel-member-who-resigned/270807/">health-care ethicist</a> and <a href="https://www.theglobeandmail.com/opinion/article-expert-panel-maid-mental-illness/">a mental health advocate panelist with lived experience</a>. </p>
<h2>Suicide prevention</h2>
<p>The whole issue of suicide prevention has been shockingly absent from many of these discussions, including those with key medical associations. In all of its consultations on <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7</a> leading up to the <a href="https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151">sunset clause</a>, the Canadian Psychiatric Association (of which I am a former past president) inexplicably <a href="https://www.cpa-apc.org/wp-content/uploads/Brief-JUST-12-Nov-2020-FIN.pdf">never once presented known evidence about suicide risks associated with mental illness</a>. </p>
<p>While some organizations such as the <a href="https://suicideprevention.ca/media/statement-on-the-expansion-of-medical-assistance-in-dying-to-those-without-a-reasonably-foreseeable-death/#:%7E:text=The%20Canadian%20Association%20for%20Suicide,process%20that%20is%20already%20happening">Canadian Association for Suicide Prevention</a> discussed the importance of preventing suicide, <a href="https://www.cpa-apc.org/wp-content/uploads/Brief-LCJC-23-Nov-2020-FIN.pdf">CPA never raised this crucial topic</a> — indeed they <a href="https://sencanada.ca/en/Content/Sen/Committee/432/LCJC/02ev-55071-e">avoided using any variant of the word “suicide.”</a></p>
<figure class="align-right ">
<img alt="A man in a dark suit and tie gestures with his hand." src="https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500677/original/file-20221213-14838-oz0t5e.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Minister of Justice David Lametti in the House of Commons on Nov. 22, 2022. Lametti recently made controversial statements about MAID.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<p>With this vacuum of national leadership and evidence-based guidance, perhaps it is not surprising that our <a href="https://www.thestar.com/politics/provincial/2022/11/29/justice-minister-david-lametti-under-fire-for-unbelievable-comparisons-between-euthanasia-and-suicide.html?rf">minister of justice recently suggested that MAID “provides a more humane way for [people with mental illness] to make a decision” when “for physical reasons and possibly mental reasons, [they] can’t make that choice themselves to do it themselves.”</a></p>
<p>This remarkable statement, coming from the person entrusted with responsibly implementing Canada’s assisted dying laws, will keep me and many of my colleagues up at night.</p>
<h2>The need to pause</h2>
<p>I am not a conscientious objector. However it is clear to me that Canada’s planned expansion of MAID to mental illness is based on ignorance — if not outright disregard — of fundamental <a href="https://www.cdc.gov/suicide/prevention/index.html">suicide prevention principles</a>. It appears to ignore what drives the most marginalized people to consider death as an alternative to life suffering. Perhaps, though, it does not ignore the <a href="https://globalnews.ca/news/7407627/health-care-costs-canada-assisted-dying/">cost savings of providing MAID</a> rather than treatment and community support for dignified living.</p>
<p>The <em><a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do">Carter v. Canada</a></em> and <a href="https://www.canlii.org/en/qc/qccs/doc/2019/2019qccs3792/2019qccs3792.html?searchUrlHash=AAAAAQANdHJ1Y2hvbiBnbGFkdQAAAAAB&resultIndex=1"><em>Truchon v. Canada</em></a> court cases shaping MAID laws did not review or rule on MAID for mental illness. Expanding MAID within three months would have meant providing facilitated suicide for the mentally ill without any standards, or any consideration of the role of suicide prevention.</p>
<p>Postponing the March 2023 expansion of euthanasia for mental illness is the only responsible course. Canadians and mental health organizations recognized this and called for it, with the Canadian Association for Suicide Prevention and over 200 individual psychiatrists so far signing <a href="https://www.socpsych.org/calltoaction">a petition to this effect</a>, and the academic chairs of the departments of psychiatry across Canada <a href="https://www.theglobeandmail.com/canada/article-maid-delay-mental-illness-medical-experts/">joining this call for delay</a>. </p>
<p>To proceed with the planned changes would have been morally, medically and politically irresponsible. Moving forward, it will be important to ensure our future policies are evidence-based. Fortunately, the situation is not yet irremediable.</p>
<p><em>If you are experiencing suicidal thoughts, you need to know you’re not alone. If your life or someone else’s is in danger, call 911 for emergency services. For support, call Canada Suicide Prevention Service (CSPS) at 1-833-456-4566. Visit <a href="https://talksuicide.ca">Crisis Services Canada</a> for more resources.</em></p><img src="https://counter.theconversation.com/content/196264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karandeep Sonu Gaind is Chief of Psychiatry and physician chair of the Humber River Hospital MAiD team, a former president of the Canadian Psychiatric Association and a founding director of the nascent Society of Canadian Psychiatry, and was retained as an expert by the former Attorney General of Canada in the Truchon and Lamb cases.</span></em></p>Canada’s planned expansion of MAID to mental illness is based on ignorance — if not outright disregard — of fundamental suicide prevention principles.Karandeep Sonu Gaind, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1866252022-07-17T13:26:48Z2022-07-17T13:26:48ZHealth-care providers and MAID: The reasons why some don’t offer medically assisted death<figure><img src="https://images.theconversation.com/files/474342/original/file-20220715-495-eypa2y.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5218%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Several factors ranging from personal spiritual beliefs to patient relationships to medical legal issues can influence whether a health-care practitioner participates in providing medical assistance in dying (MAID).
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical assistance in dying (MAID) was legalized in Canada in 2016. Since then, there have been year-over-year increases in Canadians accessing a MAID death. The most recent data from <a href="https://www.canada.ca/content/dam/hc-sc/documents/services/medical-assistance-dying/annual-report-2020/annual-report-2020-eng.pdf">2019 to 2020 highlights a 34.2 per cent increase</a> in Canadians accessing MAID. </p>
<p>Bill C-7, which passed in June 2021, changed the eligibility criteria by <a href="https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/LegislativeSummaries/432C7E#a2.1">removing the “natural death has become reasonably foreseeable” requirement</a>. As a result, more Canadians may qualify for MAID.</p>
<p><a href="https://wfrtds.org/wp-content/uploads/2021/02/Report-PAM-Survey-FINAL-.pdf">During the pandemic</a>, 23 per cent of care providers in an international survey reported that assisted death inquiries or requests had “somewhat” or “significantly” increased. MAID and COVID-19 pressures resulted in at least <a href="https://www.thestar.com/news/canada/2021/10/01/nova-scotia-is-pausing-referrals-for-medical-assistance-in-dying-amid-increased-demand-and-covid-strains.html">one Canadian province temporarily pausing referrals for patients wishing to access MAID</a>. </p>
<h2>Non-participation in MAID:</h2>
<p>Health-care providers willing to participate in patient assessment and MAID provision are essential to support Canadians who wish to access MAID. That makes it important to understand the factors that influence practitioners’ decisions to not participate in MAID. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474329/original/file-20220715-26-vk0wg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">David Lametti, Minister of Justice and Attorney General of Canada, delivers a statement on Bill C-7 on Parliament Hill in Ottawa in March 2021. The bill removed the criteria of a reasonably foreseeable death from MAID eligibility.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span>
</figcaption>
</figure>
<p>As an end-of-life researcher and registered nurse, I investigated this question with the support of my thesis committee. That <a href="https://doi.org/10.1177/10497323211008843">research highlighted</a> the <a href="https://doi.org/10.1177/10497323211027130">complex and interwoven reasons</a> why health-care practioners may not participate in MAID. </p>
<p>These factors can be divided into internal and external factors, but it’s also important to recognize that there are conscience and non-conscience-based factors that influence non-participation. </p>
<h2>Internal factors</h2>
<p>Several personal, or internally originating, factors influenced non-participation. These included a general discomfort in caring for dying patients as well as the provider’s previous personal and work experiences related to death and dying. Also, MAID did not align with some practioners’ approaches to end-of-life care. </p>
<p>Other factors that influenced non-participation included practitioners’ views of their professional duty. MAID did not align with some practitioners’ faith or spiritual beliefs, and some reported they could not imagine being at peace with the decision to participate in medically assisted dying. </p>
<p>Health-care practitioners also considered how they were likely to respond emotionally to participating in MAID. They had concerns about the future impact of MAID participation in terms of their potential risk of post-traumatic stress disorder and burnout.</p>
<h2>External factors</h2>
<ul>
<li><p><strong>Health-care system factors:</strong> The health-care system influenced non-participation. This included working for an organization with an institutional conscientious objection to MAID and the uncertainty of working within a rapidly changing legal landscape in terms of MAID regulation. There were also concerns about adequate access to alternatives to MAID, such as palliative care and chronic care support at home. Some nurse practitioners reported that they did not participate in MAID because of limiting job or practice descriptions at their current employer or a lack of billing codes that would enable them to be paid for these services.</p></li>
<li><p><strong>Community factors:</strong> Reasons for non-participation also included gauging the “community conscience,” perceiving a lack of openness in end-of-life discussions and the dominant religious beliefs of the community. Health-care practitioners were concerned about the impact of having to reduce or cancel other services in an already busy practice to make the time to provide MAID care to a single patient. They were also unsure if or how culture influenced the patient’s perception of MAID, or the patient’s perception of them as health-care practitioners if they participated or if participation would alter the community’s trust in them. </p></li>
</ul>
<figure class="align-center ">
<img alt="Cropped image of a person in a white coat standing behind a seated older person, holding their hand" src="https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=187&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=187&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=187&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=234&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=234&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474344/original/file-20220715-22-nxu8ou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=234&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The health-care practitioner-patient relationship influenced non-participation. A long relationship with the patient could make participating in MAID uncomfortable and challenging.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<ul>
<li><p><strong>Practice factors:</strong>
For some health-care practitioners, their decision to not participate in MAID was influenced by a lack of policy and program knowledge or skills to participate in the MAID assessment or provision. Another reasons was adequate pay for the time and overhead costs involved. Others said they lacked understanding about the optimal care model for MAID (such as whether MAID is provided by family medicine practitioners, end-of-life care practitioners or MAID teams). Others identified that MAID was outside their clinical interest and practice strengths.</p></li>
<li><p><strong>Visibility factors:</strong>
How MAID participation would be viewed by colleagues, clinic staff and patients also influenced the non-participation of health-care providers. This included fear of colleagues’ disapproval, fear that participation would harm patient relationships and their relationship with their faith community and a fear that participation would be interpreted as giving up on patients.</p></li>
<li><p><strong>Risk factors:</strong>
Health-care providers contemplated the risk to themselves, their practice and their families. Specifically, the risk associated with professional discipline if the patient or patient’s family disagreed with their assessments, the risk of colleagues making their professional lives difficult and the perceived risk of personal physical harm or violence to themselves or their families. </p></li>
<li><p><strong>Time factors:</strong>
Concerns about competing clinical demands, time-limited appointments that do not accommodate end-of-life conversations and lack of time to offer quality MAID care influenced non-participation as well. Some health-care providers did not wish to take on new practices at their current career stage (for example, close to retirement) and others noted a lack of time to take continuing education in MAID.</p></li>
<li><p><strong>Patient’s family factors:</strong>
Other factors that influenced non-participation in MAID related to the patient’s family. Health-care providers expressed concern that participation would impact the care provided to other family members and that there was a lack of support for the family before, during and after MAID. They also considered the potential challenges of inter-family conflict around the patient’s MAID choice and the impact of the MAID death on future family dynamics.</p></li>
<li><p><strong>Patient relationship factors:</strong>
Another factor was the health-care practitioner/patient relationship. A long relationship with the patient could make participating in MAID uncomfortable and challenging. Others noted that a long history with a patient would support open discussions about their reasons for not participating in MAID. </p></li>
</ul>
<h2>Support for health-care practitioners</h2>
<p><a href="https://hdl.handle.net/10388/13420">My research</a> outlines a model of non-participation in the formal MAID processes. In terms of conscience and non-conscience-based factors, it’s vital to differentiate between a conscientious objection <em>to</em> MAID and non-participation <em>in</em> MAID because health-care practitioners require different support for these. </p>
<p>Steps that might support health-care practitioners who are considering participating in MAID include clarifying regional models of care, which vary between provinces and territories. </p>
<p>Practice-focused MAID education could include not only policy and legal aspects but also pragmatic issues such as obtaining medications and administrative requirements, as well as discussions about relevant factors like communication skills and religious knowledge. </p>
<p>Recognizing the practice issues, time and relationship investment required to provide MAID, and developing fair remuneration policies for health-care practitioners who provide it, may support more participation in MAID.</p>
<p>Supporting health-care practitioners will be vital to a sustainable, healthy health-care system for Canadians.</p><img src="https://counter.theconversation.com/content/186625/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janine Brown has received funding from the Saskatchewan Health Research Foundation, Canadian Association of MAID Assessors and Providers and Dying with Dignity Canada. </span></em></p>For people to access medical assistance in dying (MAID) requires health-care professionals willing to provide the service. The reasons health-care providers choose not to participate are important.Janine Brown, Assistant Professor, Faculty of Nursing, University of ReginaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1676882021-09-15T21:54:14Z2021-09-15T21:54:14ZThe next national apology: Future Canadians might regret expansion of medically assisted dying laws<figure><img src="https://images.theconversation.com/files/421440/original/file-20210915-24-132d0f9.jpg?ixlib=rb-1.1.0&rect=2706%2C100%2C3993%2C2132&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Originally, medical assistance in dying was intended for people who were terminally ill and whose death was foreseeable.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>As Canadians head to the polls next week, I reflect on what “big apology” a future government will one day issue.</p>
<p>Past transgressions have made governments increasingly adept at belatedly saying sorry. Even kind and polite Canada is not immune. From lamenting <a href="https://pm.gc.ca/en/news/news-releases/2021/05/14/prime-minister-announces-apology-internment-italian-canadians-during">wartime internments</a> and <a href="https://www.rcinet.ca/en/2016/09/22/history-sept-22-1988-apology-to-japanese-canadians-of-wwii/">removal of voting rights</a>, to turning away Sikh refugees — some to their deaths — on the <a href="https://www.cbc.ca/news/canada/komagata-maru-backgrounder-apology-1.3584372">Komagata Maru</a>, to <a href="https://www.canada.ca/en/crown-indigenous-relations-northern-affairs/news/2021/06/anniversary-of-the-apology-to-former-students-of-residential-schools.html">residential school atrocities against Indigenous children</a>, national apologies have become opportunities for press conferences of contrition.</p>
<p>In the hope of foregoing future photo opportunities, perhaps we should consider what the next big apology might be, and avoid needing to make it.</p>
<p>Reconsidering wide expansion of medical assistance in dying (MAiD) may be one such opportunity. In March 2021, the Liberal government, with the support of the Bloc Québécois, passed <a href="https://www.cbc.ca/news/politics/maid-bill-vote-senate-amendments-1.5946291">new MAiD legislation</a> removing previous safeguards (notably, both left and right were united against this, with NDP, Conservatives and Greens voting against). It is one of the <a href="https://www.reuters.com/article/us-health-canada-politics-death-idUSKBN2B930V">most liberal facilitated suicide laws in the world</a>. </p>
<h2>Avoidable wrongs</h2>
<p>Consider past justifications for one of the most notorious policies discriminating against women with mental illness and Indigenous women: Forced sterilization. Forced sterilizations were justified by a combination of devaluing certain lives and rationalizing that we were actually “doing the right thing”, and occurred across the world for decades. The policy <a href="https://www.cbc.ca/news/canada/north/forced-sterilization-lawsuit-could-expand-1.5102981">officially continued in Canada until the mid 1970s</a>, with women continuing to report the practice even into the late 2010s. While clearly coercive, society comforted itself by rationalizing that <a href="https://www.npr.org/sections/health-shots/2016/03/07/469478098/the-supreme-court-ruling-that-led-to-70-000-forced-sterilizations">these women were “mentally defective” and “unfit</a>,” that they would be “better off” not having children and that society was somehow pursuing a greater good.</p>
<figure class="align-right ">
<img alt="Illustration of a tree representing eugenics from a eugenics conference in 1932" src="https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=844&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=844&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=844&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1061&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1061&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420937/original/file-20210913-19-1ijadwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1061&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An illustration from a 1932 eugenics congress.</span>
<span class="attribution"><span class="source">Wellcome Collection</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Ableist assumptions, valuing some human lives more than others, have been manifest in societal policies for centuries. In September 1921, at the <a href="https://library.missouri.edu/specialcollections/exhibits/show/controlling-heredity/america/congresses">Second International Eugenics Congress</a>, Alexander Graham Bell and prominent academics of the day provided expert reassurances of enlightened beneficence with the tag line, “Eugenics is the self direction of human evolution,” promising a better future for all and setting the stage for justifying decades of mistreatment of the mentally ill and marginalized.</p>
<h2>MAiD and marginalization</h2>
<p>Now consider the <a href="https://www.sencanada.ca/en/Content/Sen/Committee/432/LCJC/02ev-55071-e">arguments made in favour</a> of providing MAiD for mental illness: That MAiD is about respecting autonomy and providing compassionate relief from suffering. That MAiD is about dignity and valuing what people want. And perhaps most importantly, that MAiD is not the same as the tragic suicides society aims to prevent.</p>
<p>When MAiD is provided in near end-of-life conditions, when we know someone will not improve and faces enduring suffering, the above arguments are valid and supported by evidence. In these situations, we find that <a href="https://dx.doi.org/10.1136/jme.2007.022335">white, wealthy and privileged people tend to seek MAiD</a>.</p>
<p>All the above arguments become fantasies once <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">MAiD is expanded beyond near end-of-life conditions</a> to the non-dying with disabilities and mental illness, as the Trudeau government intends, with <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">even more MAiD restrictions lifting in 2023</a>. </p>
<p>In these situations, evidence shows that populations <a href="http://doi.org/10.1001/jamapsychiatry.2015.2887">marginalized by poverty, loneliness and unresolved life suffering seek MAiD</a>, with twice as many women as men being euthanized for psychiatric disorders. This is the same ratio of women to men who <a href="https://www.suicideinfo.ca/resource/women-and-suicide/">attempt suicide when mentally ill</a> but who, absent the 100 per cent lethal means of MAiD, <a href="https://www.hsph.harvard.edu/means-matter/means-matter/survival/">survive the attempt and do not try again</a>.</p>
<p>Yet, despite <a href="https://theconversation.com/medical-assistance-in-dying-for-mental-illness-ignores-safeguards-for-vulnerable-people-156012">lack of evidence that MAiD can responsibly be provided for mental illness</a>, MAiD expansionists blindly forward the same arguments to push <a href="https://www.sencanada.ca/en/Content/Sen/Committee/432/LCJC/02ev-55071-e">broader access to MAiD with fewer safeguards</a>. This benefits the white, wealthy and privileged to have even more autonomy, while sacrificing our most vulnerable, those marginalized by sexism, racism, ageism and ableism, to <a href="https://www.thestar.com/opinion/contributors/2021/03/01/maid-for-mental-illness-is-grave-discrimination.html">entirely avoidable premature deaths</a>. </p>
<figure class="align-center ">
<img alt="David Lametti wearing a face mask standing at a podium" src="https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420971/original/file-20210914-23-kktgm7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">David Lametti, minister of justice and attorney general of Canada, arrives to deliver a statement on Bill C-7 on Parliament Hill on March 11.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span>
</figcaption>
</figure>
<p>Ironically, it sacrifices them to these deaths under the pretence of autonomy, disregarding how <a href="https://health.jotwell.com/how-the-mantra-of-informed-consent-in-the-canadian-assisted-dying-debate-obscures-somatic-oppression/">internalized oppression would force our most vulnerable</a> to make an impossible, and unfair, choice to “die well” because society never gave them a chance to live well. Evidence shows that these are often <a href="https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf">ambivalent suicidal wishes</a> in people who could have gotten better and are seeking escape from social disenfranchisement, not from inevitable medical suffering. These people would want to live if given a true choice of life with dignity instead of the enticement of a painless death to escape a painful life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medical-assistance-in-dying-for-mental-illness-ignores-safeguards-for-vulnerable-people-156012">Medical assistance in dying for mental illness ignores safeguards for vulnerable people</a>
</strong>
</em>
</p>
<hr>
<p>From eugenics to forced sterilizations, public figures and ideologues of the day ignored cautions of dissent and assured society it was “doing the right thing,” allowing us to overlook the reality that the most vulnerable amongst us were being discarded.</p>
<p>Today, ignoring the evidence, <a href="https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151">prominent politicians, senators and, sadly, some of my psychiatrist colleagues</a> are similarly reassuring Canadians that our wide MAiD expansion is enlightened and “safe.” It may be safe for the privileged who already live well and will have more autonomy to die better. For others, the non-dying disabled and marginalized whose social suffering will be solved with death, it will eventually be called something else.</p>
<p>If we knowingly ignore this reality, we can anticipate the inevitable press conference with a future Canadian prime minister issuing a heartfelt apology for our current sins.</p><img src="https://counter.theconversation.com/content/167688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karandeep Sonu Gaind acted as an expert witness and consultant for the crown in the Truchon and Lamb cases, sat on the Council of Canadian Academies Expert Panel on MAiD and Mental Illness, is physician chair of the Humber River Hospital MAiD Team, is a past president of the Canadian Psychiatric Association (CPA) and chaired the time-limited CPA Task Force on MAiD.</span></em></p>Research suggests that expanded access to MAiD tends to benefit people with wealth and privilege, offering them choices and autonomy. At the same time, it puts marginalized people at risk.Karandeep Sonu Gaind, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1619942021-06-14T17:59:34Z2021-06-14T17:59:34ZWhy is access to medically assisted death a legislated right, but access to palliative care isn’t?<figure><img src="https://images.theconversation.com/files/405982/original/file-20210611-17-yjynd9.jpg?ixlib=rb-1.1.0&rect=739%2C8%2C4564%2C3101&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Getting a referral to palliative care can be a complicated process.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>John started his first appointment in the Neuropalliative Care Clinic with, “I want to talk about MAID.” In our clinic, his request for medical assistance in dying is common. As legislated by government, I referred him to the MAID navigator. I had one request: that John wait to make his MAID decision until after seeing a community palliative care physician. </p>
<p>At his next appointment, John informed us he had withdrawn his MAID request because his primary symptom —pain — was now well controlled after our suggestions and those of the community palliative care doctor. John lived for two more years, during which he became closer with his daughter and continued to enjoy the company of his siblings.</p>
<p>John is not unusual. Neurologic illness accounts for 18 per cent of deaths in the Canada but <a href="https://doi.org/10.1016/j.parkreldis.2020.06.011">rarely has palliative care involvement</a>. By contrast, <a href="https://doi.org/10.25318/1310039401-eng">cancer accounts for 20 to 30 per cent of deaths</a>, but typically receives <a href="https://doi.org/10.1177%2F0269216317727157">75 per cent of palliative care</a>. </p>
<p>Part of the challenge is that palliative care services are often hospital-based, but most people who could benefit get their care in the community. Similarly, patients have recently refused palliative care <a href="https://www.virtualhospice.ca/Assets/MAiD_Report_Final_October_15_2018_20181218165246.pdf">in the belief that is the same as MAID</a>. In 2017, <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-april-2019.html">MAID accounted for 1.07 per cent</a> of deaths in Canada, increasing to <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html">two per cent in 2019</a>.</p>
<p>In June 2016, the <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html#a1">passed legislation that gave all eligible Canadians the right to request MAID</a>. Colleges of Physicians and Surgeons required physicians to refer people who request MAID to services or arrange for a physician who would make the referral. </p>
<figure class="align-center ">
<img alt="A male doctor consulting with an older female patient" src="https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The workforce for palliative care is inadequate to meet the needs for Canadians with chronic burdensome illnesses.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Since then, every province and territory devoted resources to navigate requests and assessments for MAID. Typically, provinces have a <a href="https://www.albertahealthservices.ca/info/Page13497.aspx">website for self-referral</a>, easily found by internet search and/or dedicated health-care staff to help navigate the MAID process or inform those who are MAID-curious. </p>
<h2>Complicated referrals</h2>
<p>By contrast, the referral process for palliative care is often convoluted. Many provincial web pages simply give a definition of palliative care (some confuse the issue by including the MAID navigation site) but do not provide a central access point for physicians or nurses. Referral forms (where available) are complex, which creates another barrier to access. Many palliative care programs have an unofficial prognosis of three to six months’ life expectancy for services, despite research demonstrating that early palliative care <a href="https://doi.org/10.1056/nejmoa1000678">improves outcomes and in fact, can prolong life</a>. </p>
<p>What is the disconnect? Health-care providers are an unexpected barrier as they often cling to the belief that palliative care is for the imminently dying or means to give up hope. <a href="https://doi.org/10.1177/0269216313502372">For the public, palliative care means dying soon</a>.</p>
<p>But <a href="https://www.who.int/news-room/fact-sheets/detail/palliative-care">modern palliative care</a> is about living well now, meeting patients’ goals and finding meaning in life. For John, we helped him set goals, focused on the positive in his life, like his better relationships with his children and ongoing closeness with his siblings. His sharp sense of humour emerged despite communication challenges.</p>
<p>Additionally, many palliative care programs exist in the oncology (cancer) department and thus, their focus is cancer-based. Twenty per cent of people die from cancer, but <a href="https://doi.org/10.1177%2F0269216313502372">receive 75 per cent of palliative care services</a>. Current training for palliative care physicians requires exposure to other patient populations like heart failure, kidney failure and neurologic illnesses, but health-care systems are slow to change. </p>
<figure class="align-center ">
<img alt="A man in a hospital bed and a woman holding his hand, listening to a doctor whose back is to the camera." src="https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Placing as much importance on palliative care as we do on MAID might make navigation to palliative care less difficult.</span>
<span class="attribution"><span class="source">(shutterstock)</span></span>
</figcaption>
</figure>
<p>And finally, the workforce for palliative care is inadequate to meet the needs for Canadians with chronic burdensome illnesses.</p>
<h2>Making palliative care more accessible</h2>
<p>The solution requires a multi-faceted approach. All health-care providers need to have general palliative care skills because, in the way we all learn to control blood pressure and read a basic electrocardiogram, palliative care is part of good medical care. </p>
<p>At a systems level, placing as much importance on palliative care as we do on MAID might make navigation to palliative care less difficult for patients and clinicians. Given the broader applicability of palliative care, it is time for palliative care to become an independent department. Up to 28 per cent of Canadians will be seniors, which means <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/aging-chronic-diseases-profile-canadian-seniors-executive-summary.html">more people with multiple, chronic conditions that could benefit from a palliative approach</a>.</p>
<p>Building the palliative care workforce is essential. The palliative care workforce in Canada is <a href="https://surveys.cma.ca/en/viewer?file=%2fdocuments%2fSurveyPDF%2fCMA_Survey_Workforce2017_Q6i_FPfocus-e.pdf#phrase=false">estimated to be 773 doctors for a population of 39 million</a>. Once the palliative care workforce is established, educating the public that palliative care includes a holistic approach to wellness and meaning in life can help re-frame and increase acceptance.</p>
<p>There are more people like John who should connect with a palliative care team before walking down the road to MAID. Let palliative care help you live well, now.</p><img src="https://counter.theconversation.com/content/161994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janis M. Miyasaki receives funding from Patient Centered Outcomes Research Institute, US; NINDS. Vice President of the American Academy of Neurology; Board Member, International Neuropalliative Care Society. </span></em></p>Palliative care is about living well and meeting patients’ goals, but referral can be more complex than access to medical assistance in dying (MAID). Palliative care should be as accessible as MAID.Janis M. Miyasaki, Professor, Department of Medicine, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1560122021-02-28T13:36:42Z2021-02-28T13:36:42ZMedical assistance in dying for mental illness ignores safeguards for vulnerable people<figure><img src="https://images.theconversation.com/files/386569/original/file-20210225-19-awxcaq.jpg?ixlib=rb-1.1.0&rect=11%2C2%2C1813%2C1152&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bill C-7 seeks to expand access to medical assistance in dying (MAID) to people who are not terminally ill, including those who suffer solely from mental illness.</span> <span class="attribution"><span class="source">(Pixabay)</span></span></figcaption></figure><p>The federal government’s proposed <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7 seeks to expand access to medical assistance in dying</a> (MAID) to people whose death is not reasonably foreseeable, significantly reducing the safeguards that protect vulnerable people. </p>
<p>The bill was <a href="https://www.cbc.ca/news/politics/senate-maid-bill-third-reaading-pass-1.5917798">reviewed by the Senate in February</a> and returned to the House of Commons with amendments that would broaden access even further. </p>
<p>People whose suffering is caused by mental illness alone do not currently have access to MAID. However, the Senate recommended Bill C-7 contain a “sunset clause” that would lift this exclusion in 18 months. The <a href="https://www.ourcommons.ca/DocumentViewer/en/43-2/house/sitting-64/order-notice/page-13">Trudeau government has extended the clause to 24 months</a> but has otherwise accepted it, meaning that in 18 to 24 months, MAID will be provided to those suffering solely from a mental illness.</p>
<p>Notwithstanding diverse opinions on this issue, the real question is not about whether MAID should be offered for mental illness. It’s whether mental illnesses could possibly qualify for MAID under conditions the Canadian public has been assured MAID is being provided for. On this question, there is no legitimate debate.</p>
<h2>The underpinning of MAID</h2>
<p>The fundamental underpinning of all MAID requests is supposed to be the presence of “<a href="https://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent">a grievous and irremediable medical condition</a>.” The blunt and indisputable reality is that, unlike for much more predictable medical conditions with better understood biologies, it remains currently impossible to predict whether mental illness is irremediable. </p>
<p>The <a href="https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/camh-position-on-mi-maid-oct2017-pdf.pdf">Centre for Addiction and Mental Health has concluded</a>: “There is simply not enough evidence available in the mental health field … to ascertain whether a particular individual has an irremediable mental illness.” </p>
<p>After 15 months of studying global evidence, the <a href="https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf">Council of Canadian Academies</a> came to the same conclusion, as did the <a href="https://www.eagmaid.org/">Expert Advisory Group on MAID</a>. Both the <a href="https://www.washingtonpost.com/blogs/post-partisan/wp/2016/12/15/at-last-american-psychiatrists-speak-out-on-euthanasia/">American Psychiatric Association</a> (APA) and <a href="https://www.ranzcp.org/news-policy/news-archive/news-archive-2016/mental-illness-is-no-basis-for-euthanasia">Royal Australian and New Zealand College of Psychiatrists</a> (RANZCP) have also concluded that there’s no evidence to support providing MAID solely for mental illness.</p>
<figure class="align-center ">
<img alt="Silhouette of a person in fetal position, fragmenting into the wind." src="https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386571/original/file-20210225-21-1ibxylh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In 18 to 24 months, MAID will be provided to those suffering solely from a mental illness.</span>
<span class="attribution"><span class="source">(Canva/Pixabay)</span></span>
</figcaption>
</figure>
<p>Those who advocate expanding access to MAID propose <a href="https://sencanada.ca/en/Content/Sen/Committee/432/LCJC/55130-e">mitigating this reality with “safeguards</a>.” This ignores the fact that irremediability is itself the primary safeguard built into the MAID framework, and bypassing it renders all other supposed “safeguards” meaningless. </p>
<p>Because we cannot predict irremediability, there is 100 per cent certainty that MAID will be provided to some people who could recover — there is no safeguard against that. Suggesting otherwise is akin to a society that declines to use the death penalty over concerns of potentially executing the innocent, but then implements the death penalty anyway with false “safeguards” to reassure the public even as the wrongly convicted are executed.</p>
<p>Regrettably, while the APA and RANZCP have provided meaningful evidence-based guidance in their societies’ debates on MAID and mental illness, Canadian psychiatric associations have not. After <a href="https://www.canadianhealthcarenetwork.ca/healthcaremanagers/discussions/wish-i-didnt-have-to-write-this-40221">failing to consult members for two years</a>, the <a href="https://www.cpa-apc.org/wp-content/uploads/2020-CPA-Position-Statement-MAID-EN-web-Final.pdf">Canadian Psychiatric Association released its position statement</a> in 2020 that “patients with a psychiatric illness … should have available the same options regarding MAID as available to all patients.” Remarkably, the association also said that its statement was “never intended to … examine <a href="https://www.webcampaign.org/background">whether psychiatric conditions are irremediable</a> and if so, how this should be assessed.” </p>
<figure class="align-center ">
<img alt="Silhouettes of two heads facing different directions" src="https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&rect=0%2C33%2C5750%2C3955&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=216&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=216&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=216&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=272&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=272&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386282/original/file-20210224-21-krg0a2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=272&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Without being able to predict whether psychiatric conditions are irremediable, there is 100 per cent certainty that MAID will be provided to someone who could have gotten better.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Equally remarkably, the president of the Québec Psychiatric Association (AMPQ) responded to concerns about the lack of supporting evidence by saying in recent Senate hearings: “<a href="https://sencanada.ca/en/Content/Sen/Committee/432/LCJC/55130-e">This is not a data-driven question, this is an ethical question</a>.”
That sentiment is reflected in an <a href="https://ampq.org/wp-content/uploads/2020/12/mpqdocreflexionammenfinal.pdf">AMPQ document</a> offering guidance on developing a MAID framework for mental illness. </p>
<p>Medical bodies should provide evidence-based guidance within the wheelhouse of their expertise, not sidestep evidence to present other opinions based on other values.</p>
<p>Other evidence <a href="https://www.theatlantic.com/ideas/archive/2019/06/noa-pothoven-and-dutch-euthanasia-system/591262/">highlights the risks</a> of providing access to easy death to suicidal, vulnerable and marginalized people who <a href="http://doi.org/10.1001/jamapsychiatry.2015.2887">are not dying but suffering from psychosocial life stress</a>. Even the <a href="https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=26687&LangID=E">Office of the United Nations High Commissioner for Human Rights</a> has raised the alarm that Canada’s pending MAID policy <a href="https://www.ctvnews.ca/health/un-experts-alarmed-by-trend-toward-assisted-dying-for-non-terminal-conditions-1.5283804">will prematurely end vulnerable lives</a>. </p>
<p>These concerns simply serve as icing on the cake to the indisputable, evidence-based reality that there is no predictably irremediable mental illness for which MAID can be provided. And the government’s 24-month sunset clause is as meaningful as a decree telling coronavirus to disappear — non-existent evidence cannot simply be commanded to appear.</p>
<h2>Mental illness is all too common</h2>
<p>We are poised to provide death for mental illness to potentially suicidal, non-dying marginalized people suffering from life distress who have the potential to recover — all based on <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/fact-sheets/drugs-reviewed-canada.html">less evidence than is required for the approval of any sleeping pill</a>. Given the <a href="https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics">ubiquity of mental illness</a>, no family needs to look very far to appreciate the implications. </p>
<figure class="align-right ">
<img alt="Margaret Trudeau at a microphone in front of a mental illness banner" src="https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=832&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=832&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=832&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1046&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1046&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386618/original/file-20210226-23-1t9t9ao.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1046&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Margaret Trudeau talks to reporters about her experiences with mental illness during a press conference in Vancouver on Feb. 12, 2007.</span>
<span class="attribution"><span class="source">(CP PHOTO/Richard Lam)</span></span>
</figcaption>
</figure>
<p>Years ago, I had the pleasure of meeting our prime minister’s mother, <a href="https://margarets.ca/margaret-trudeau-advocacy-award/">Margaret Trudeau</a>, to present her a mental health advocate award from the Ontario Psychiatric Association. I recall her vibrancy as she spoke of her life experiences and graciously mingled with my colleagues and me after dinner. I also recall the poignancy of her descriptions of despair during her periods of deep depression, including hopeless times she wished to die.</p>
<p>While of course no one can know what choices they would have made differently in the past, it is undeniable that, if MAID for mental illness is allowed in pending legislation, somebody’s mother or father will be provided MAID while they remain competent during a period of despair. They will not have the chance Margaret Trudeau fortunately had to improve and continue living a more fulfilling life with her family.</p>
<p>If Canada wants to provide MAID to people who are suffering but whose illness might get better, we should have an honest debate and our MAID framework should reflect that. But if MAID is meant for irremediable conditions, evidence shows it would be a dishonest and hypocritical deception to offer it for mental illness.</p>
<p>Unfortunately, in Canada’s debate about medical assistance in dying, evidence has already been provided a medically assisted death.</p><img src="https://counter.theconversation.com/content/156012/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karandeep Sonu Gaind acted as an expert witness and consultant for the crown in the Truchon and Lamb cases, sat on the Council of Canadian Academies Expert Panel on MAiD and Mental Illness, is physician chair of the Humber River Hospital MAiD Team, is a past president of the Canadian Psychiatric Association (CPA) and chaired the time-limited CPA Task Force on MAiD</span></em></p>The fundamental underpinning of all MAID requests is supposed to be the presence of an incurable medical condition, but it’s not possible to predict that a mental illness will not improve.Karandeep Sonu Gaind, Associate Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1535402021-02-08T16:32:44Z2021-02-08T16:32:44ZA dangerous path: Why expanding access to medical assistance in dying keeps us up at night<figure><img src="https://images.theconversation.com/files/382707/original/file-20210205-14-1nfo1ub.jpg?ixlib=rb-1.1.0&rect=105%2C6%2C4016%2C2725&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Minister of Justice David Lametti gives a thumbs up as he rises to vote in favour of a motion on Bill C-7, medical assistance in dying, in the House of Commons on Dec. 10, 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span></figcaption></figure><p>When a government starts making laws based on the premise that some lives are not worth living, it is setting out on an extremely dangerous path. </p>
<p>That is the path that <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7, the proposed law to expand access to Medical Assistance in Dying</a> (MAID) to people whose death is not imminent, sets Canada on.</p>
<p>This is what keeps us — two MDs and a PhD on wheels — up at night. We each have a different perspective on the dangers of expanding MAID eligibility to people who are not dying. </p>
<p>Bill C-7 was <a href="https://www.cbc.ca/news/politics/maid-commons-senate-c7-1.5836319">passed in the House of Commons in December</a>, and is proceeding to the senate in February.</p>
<h2>Health ethics: Careening down a slippery slope</h2>
<p><em>Heidi Janz is an ethics professor at the University of Alberta, and chair of the Council of Canadians with Disabilities’ Ending-of-Life Ethics Committee</em></p>
<p>I describe myself as a long-hauler in the struggle against the legalization of assisted suicide and euthanasia for people with disabilities.</p>
<p>What first activated me was the <a href="https://www.researchgate.net/publication/317816777_DISABLING_IMAGES_AND_THE_DANGERS_OF_PUBLIC_PERCEPTION_A_COMMENTARY_ON_THE_MEDIA%27S_COVERAGE_OF_THE_LATIMER_CASE">unqualified media and public support that Robert Latimer received in 1993 when he was charged with killing his daughter, Tracy, who had cerebral palsy</a>. I remember watching a news magazine show on the topic <em>When is it right to kill someone with severe disabilities?</em> and realizing that most Canadians would consider my life not worth living.</p>
<p>The Latimer case revealed the prevalence of <a href="https://doi.org/10.1057/dev.2008.17">ableism</a> in Canada and marked the start of the slippery slope down which our country is careening. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/liks62ZcMK0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Heidi Janz’s testimony before the House of Commons Justice Committee studying Bill C-7.</span></figcaption>
</figure>
<p>As a professor of health ethics who has disabilities, I worry about the effect that the expansion of MAID under Bill C-7 will have on kids and youth with disabilities. <a href="http://dx.doi.org/10.1108/S1479-363620170000010007">I attended a school for kids with disabilities</a>. Roughly half the students had muscular dystrophy, and a life expectancy of 14-18 years. Growing up, we all knew that some of us would live longer than others. But we also knew that all of us would live with the best quality of life possible, until we died.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/think-disability-is-a-tragedy-we-pity-you-82047">Think disability is a tragedy? We pity you</a>
</strong>
</em>
</p>
<hr>
<p>What keeps me up at night is knowing that this is not the message the current generation of kids with disabilities is getting. Instead, they’re hearing about <a href="https://globalnews.ca/news/3826108/assisted-death-canada-children/">parents requesting MAID for their disabled kids</a>.</p>
<p>I hope that Canadians with disabilities can find safe doctors who will fight for our lives, instead of encouraging us to end our lives.</p>
<h2>Palliative care: Healing vs. hastening death</h2>
<p><em>Leonie Herx is past president of the Canadian Society of Palliative Care Physicians and chair of the Division of Palliative Medicine at Queen’s University</em></p>
<p>As a palliative care physician, I was drawn into the “assisted dying” debate when the <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/scc-csc.html">Supreme Court of Canada</a> struck down the <a href="https://www.cbc.ca/news/politics/supreme-court-says-yes-to-doctor-assisted-suicide-in-specific-cases-1.2947487">prohibition against assisted suicide in the 2015 Carter decision</a>.</p>
<p>After the Carter ruling, there was a lot of <a href="https://doi.org/10.1093/annonc/mdp048">erroneous talk about how palliative care already hastens death</a>, and an expectation that palliative physicians would therefore take on this life-ending procedure as part of our practice. Our speciality has spent a lot of time helping people understand that hastening death or intentionally ending life violates the <a href="https://www.cspcp.ca/wp-content/uploads/2019/11/CHPCA-and-CSPCP-Statement-on-HPC-and-MAiD-Final.pdf">core principles and</a> internationally recognized <a href="https://www.cspcp.ca/wp-content/uploads/2019/11/CHPCA-and-CSPCP-Statement-on-HPC-and-MAiD-Final.pdf">definition of palliative care</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/jfNBIPOV888?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Leonie Herx’s testimony before the House of Commons Justice Committee studying Bill C-7.</span></figcaption>
</figure>
<p>One of my concerns is that physicians would be expected to raise MAID as if it were like any other medical option, when it is not. For a doctor to say, “Well, you could choose this drug, or these supports to help you, or you could choose death,” would be suggesting to someone that their life isn’t worth living.</p>
<p>As a physician, my job is to restore hope and promote healing. It’s not to suggest death as the answer to suffering and to facilitate ending someone’s life.</p>
<p>Bill C-7 is based on a very narrow view of autonomy and <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html#a3.2">people who want to have control over their own death via an assisted suicide make up a very small percentage of the population, around two per cent</a>. Legislative protections need to be put in place to prevent people from being pressured into MAID and doctors from being forced to facilitate it.</p>
<h2>Family medicine: Support for the vulnerable</h2>
<p><em>Ramona Coelho is a family physician in London, Ont.</em></p>
<p>As a family physician who cares for people with chronic illnesses and disabilities, I was drawn into the debate around assisted dying out of concern for my patients, who often suffer from <a href="https://www.macleans.ca/opinion/dying-for-the-right-to-live">poverty and inadequate resources</a>. So they might feel pressured to choose death <a href="https://www.zonmw.nl/nl/onderzoek-resultaten/ouderen/programmas/project-detail/vooronderzoek-voltooid-leven/het-perspectief-project-perspectieven-op-de-doodswens-bij-voltooid-leven-de-mens-en-de-cijfers/">because of inadequate supports</a> to live or because a doctor perceives that they might be <a href="https://nationalpost.com/news/canada/denied-assisted-life-by-hospital-ontario-man-is-offered-death-instead-lawsuit">better off dead</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/UFdBFmgOn2Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Ramona Coelho’s testimony before the Senate Committee Pre-Study on Bill C-7.</span></figcaption>
</figure>
<p>By expanding MAID, I believe we are ignoring the common good. <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html">We are wearing masks right now to protect our vulnerable due to COVID-19</a>. But we must similarly consider how expanding MAID will affect vulnerable persons.</p>
<p>One of my patients told me she is planning to access MAID because she lives in poverty and isolation, and doesn’t have home care supports for her disability. Sadly, <a href="https://www.citynews1130.com/2020/07/27/vancouver-woman-disabilities-medically-assisted-dying/">many other people with disabilities share her desperation</a>.</p>
<p>No one belongs on the margins of society. I chose to practise medicine because built into this work is the opportunity to help and heal. What a privilege! If many of us can keep our focus on <a href="https://inclusioncanada.ca/wp-content/uploads/2018/02/CACL-and-PFC-Brief-Accessibility-and-Poverty-Reduction-Final-June-2017.pdf">reducing social inequality</a>, I can remain hopeful.</p>
<h2>Losing sleep</h2>
<p>We each have different reasons to lose sleep over Bill C-7 as it inches its way closer to becoming law. As the bill proceeds to the Senate, Canadians need to consider where this path leads, and understand how it will affect vulnerable people. </p>
<p>Rather than expanding access to MAID, the priority should be to ensure access to the care and supports necessary to live and, when the time comes, to have a peaceful natural death with high quality palliative care.</p>
<p><em>This article was also co-authored by Ramona Coelho, a family physician in London, Ont.</em></p><img src="https://counter.theconversation.com/content/153540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Expanding access to medical assistance in dying (MAID) to those not terminally ill puts vulnerable people at risk of feeling pressured into MAID, and doctors at risk of being forced to facilitate it.Heidi L. Janz, Adjunct Professor of Disability Ethics, John Dossetor Health Ethics Centre, University of AlbertaLeonie Herx, Division Chair & Associate Professor of Palliative Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249552019-10-09T22:35:46Z2019-10-09T22:35:46ZThe latest medical assistance in dying decision needs to be appealed: Here’s why<figure><img src="https://images.theconversation.com/files/296098/original/file-20191008-128648-1coihlo.jpg?ixlib=rb-1.1.0&rect=40%2C67%2C2941%2C1890&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Jean Truchon, right, looks on as lawyer Jean-Pierre Menard gives their reaction to a Québec judge overturning parts of provincial and federal laws on medically assisted dying on September 12, 2019.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span></figcaption></figure><p>The federal and Québec governments appear reluctant to appeal what’s known as the <a href="http://t.soquij.ca/o4WQp">Truchon decision</a>, which invalidated Canada’s “reasonable foreseeable death” and Québec’s “end of life” access criteria for medical assistance in dying. </p>
<p>The case was brought by Nicole Gladu and Jean Truchon, two Québec residents who each have physical disabilities that severely restrict their ability to complete daily tasks, remove or reduce significantly their mobility and cause intolerable pain. After being deemed ineligible to receive medical assistance in dying (MAID) because they were not at the end-of-life stage, <a href="https://www.cbc.ca/news/canada/montreal/quebec-assisted-dying-jean-truchon-nicole-gladu-1.5023505">they went to court to challenge the federal and Québec laws</a>. </p>
<p>In response, the <a href="https://www.cbc.ca/news/canada/montreal/medically-assisted-dying-law-overturned-quebec-1.5280702">Québec Superior Court struck down the law’s requirement that people can only receive medical assistance to end their lives when death is reasonably foreseeable</a>. Justice Christine Baudouin ruled that the law violated the right to life, liberty and security of the person, and discriminated against people with disabilities who aren’t near death.</p>
<p>Some health professional organizations in Québec have <a href="https://www.ledevoir.com/societe/563838/des-medecins-sur-l-aide-a-mourir">urged the federal and provincial government not to appeal the decision</a>. We disagree. We feel strongly that they should appeal. </p>
<p>And here is why: The ruling raises important questions about the application of the Canadian Charter of Rights and Freedoms that require clarification. The court’s ruling undermines Parliament’s power to issue broad legislation aimed at protecting the rights and interests of people who are elderly, ill or disabled, and at preventing suicide. We also believe the use of some of the evidence in the decision raises concerns about its reasonableness.</p>
<h2>The value and quality of a life</h2>
<p>First, Justice Baudouin rejected two explicitly stated goals of the <a href="https://laws-lois.justice.gc.ca/eng/AnnualStatutes/2016_3/FullText.html">federal medically assisted dying law</a>: the confirmation of the inherent and equal value of every person’s life, combined with the prevention of negative perceptions of the quality of life of persons who are elderly, ill or disabled; and the prevention of suicide. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296101/original/file-20191008-128665-191o8zm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nicole Gladu, who is incurably ill, filed an action in Québec Superior Court with Jean Truchon, arguing the eligibility requirements for physician-assisted death are too restrictive and violate their rights to the procedure.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span>
</figcaption>
</figure>
<p>As a result, she failed to evaluate whether the broader societal impact of an expansive MAID regime could justify the current restriction to end-of-life. Parliament explicitly introduced this restriction to balance the autonomy of people requesting physician-assisted deaths with the need to protect the interests of vulnerable people, as well as the broader societal interests of avoiding negative perceptions and preventing suicide. </p>
<p>Baudouin only ruled on whether the restriction is necessary to protect vulnerable people from being induced to end their lives. She concluded that not all people with disabilities are vulnerable and that existing medically assisted death practices will suffice to offer that protection.</p>
<p>By focusing only on the need to protect vulnerable people, she did not sufficiently consider the more complex evidence related to negative perceptions of the quality of life of people who are elderly, ill or disabled, or the challenges related to suicide prevention.</p>
<h2>Disabled lives are worth living</h2>
<p>The disability community has long expressed concern about how laws and policies reflect views that disabled lives as not worth living. These laws can result in practices that undermine the rights and well-being of people with disabilities and may influence how people think about disabled lives and what health-care choices they should have. </p>
<p>There are historical precedents for this concern: policies portraying disabled lives as not worth living were <a href="https://www.thecanadianencyclopedia.ca/en/article/eugenics">prevalent during the eugenics movement in the 20th century</a>. In Canada, manifestations of the eugenics movement can be seen in the sexual sterilization laws designed to prevent people with disabilities from reproducing. </p>
<p>Even more recently, concerns have been expressed that gene editing casts a similar negative light on the existence of people with disabilities.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_vdeeR5DOSo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Activist Alice Wong speaks on ‘Resisting Abelism: Disabled People and Human Gene Editing’</span></figcaption>
</figure>
<p>There are also concerns, fuelled by developments in the few countries that provide access to MAID outside the end-of-life context, that being elderly and fragile is increasingly accepted as a reason for a physician-assisted death and that this may create subtle pressure. A recent analysis of Dutch assisted dying cases of patients with intellectual disabilities and autism <a href="https://link.springer.com/content/pdf/10.1186/s12910-018-0257-6.pdf">suggested that physicians’ value judgments and prejudices may have influenced how they evaluated their requests</a>. </p>
<p>By rejecting the broader goals of the law, the court failed to fully evaluate why people with disabling health conditions make their decisions. This includes the way in which law, funding policies, social-support mechanisms, access to alternative treatments and societal and personal perceptions interact. </p>
<p>These longer term and broader concerns, as well as the impact on suicide prevention, were not taken seriously enough by the Québec Superior Court in its proportionality assessment under Section 1 of the Charter. They should have been.</p>
<h2>An irreversible, life-ending act</h2>
<p>A related problem underlies discrimination concerns. Baudouin invoked two reasons why the restriction to end-of-life is discriminatory: one is that it makes a distinction between people who have a disability or disease that makes it difficult or impossible to commit suicide and people who do not have this difficulty. The second is that it distinguishes between people with disabilities who are at the end of their lives and those who are not. Both may be incapable of ending their own lives when they are suffering unbearably, yet only those at the end of life are being offered medically assisted deaths.</p>
<p>Baudouin is <a href="https://www.bccourts.ca/jdb-txt/SC/12/15/2012BCSC1587.htm">not the first to look at the law from the perspective of discrimination</a>.
But no majority of the Supreme Court has ever done so before, and perhaps for a reason.</p>
<p>We’re dealing with a criminal law-based limit on when health professionals can perform a radical life-ending procedure. To conclude that a policy limiting it to the end-of-life is discriminatory, it seems essential to look at all the evidence and arguments in support of this restriction. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1114347308496445441"}"></div></p>
<p>By limiting the goals of the legislation, Baudouin failed to look at the delicate balance between providing access to medically assisted dying, protecting people against premature death and preventing stereotypes about the value of a life with disabilities, and in the context of a practice that raises unique challenges. </p>
<p>Unlike other claims of discrimination, this is not about claims of access to an unconditional good such as essential medicines, or high-quality supportive care, or accommodation to empower people with disabilities. We are dealing with an irreversible, life-ending act. </p>
<p>While death may seem desirable in some circumstances, there are unique concerns about the impact of MAID, precisely on those who are already disadvantaged.</p>
<h2>Inhumane treatment in long-term care</h2>
<p>More explicitly, while the MAID law indeed requires consent, these irreversible choices about ending a life are made in a complex social, cultural and health-care context, where lack of access to adequate care, lack of social support and <a href="https://www.forbes.com/sites/civicnation/2019/08/07/enabling-sexual-and-reproductive-rights-for-people-with-disabilities/#29092dce7a59**">overall ableist stigma</a> have an impact on the choices people with disabilities may have. </p>
<p>Under the existing regime, we already see troubling examples of how a lack of good health care and support may push people towards a medically assisted death. For example, in British Columbia, <a href="https://www.cbc.ca/news/canada/british-columbia/alsbc-man-medically-assisted-death-1.5244731">Sean Tagert struggled to pay for 24-hour care at home until he eventually gave up in frustration and chose a medically assisted death</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"789810267928616960"}"></div></p>
<p>Similarly, in Montréal, <a href="https://montrealgazette.com/news/local-news/saying-goodbye-to-archie-rolland">Archie Rolland, a landscape architect, decided to end his life instead of continuing to suffer at a long-term care facility</a> that he said was treating him inhumanely. </p>
<p>The law’s end-of-life criterion should create the necessary space to prioritize substantive support for people with disabilities. We need more complex discussions around support for the rights to life of people with disabilities, including those in palliative care, not a reduction of the opportunities for this support by expanding access to physician-assisted deaths.</p>
<h2>The judge’s analysis of the evidence</h2>
<p>There are also reasons why an appeal court should review the reasonableness of the court’s use of evidence.</p>
<p>The relevance of much of the evidence (for example from suicide experts and disability studies experts) was already undermined by the court’s restriction of the goals of the law. But even in the assessment of directly relevant evidence — for example in determining capacity and distinguishing MAID from suicide in the context of mental illness — Baudouin too easily brushed aside the government’s experts as having only theoretical knowledge and being prejudiced. </p>
<p>They included leading psychiatric experts, including one with unique expertise on capacity assessments in the few jurisdictions that allow medically assisted death for mental health reasons, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5097685/">who had published several analyses on the topic in peer-reviewed literature</a>.</p>
<p>In contrast, Baudouin appeared to take at face value two experts for the plaintiffs who currently conduct medically assisted death assessments in Canada’s system, but who have not done so in relation to mental illness.</p>
<p>It would send a terrible signal if both the federal and Québec governments concede that one judge can curtail Parliament’s power to promote broader societal interests in protecting people who are elderly, ill or disabled.</p>
<p>Given that we are currently in an election period, and that it will take time before a new government is put in place, it seems particularly important to create the time and space for careful assessment of our options in this complex area of policy-making. </p>
<p>In the interests of society, the attorneys general in both Québec and in Ottawa need to appeal this case.</p>
<p><em>This is an updated version of a story originally published on Oct. 9, 2019. This story clarifies that the “end of life” criteria is in Québec law.</em></p>
<p>[ <em><a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/124955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trudo Lemmens was an expert witness for the federal Attorney General in the Truchon case. </span></em></p><p class="fine-print"><em><span>Laverne Jacobs is part of a team of researchers that has received funding from the Canadian Institutes of Health Research.</span></em></p>One judge must not be allowed to curtail parliament’s power to promote broader societal interests and protect people who are elderly, ill and disabled.Trudo Lemmens, Professor of Health Law and Policy, University of TorontoLaverne Jacobs, Associate Dean (Research & Graduate Studies) and Associate Professor, Faculty of Law, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/966982018-05-23T22:53:43Z2018-05-23T22:53:43Z‘Suicide tourism’ and understanding the Swiss model of the right to die<p>Two weeks ago, <a href="https://www.theglobeandmail.com/world/article-australian-man-104-dies-in-assisted-suicide-in-switzerland/">the 104-year-old Australian scientist David Goodall flew from his home in Western Australia to Switzerland to access assisted suicide</a> with the help of lifecircle and Exit International, two right-to-die societies.</p>
<p>Goodall was part of a broader but marginal phenomenon sometimes referred to as “suicide tourism.” This occurs when a person travels to Switzerland in order to access an assisted death, because this is forbidden or access criteria are more restrictive in their home country. </p>
<p>His story made headlines all around the world and fuelled public debates. Yet the media coverage has not promoted a greater understanding of the Swiss model of assistance in dying.</p>
<p>Cases of “suicide tourism” presented in the media typically say little about the functioning of the Swiss model. Instead, the coverage of “suicide tourism” speaks more to the state of the public debate in a given country on assistance in dying. </p>
<p>However, Switzerland is not only the final destination in the journey of a person towards death. It is also the starting point of recurrent public debates in the countries of origin of those foreign nationals seeking an assisted death in Switzerland.</p>
<p>The fact that citizens of one country make the decision to die in another country, far from their home and family, has a powerful effect on the public. It provides convincing evidence of determination and suffering. It also shows that other possibilities for regulating assistance in dying exist.</p>
<p><a href="http://www.trudeaufoundation.ca/en/community/samuel-blouin">I have been carrying out research for the last three years comparing Canada and Switzerland, more specifically the province of Québec and the canton de Vaud, Switzerland</a>. While I look at public policies, the main focus of my preliminary findings examine the meanings and experiences of those involved in assisted dying practices.</p>
<h2>Medical assistance in dying</h2>
<p>Some people undertaking this journey are conscious of the public appeal of their decisions, as shown by <a href="https://livestream.com/accounts/16944724/events/8197566/videos/174637802/player">the news conference held by Goodall</a> on May 9, 2018, before his death in Basel. Some, like Goodall, participate in a movement of older right-to-die activists advocating for <a href="https://doi.org/10.1111/soc4.12456">“old age rational suicide.”</a> For others, suffering related to a medical condition is the main motivation.</p>
<p>Switzerland sometimes shows up in the national conversation on assisted dying in Canadian news stories. The most well-known occurrence was the story of <a href="https://www.theglobeandmail.com/life/health-and-fitness/good-death-in-swiss-clinic-held-up-as-model/article4247221/">Kay Carter</a>, suffering from spinal stenosis, who died in Switzerland with the help of Dignitas, a Swiss right-to-die society. </p>
<p>Assisted dying was not yet legal in Canada. Following years of legal challenges in which Carter was one of the plaintiffs, her name is now attached to the <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do?r=AAAAAQAPY2FydGVyIHYgY2FuYWRhAQ">Supreme Court of Canada decision</a> that decriminalized medical assistance in dying (MAiD) in Canada in 2015.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220165/original/file-20180523-117628-h7go1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lee Carter, daughter of Kay Carter, speaks at a press conference on doctor-assisted death legislation, Bill C-14, while her brother, Price Carter, listens on Parliament Hill in Ottawa on April 21, 2016.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/ Patrick Doyle</span></span>
</figcaption>
</figure>
<p>In Québec, the <a href="http://www.worldcat.org/title/manon-le-dernier-droit/oclc/551397551">2004 documentary <em>Manon: Le dernier droit?</em></a> follows Manon Brunelle, a woman suffering from multiple sclerosis who left Canada to die with Dignitas in Switzerland. This film sparked a public conversation.</p>
<p>The legalisation of MAiD in Canada did not bring an end to so-called “suicide tourism” by Canadians. According to <a href="http://dignitas.ch/images/stories/pdf/statistik-ftb-jahr-wohnsitz-1998-2017.pdf">Dignitas’ statistics</a>, 60 Canadians used its service between 1998 and 2017, including 12 in 2017.</p>
<h2>Assisted dying as an act of citizenship</h2>
<p>Under the radar of international controversies, other Swiss right-to-die societies have developed practices that tend to go unnoticed.</p>
<p>Dignitas, which is only one out of eight Swiss right-to-die societies, garners most of the attention as it is perceived as the most controversial. <a href="https://www.thelocal.ch/20180518/head-of-swiss-assisted-suicide-group-dignitas-in-court-on-charges-of-profiteering">The founder, Ludwig Minelli, is currently being prosecuted</a> for making a personal profit out of three assisted suicides, which is prohibited by the <a href="https://www.admin.ch/opc/en/classified-compilation/19370083/201803010000/311.0.pdf">Swiss Criminal Code</a>. These charges have not yet been proven in court.</p>
<p>In Switzerland, assisted suicide has been tolerated since 1942 provided that the person assisting has no selfish motive. Moreover, the person requesting such assistance must self-administer the lethal drug and must have decision-making capacity.</p>
<p>Compared to the comprehensive Canadian federal and provincial laws on MAiD, Swiss regulation and safeguards can be perceived as lacking. However, this misses the meaning of assisted suicide in Switzerland.</p>
<p>Unlike in Canada, assisted suicide is an act of citizenship in Switzerland, not a health-care intervention. Switzerland proposes a much less medicalized approach to assisted dying.</p>
<h2>Swiss guidelines</h2>
<p><a href="https://doi.org/10.1111/bioe.12304">The Swiss model rests mostly on ethical guidelines drawn up by various health-care organizations and on the rules decided by right-to-die associations</a>. </p>
<p>For example, the nonprofit EXIT association active in the French-speaking region of Switzerland has more than 26,000 members who all have a vote at the annual general meeting. To become a member, a person must pay an annual fee of US$40 (equivalent to 40 Swiss Francs), be over 20 years old and also be a Swiss resident. The association provides assistance in suicide, free of charge, to its members. Nonresidents and minors are thus inadmissible.</p>
<p>Besides the legal requirements, the association has its own criteria according to which volunteers can help a member die. <a href="http://www.exit-geneve.ch/conditions.htm">These criteria include</a>:</p>
<p>» Suffering from an incurable disease or from an important invalidity or experiencing intolerable suffering.</p>
<p>» Or suffering from disabling polypathologies related to old age. </p>
<p>A consulting physician assesses whether or not the requester meets the criteria and, if they do, she will prescribe a lethal drug that a volunteer will bring. </p>
<p>Volunteers are not chosen on the basis of their professional qualifications but on their skills as accompanying persons — their capacity to demonstrate compassion and understanding.</p>
<p>After the death, the volunteer calls the police who will investigate the case. The public prosecutor will then decide whether or not criminal charges will be brought against the persons involved.</p>
<h2>Dignity at the end of life</h2>
<p>In Québec, the Act respecting end-of-life care was adopted in 2014 and entered into force in 2015. Besides creating a right to palliative care and regulating continuous palliative sedation among other things, the law legalized medical aid in dying which includes only euthanasia (administration by a doctor) and not assisted suicide (self-administration). In this context, assisted suicide was ruled out as an appropriate option because it “<a href="http://www.assnat.qc.ca/Media/Process.aspx?MediaId=ANQ.Vigie.Bll.DocumentGenerique_54787en&process=Default&token=ZyMoxNwUn8ikQ+TRKYwPCjWrKwg+vIv9rjij7p3xLGTZDmLVSmJLoqe/vG7/YWzz">does not reflect the values of medical support and safety</a>.”</p>
<p>The federal law legalized medical assistance in dying in 2016 and includes both euthanasia and assisted suicide.</p>
<p>Even though the federal legislation on MAiD allows for both euthanasia (administration by a doctor or nurse practitioner) and assisted suicide (self-administration), Canadians almost exclusively favour the first option. </p>
<p>According to a <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-sep-2017.html">report published in October 2017</a>, only five persons out of 2,149 have chosen a self-administered death. Thus, Switzerland might not be a model for Canada.</p>
<p>On the other hand, the comparison that I have been carrying out between Canada and Switzerland shows that assistance in dying can be considered not only as a patient’s but as a person’s decision. Just as there are non-medical options to assist birth, non-medical or less medical ways to assist death could be entertained.</p>
<p>Besides the option of palliative care and other social programs, the Swiss model is an invitation to imagine and consider other societal responses to the challenges of suffering and dignity at the end of life.</p><img src="https://counter.theconversation.com/content/96698/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Blouin receives funding from the Pierre Elliott Trudeau Foundation and has received funding from the Vanier Canada scholarship program of the Social Sciences and Humanities Research Council of Canada.</span></em></p>Recent stories in the media highlight the idea of suicide tourism to Switzerland. But what does that mean? How is the Swiss view of assisted dying different from the Canadian one?Samuel Blouin, PhD Candidate in Sociology and Pierre Elliott Trudeau Foundation Scholar, Université de Montréal and Université de Lausanne, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944752018-04-23T22:33:13Z2018-04-23T22:33:13ZCan we die? The seriously ill need clarity<p>More than 2,000 people have <a href="https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-sep-2017/medical-assistance-dying-interim-report-sep-2017-eng.pdf">died with the help of a doctor</a> since <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html">Canada’s new medical assistance in dying law, Bill C-14,</a> received royal assent on June 17, 2016.</p>
<p>This legislation has, however, come under sustained criticism for its ambiguity. When it was first introduced, concerns were immediately expressed about the eligibility criterion that “natural death has become reasonably foreseeable.” </p>
<p>This phrase “reasonably foreseeable” was deemed by many to be <a href="http://www.cmaj.ca/content/188/11/E243.full">unfamiliar and unclear for physicians and their regulators</a>. It has led to confusion and a variety of interpretations among providers and assessors of medical assistance in dying (MAiD).</p>
<p>Now the Nova Scotia College of Physicians and Surgeons has <a href="https://cpsns.ns.ca/wp-content/uploads/2016/06/Professional-Standard-regarding-Medical-Assistance-in-Dying.pdf">developed a statement that clarifies this criterion</a>. This will remove a barrier to access to MAiD for some seriously ill patients in the province — such as, for example, a dialysis-dependent patient who decides to stop dialysis. </p>
<p>As researchers who have engaged with clinicians, lawyers and philosophers on the meaning and implementation of the legislation, we think this statement is a much-needed contribution to the care of individuals with grievous and irremediable conditions causing intolerable suffering.</p>
<p>We hope that the other provincial and territorial regulators of physicians, nurse practitioners and pharmacists will soon follow Nova Scotia’s lead. Suffering individuals across Canada should not be blocked from accessing MAiD just because of confusion about the meaning of the legislation. </p>
<h2>‘We will all die’</h2>
<p>The definition of a “reasonably foreseeable” death has perplexed many patients, doctors and nurse practitioners.</p>
<p>“‘Reasonably foreseeable’ does not have a medical meaning because <a href="http://www.ourcommons.ca/DocumentViewer/en/42-1/JUST/meeting-11/evidence">it is reasonably foreseeable that we will all die</a>,” cautioned Monica Branigan, chair of the Canadian Society of Palliative Care Physicians, as she testified before the House of Commons Standing Committee on Justice and Human Rights.</p>
<p>The requirement, “<a href="http://www.ourcommons.ca/DocumentViewer/en/42-1/JUST/meeting-13/evidence">that natural death be reasonably foreseeable means nothing to us as physicians</a>,” said Catherine Ferrier, President of the Physicians’ Alliance Against Euthanasia. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215695/original/file-20180419-164001-j90xoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In Nova Scotia, if a paraplegic patient who is experiencing enduring, intolerable and irremediable suffering decides to refuse the care required to prevent bedsores they may now be eligible for medical assistance in dying.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Not surprisingly, as the legislation has been implemented in Canada since June 2016, there has been considerable variability in the interpretation of “reasonably foreseeable” by doctors and nurse practitioners. </p>
<p>Some appear to have interpreted it to mean “death expected within 12 months” or in the “near future.” Some have interpreted it to mean “anticipated survival of as much as 10 years.” Others have decided it does not require a prognosis as to any specific length of time.</p>
<h2>Leadership from Nova Scotia</h2>
<p>Fortunately, we are beginning to see leadership from the very groups who first sounded the alarm about the vagueness of this eligibility criterion — colleges of physicians and surgeons.</p>
<p>On Feb. 8, 2018, the Executive Committee of the Nova Scotia College of Physicians and Surgeons approved the following text for their <a href="https://cpsns.ns.ca/wp-content/uploads/2016/06/Professional-Standard-regarding-Medical-Assistance-in-Dying.pdf">Professional Standard Regarding Medical Assistance in Dying</a>:</p>
<blockquote>
<p><em>“The only court decision to date addressing ‘reasonably foreseeable’ states that: natural death need not be imminent and that what is a reasonably foreseeable death is a person‐specific medical question to be made without necessarily making, but not necessarily precluding, a prognosis of the remaining lifespan. In formulating an opinion, the physician need not opine about the specific length of time that the person requesting medical assistance in dying has remaining in his or her lifetime. (AB v. Canada 2017 ONSC 3759, para 79‐80) Therefore, natural death will be reasonably foreseeable if a medical or nurse practitioner is of the opinion that a patient’s natural death will be sufficiently soon or that the patient’s cause of natural death has become predictable.”</em></p>
</blockquote>
<p>The clear implication of this is that the MAiD provider and assessor need not form an opinion as to the anticipated survival time, when the cause of death can be predicted. </p>
<p>In other words, they must be able to predict either the when or the how of death — but do not have to be able to predict both.</p>
<h2>Serving the public interest</h2>
<p>According to this professional standard, a patient’s natural death could have become reasonably foreseeable 20 years from death — for example, when a patient has a diagnosis of Huntington’s disease. </p>
<p>Obviously, they will not meet all the eligibility criteria for MAiD on the day of diagnosis. For example, their decline in capability will not yet be advanced and their suffering not yet enduring and intolerable. But they will have an incurable condition and their natural death will have become reasonably foreseeable.</p>
<p>This also means that a patient’s natural death could become reasonably foreseeable when potentially life-saving interventions are declined. </p>
<p>For example, when a paraplegic patient decides to refuse the skin care and changing of positions required to prevent bedsores and then antibiotics to treat the infections that will inevitably result. Or when a patient with multiple sclerosis refuses food and liquids. </p>
<p>For each of these people, the cause of natural death has become predictable.</p>
<p>With its recent statement, the Nova Scotia College of Physicians and Surgeons has made a significant contribution to the clarification of “reasonably foreseeable” (at least within the province). </p>
<p>In doing so, they are modelling the statutory mandate of regulators of health professionals to “serve and protect the public interest.”</p><img src="https://counter.theconversation.com/content/94475/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jocelyn Downie receives a Fellowship from the Pierre Elliott Trudeau Foundation. The project for her fellowship relates to the legal regulation of end of life care (including medical assistance in dying).</span></em></p><p class="fine-print"><em><span>Jennifer Chandler receives research funding from SSHRC, CIHR, Bertram Loeb Organ and Tissue Donation Institute, Canadian and Blood Services.</span></em></p>In Nova Scotia, it’s clearer now who qualifies for medical assistance in dying. Will the other provinces and territories follow suit?Jocelyn Downie, University Research Professor, Faculties of Law and Medicine, Dalhousie UniversityJennifer Chandler, Professor of Law, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/937832018-04-18T23:14:18Z2018-04-18T23:14:18ZPoor communication is compromising care for the dying<figure><img src="https://images.theconversation.com/files/214620/original/file-20180412-540-1cbckjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In one study of seriously ill older Canadians, 28 per cent of participants wanted “comfort care” (meaning no curative treatments) but this was documented in only four per cent of their charts.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Research shows that up to <a href="http://www.dx.doi.org/10.1001/jamainternmed.2013.180">70 per cent of seriously ill, hospitalized elderly Canadians are receiving invasive end-of-life treatments that they don’t want</a>. </p>
<p>This could be your mother or your grandfather. Maybe someday, it will be you.</p>
<p>For more than 10 years, our team of health researchers, <a href="http://thecarenet.ca/">Canadian researchers at end-of-life network or CARENET</a>, has been working to understand and improve palliative and end-of-life care in Canada. </p>
<p>We know that <a href="https://www.ncbi.nlm.nih.gov/pubmed/9005760">many older patients with serious illness want to maintain quality of life rather than prolong it</a>. However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/11075528">the use of aggressive life-sustaining technologies in this vulnerable population is common</a>. </p>
<p>Instead of a peaceful end-of-life experience, they are receiving invasive medical treatments during their last days. </p>
<h2>Too little, too late</h2>
<p>A national, multi-year study involving seriously ill older Canadians revealed that even though 28 per cent of the participants stated a preference for “comfort care” (meaning no curative treatments), <a href="http://www.dx.doi.org/10.1001/jamainternmed.2013.180">this was documented in only four per cent of their charts</a>. </p>
<p>This discrepancy can lead to a <a href="http://www.dx.doi.org/10.1001/jama.300.14.1665">poor end-of-life experience and an increase in family distress</a>. </p>
<p>Why is this happening? Often, it comes down to a lack of communication. Even though studies have shown that seriously ill patients and families have identified <a href="https://doi.org/10.1503/cmaj.100131">end-of-life communication and decision-making as high priority targets for quality improvement</a>, these conversations are typically “<a href="https://doi.org/10.1503/cmaj.140673">too little, too late and not great.”</a></p>
<p>The gap doesn’t just exist within the hospital setting. A <a href="http://www.hpcintegration.ca/media/55755/CHPCA_The%20Way%20Forward%20Survey_Final%20Report_August2014.pdf">2014 Ipsos Reid survey</a> revealed that 60 per cent of Canadians want their family doctor to talk to them about their preferences for care at the end of life, but only 26 per cent of primary-care physicians are comfortable having those discussions. Sixty-seven per cent of primary-care physicians said they need more resources and information. </p>
<p>These conversations are also rare in long-term care homes, even though death is commonplace in this setting. </p>
<p>It’s clear that we are failing to provide optimal care to older Canadians at the most vulnerable time of their lives.</p>
<h2>A road map for conversations</h2>
<p>A <a href="http://thecarenet.ca/24-researchers/our-projects/1027-the-ican-acp-study">new three-year national study, called iCAN-ACP</a>, aims to improve this situation by introducing and evaluating “advance care planning” tools. We hope this will result in more, earlier and better conversations between older adults, families and their health-care teams. </p>
<p>Advance care planning involves thinking about and communicating your preferences for care in a way that expresses your values. It also includes choosing someone to be your “substitute decision-maker,” someone who could speak for you and make decisions if you couldn’t speak for yourself.</p>
<p>The iCAN-ACP project, funded by the Canadian Frailty Network, has just been launched in long-term care homes, family doctors’ offices and hospitals across Canada, bringing together a team of 32 investigators from 16 universities, five international collaborators and 42 partner organizations. </p>
<p>The project will study conversation aids, including workbooks and interactive websites for older adults and their families, and conversation guides for health-care practitioners. </p>
<p>The “<a href="https://www.ariadnelabs.org/areas-of-work/serious-illness-care/resources/#Downloads&%20Tools">Serious illness conversation guide</a>,” developed by colleagues from Ariadne Labs at Harvard Medical School, is an example of a conversation aid we will be studying. The guide gives practitioners a “road map” to having better and more person-centred conversations with patients who are facing serious illness, so that <a href="https://www.ariadnelabs.org/areas-of-work/serious-illness-care/">patients can receive care that is consistent with their goals</a>.</p>
<p>We know from past research that <a href="http://www.dx.doi.org/10.1136/bmj.c1345">advance-care planning can have a significant impact on end-of-life experiences for both patients and their families</a>. But all too often, these conversations are not happening early or often enough. </p>
<p>iCAN-ACP will engage older Canadians living with frailty, and their families, as well as clinicians, health organizations and related patient associations — to evaluate several of these conversation aids. </p>
<p>Our goal is to identify valuable tools that will reduce unwanted treatments and ensure that patient voices are heard.</p><img src="https://counter.theconversation.com/content/93783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John You receives funding from the Canadian Frailty Network. </span></em></p>Most elderly Canadians do not receive the end-of-life care they desire. A new study hopes to rectify this.John You, Associate Professor of Medicine, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/836312017-10-10T22:47:07Z2017-10-10T22:47:07ZWho will be the doctors of death in a time of assisted suicide?<figure><img src="https://images.theconversation.com/files/189070/original/file-20171005-6575-iqsezw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical assistance in dying has been legal in Canada since July 2016, but there are no 'specialists' responsible for doctor-assisted suicide and many doctors are overwhelmed with requests. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical assistance in dying (MAID) became a reality in Canada when <a href="http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent">legislation was passed</a> in July 2016. This is the hastening of death through a lethal dose of medication — either by self-ingestion (assisted suicide) or physician injection (euthanasia). </p>
<p><a href="http://www.cbc.ca/news/politics/medical-assistance-death-figures-1.4344267">More than 2,000 Canadians</a> have received MAID, administered by a number of physicians. Few of those doctors are palliative care specialists, who are purposely <a href="http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf">keeping their distance from MAID</a> to avoid further stigmatization as the physicians of death. They do not want to be associated with treatment failure, or viewed as only providing care to those who have either <a href="http://nationalpost.com/health/when-to-give-up-treatment-or-comfort-for-late-stage-cancer">given up</a> or been deemed hopeless. </p>
<p>This has left MAID without leadership or co-ordination, leading to unequal access and confusion among the public and health-care providers.</p>
<p>I am a palliative care physician at Queen’s University who teaches medical students, residents and other health-care providers. I am adjusting to the new reality of palliative care in the MAID era. Many patients and families ask me about it and a fair number receive it. One patient asked me to be there for his MAID death. </p>
<p>I speak to nursing and physician groups and at <a href="http://www.queensu.ca/eventscalendar/calendar/events/barry-smith-symposium-end-life-care-death-and-dying">public events</a> where I can be simultaneously applauded and criticized for not providing doctor-assisted suicide as part of my palliative care. At these events, there is always uncertainty about MAID: the ethics, legalities, practicalities (how, where, by whom). And there are questions about the comfort of health-care providers with an intervention aiming to administer death rather than stave it off.</p>
<h2>Doctors who improve quality of life</h2>
<p>To understand why palliative care does not wish to “own” MAID requires an understanding of the <a href="http://www.who.int/cancer/palliative/definition/en/">meaning of palliative care</a>. </p>
<p>Palliative care is an approach that improves the quality of life of patients and their families facing a life-threatening illness by preventing and relieving suffering through treatment of pain and other problems — physical, psychosocial and spiritual. It is often provided alongside disease-focused treatments like chemotherapy, radiation or surgery.</p>
<p>Traditionally, palliative care has mostly provided care to <a href="http://www.cancer.ca/en/about-us/for-media/media-releases/national/2016/palliative-care-report-2016/?region=on">patients with cancer</a>, but it is appropriate for anybody with advanced diseases of organs like the <a href="https://www.heartandstroke.ca/heart/conditions/heart-failure">heart</a>, <a href="https://www.lung.ca/copd">lung</a>, <a href="https://www.kidney.ca/kidney-disease">kidneys</a> and <a href="https://www.liver.ca/patients-caregivers/liver-diseases/cirrhosis/">liver</a>. And for those with nervous system disorders like <a href="https://www.als.ca/about-als/">ALS</a> or <a href="http://www.alzheimer.ca/en/About-dementia">dementia</a>. Palliative care is also <a href="http://www.sickkids.ca/patient-family-resources/paediatric-advance-care-team/index.html">provided to children</a> with the above illnesses and also those with congenital disorders.</p>
<p>Research shows that palliative care can <a href="https://doi.org/10.1191/026921698676226729">improve symptom control</a>, <a href="https://dx.doi.org/10.1001/jama.2009.1198">quality of life</a> and, in some cases, <a href="https://dx.doi.org/10.1056/NEJMOa1000678">lead to improved survival</a>. But palliative care is still often seen as the care provided “when nothing else can be done” and when <a href="https://dx.doi.org/10.1503/cmaj.151171">someone is close to death</a>. </p>
<p>This causes problems where patients don’t want to see palliative care “too early” and their doctors are reluctant to refer for <a href="https://dx.doi.org/10.1002/cncr.24206">similar reasons</a>. This shrinks the time in which doctors can help with symptoms and care plans for the future. A large cancer centre in the U.S. noted this problem and changed the name of their “palliative care” team to “supportive care.” </p>
<p>There was an immediate <a href="https://dx.doi.org/10.1634%2Ftheoncologist.2010-0161">41 per cent increase in referrals</a> and those referrals came earlier due to less stigma around the name.</p>
<h2>Reducing suffering, not stopping life</h2>
<p>Admittedly, palliative care and MAID are both trying to treat suffering, but the methods are different: palliative care does not try to speed up (or slow down) death whereas MAID expressly speeds up death. Palliative care tries to reduce suffering by treating physical, psychosocial and spiritual distress whereas MAID stops suffering by stopping life. </p>
<p>Before MAID was legalized, patients whose suffering couldn’t be fixed by other means would get palliative sedation to reduce their awareness and suffering until they died.</p>
<p>While most palliative care doctors don’t provide MAID, we’re not all opposed to its legalization. I support a person’s choice to hasten their death if they have “grievous and irremediable” suffering, which is the terminology used in the <a href="http://www.cbc.ca/news/politics/supreme-court-says-yes-to-doctor-assisted-suicide-in-specific-cases-1.2947487">Supreme Court decision</a>. There are some patients that, despite our best interventions, still suffer a bad death. Many more patients never get the “best” intervention as they <a href="https://beta.theglobeandmail.com/news/national/canadians-lack-proper-access-to-palliative-care-study-finds/article28122378/">can’t access expert palliative care</a> where they live or the system is too overburdened to provide care.</p>
<h2>Who will be the doctors of death?</h2>
<p>So who should have responsibility for MAID? There are no “specialists” that reliably provide MAID, and many doctors struggle to manage the requests of patients. The few doctors who provide it are generally doing it on top of their regular work, risking burnout. </p>
<p>A new group — the <a href="http://camapcanada.ca/">Canadian Association of MAID Assessors and Providers</a> — provides peer support and clinical guidelines. They are also trying to keep up with a legal landscape that is <a href="https://beta.theglobeandmail.com/news/national/ontario-judge-rules-woman-fits-criteria-for-medically-assisted-death/article35375467/">changing frequently</a>, especially around the <a href="http://www.cbc.ca/news/canada/british-columbia/assisted-dying-law-canada-moro-1.4294809">“reasonably forseeable” death</a> clause which was included in the legislation but has not been defined and thus is subject to varying interpretation.</p>
<p>They are also expecting legal challenges regarding “<a href="http://www.cbc.ca/news/politics/doctor-assisted-death-minors-1.3466769">mature minors</a>” and patients with advanced directives who are not able to request MAID, such as those with advanced dementia. Currently only adults who are mentally competent to consent at the time of the MAID procedure are eligible to receive it. Nobody can ask for MAID in a living will or have their loved ones request it on their behalf.</p>
<p>In the end, palliative care doctors, providers of MAID and the public all have the same goal: to alleviate suffering, to maximize quality of life and to respect autonomy for those suffering from life-limiting illnesses. </p>
<p>Almost everyone agrees that palliative care needs to be strengthened in Canada with more education, capacity and funding. Better palliative care will mean less suffering for patients. For those who request MAID due to their suffering, they should be able to access it in an equitable, respectful and expedient way. </p>
<p>End-of-life care remains an uncomfortable but critically important topic and is really the responsibility of everyone.</p><img src="https://counter.theconversation.com/content/83631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Craig Goldie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More than 2,000 Canadians have chosen medical assistance in dying (MAID) since legalization in 2016. But palliative care doctors aren’t embracing assisted suicide as part of their job.Craig Goldie, Assistant Professor, Palliative Physician, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.