Canada must change course on assisted suicide

Canada has long been regarded as a frontier example of euthanasia zealotry. Assisted suicide and euthanasia have been legal in Canada for a decade now, under the nation’s Medical Assistance in Dying (MAID) regime which commenced in 2016. 

Following its introduction, the law regarding euthanasia has undergone a rapid expansion

Following its introduction, the law regarding euthanasia has undergone a rapid expansion. In 2021, only five years after becoming law, Canada repealed the facet of the law that required an individual’s natural death to be “reasonably foreseeable” for them to be eligible to end their life by euthanasia or assisted suicide. This meant that many individuals who were not terminally ill but simply living with disabilities or chronic health conditions could now end their lives with the assistance of the state.

In 2024, legislation was introduced that would have extended the availability of these end of life methods to people whose sole basis for applying would be a mental health condition. Such a law was scheduled to come into force automatically in March 2027.

That changed this month. Canada’s Justice Minister, Sean Fraser, delivered a brief and somewhat chaotic press conference in which he stated that the Canadian Government would no longer be pressing ahead with this policy. 

“While there is not a perfect consensus on this issue, we believe this is the correct approach at this particular time,” he said.

Canada has been attempting to legislate for such an expansion for several years now, with the expansion subsequently delayed several times, the last being in 2024. In 2021, a Special Joint Committee on Medical Assistance in Dying was created with the aim of assessing the safety and feasibility of providing euthanasia and assisted suicide solely on the basis of mental illness. Among many concerns that the Committee raised was the difficulty in discerning when an individual was simply suicidal, and when they were making a request to end their life under the terms of the law. Some key witnesses told the Committee there was “no way to distinguish” between the two. Suicide is suicide.

Despite these concerns being raised several years ago, the Government still remained determined to press ahead with the expansion in the law. Fortunately, now, that appears to have come to an end.

However, this positive news is tempered with some less positive news. In the same legislation that the Government is putting forward to halt the expansion for mental illnesses, it will also be proposing an expansion in the law to allow individuals with a progressive, incurable illness to consent in advance to ending their life, in case they lose the ability to consent at a later date. 

This is extremely worrying. While these advance requests, as they are known, are commonplace in the medical world, they generally relate to receiving treatment — not suicide. In one of the few places where they are currently legal for euthanasia, the Netherlands, there have been countless horror stories. In one case, a woman with dementia was euthanised after making an advance request, despite wanting to live and being confused why her life was being ended at the time of her euthanasia. She was subsequently held down and euthanised by force. 

I spoke to Professor Mark Taubert, a palliative medicine consultant, about this, who told me that while he generally supports advance requests with regard to a patient’s wishes and preferences about treatments or care, he cannot support them for the future administration of substances that will end the life of a person who, at that time, cannot consent to it.

“It is rare to get patients who hold an advance decision to refuse treatment,” he tells me. Individuals are, of course, under no obligation to undergo treatment for any illness they may be living with. Although it is rare, such a wish not to undergo treatment can be given in advance, similarly to how individuals can give “do not resuscitate” orders. The reason it is rare, Professor Taubert says, is because “your younger self may not easily predict what your future self may feel or think about a given situation”. 

When it comes to the decision to make an advance request to end one’s life, the situation becomes even more nuanced, he says.

“I have seen and treated many people in their own homes and in care home settings with dementia. I see people in the local community and shops with dementia or cognitive impairment. Some of them seem perfectly happy.”

“How might we square the fact that they have lost a degree of mental capacity now, that they have left instructions when they were younger to end their life when this happens, with the fact that they are perhaps the most content they have been in their whole life?” he asks. 

It is an interesting question, and one that does not have a satisfactory answer. In Canada, in particular, there is a worry that opening the door to allowing individuals with some conditions advance requests to die could enable this particular facet of the law to be expanded widely to cover many other conditions, including dementia.

Dr Ramona Coelho, a family physician in Ontario, Canada, who is a former member of Ontario’s MAID Death Review Committee (MDRC), agreed that consent given in advance in this scenario “cannot be fully informed”.

“My father had dementia, and his days held joy, laughter, love and dignity that neither he nor I could have foreseen,” she revealed to me.

“Ontario’s MDRC review of dementia cases found requests driven by fear of future decline, families raising MAID repeatedly on a patient’s behalf, and only 13.6% [of patients] receiving palliative care first.”

While Dr Coelho is grateful that the law appears to be in the process of being halted — or, at the very least, paused for an indeterminate period of time — she is still wary that it is far more broad than it should be, and has expressed concerns that the same law that is pausing one bad part of the law will expand another part.

She reiterates that all of this must be sorted out and a Bill must be passed before March 2027, otherwise euthanasia and assisted suicide on the sole basis of mental illness will automatically become law. That is a very tight deadline to consider every nuance and ensure that such legislation is watertight. 

“That’s exactly how the mental illness expansion got into the law in 2021,” she tells me. “Back then, the Senate added it almost as an afterthought, and the House passed it under a closure motion, limiting final debate.”

These are similar tricks to those we saw in our own debate around introducing assisted suicide in England and Wales. The initial version of the Terminally Ill Adults (End of Life) Bill was brought forward as a non-Government Private Members’ Bill, put forward by a backbench MP, meaning there was little time set aside for scrutiny of the Bill in its early stages before being passed, with its supporters telling the House of Commons that any issues could be figured out at a later stage. 

Despite this, Dr Coelho welcomes any attempt at stopping the expansion of the law in Canada for those with mental illness, but argues that a better course of action would be to entirely repeal the 2021 law that removed the requirement for a natural death to be “reasonably foreseeable”. 

Just last week, Philippe Couillard, the former Liberal Premier of Quebec who oversaw the introduction of the province’s first assisted suicide and euthanasia law, said he was worried that the law’s expansion has gone too far. 

Initially, MAID was “reserved for terminal or pre-terminal conditions with a defined, unfortunate road to the end of life,” he said, adding that “this is not the case anymore”.

“I’m not sure that I would have again voted for that law with the extension that we have seen in recent years,” the former Premier revealed.

Interestingly, in Quebec, doctors are already allowed to accept advance requests for euthanasia for people suffering from conditions like Alzheimer’s disease. Such advance requests remain illegal, but in Quebec those who carry out euthanasia procedures subsequently are not prosecuted.

Professor Kevin Yuill, CEO of Humanists Against Assisted Suicide and Euthanasia, told me that he viewed the decision to bring the whole of Canada into line with Quebec — or worse, legalising the practice of advance requests entirely — as “monstrous”. 

“An advance directive means that medics will be holding down and killing a patient who cries out ‘No, no, no!’”

Because that is precisely what the situation in Quebec may be: killing individuals against their will, contrary to the law.

Yuan Yi Zhu, an assistant professor at Leiden University who has served as a senior policy advisor in the Canadian House of Commons, expanded on this, telling me that such a situation was “remarkable”.

“Advance requests for euthanasia are still illegal under Canada’s Criminal Code and to carry one out is murder as a matter of Canadian law,” he explained. “Yet doctors who carry them out in Quebec are simply not prosecuted because the province has tried to nullify the relevant prohibition in the Code. In effect, certain types of murder are legal in Quebec.”

“In any other context, there would be an uproar if the government refused to enforce the law against murder. Because it happens in the context of MAID, in which scandals are commonplace and accepted, it passes without comment,” Zhu added.

The correct decision is to admit that mistakes were made, and to throw the programme into reverse

Additionally, he posited that the grouping of this expansion of the law with the indefinite halting of the mental illness expansion is simply the Liberal Party attempting to appease both sides by political triangulation. The Liberals are surely aware that introducing MAID on the sole basis of mental illness would be a disaster; their own Committee discerned as much several years ago. Yet, through this latest endeavour, they want to save face in walking it back by throwing a bone to the pro-euthanasia “progressives”. 

In Canada, the pendulum of assisted death seems to have reached its peak, and has finally begun to swing back the other way. Some of its most zealous adherents, however, are hanging on to the pendulum for dear life, hoping to hold it where it is. In attempting to keep everyone happy, the Canadian Government is threatening the lives of the people it was elected to represent, while continuing to adopt policies that most reasonable people view as incoherent and unsafe. The only safe and practical course of action is to begin the repeal of all of the expansions to the assisted suicide and euthanasia law in Canada, the leniencies of which are the root cause of most of the tragedies that have occurred under the MAID regime. The correct decision is to admit that mistakes were made, and to throw the programme into reverse.