One retort to this would that this doesn't specify the exact type of palliative care patients received (and it's true that it's a limitation of the report). At the same time however, there isn't an implication that the care received was sub-standard. When you look at Belgium, Oregon, and New Zealand for example (I don't know what the percentage is for patients in the Netherlands, Switzerland, Australia, or the other various US states that legalised MAID) you also see that the great percentage of patients who received assisted-dying underwent palliative care beforehand.
I truly believe that given from all the evidence so far, that even if 99% of MAID applicants were receiving the very best palliative care most MAID requests wouldn't be rescinded. Why? Because pain isn't one of the top reasons why people request assisted-dying in the jurisdictions that have legalized it. Loss of autonomy, loss of dignity, and inability to engage in the activities they find to be enjoyable are by far and large the most common reasons. Palliative care is primarily about symptom management, which doesn't target this.
DS, thank you for this perspective and these data, and for your civil comment.
Your point about palliative care is important. We need to know more about the care that was received at the end of life. I know more about mental health care and I don't think it's likely that patients received adequate mental health care before dying.
I agree with this point: "Loss of autonomy, loss of dignity, and inability to engage in the activities they find to be enjoyable are by far and large the most common reasons." However, this is where I part company with MAID advocates. I don't think becoming dependent means you lose human dignity. And I don't think assisted suicide should be a standard care for patients who do not want to become dependent or are losing the ability to engage in things they find to be enjoyable.
That's fair. I'm personally of the opinion that it isn't wrong to value autonomy or being able to engage in the activities that people find pleasurable in life.
I'm not suggesting that there is anything wrong with either autonomy or being able to engage in pleasurable activities. Better: both are critical to human well-being. I'm saying that we should draw a line such that doctors would not be permitted to assist suicide or perform euthanasia for those reasons.
I acknowledge that this will come at a cost for some people who want to die for those reasons. There are no easy solutions here.
Thank you for this piece. The offer of MAiD by your oncologist reminded me of what appeared to be an approval based on a very limited and in some significant ways, completely wrong, knowledge of my father. I wrote the experience here. https://christopherlyon.substack.com/p/dying-indignity
I'm also concerned about who is attracted to providing MAiD. It's one thing to feel that ending the life of someone in extremis is perhaps a benefit to them, but quite another to want to involve themselves in ending the lives of people who are not dying and/or children, and who express personal gratification as a result. If we propose screening patients of suicidality and mental illness, we should do likewise for clinicians wishing to involve themselves in MAiD.
Thank you for this helpful article on MAID including comments from your personal and medical experience. I was horrified that your surgeon suggested assisted-suicide based on his calculation of your life span (which was off by more than a few years!). Medical ethics need to be discussed and laws/ policies constantly reviewed, especially when they have life-changing consequences.
I came to your substack after reading "Eucharist ,Cancer, Love", your beautiful, poignant and insightful article in Comment Magazine, Winter 2023. May the Lord bless you for teaching us how to use each precious day of life well, in the centre of God's love.
Great article. In addition to personal awful circumstances (homelessness, poverty) I think I would add sense of being burden to family would prompt suicide. Offering by physicians legitimizes the choice when people are very vulnerable.
Insightful reflections. It rejoins a piece we wrote when Bill C7 was being debated. Canada's MAID system is unique in that respect. No other regulatory regime treats MAID as first line therapy available to be put on the table for any seriously ill or disabled person (i.e. everyone with serious illness, disease, or disability and has irreversible decline of capability (quite an ableist/ageist concept, in fact: who doesn't have that?) and who may be suffering intolerably. It's CAMAP's recommendation to explicitly introduce it to everyone who 'might qualify;, and the law doesn't prevent that and also doesn't require that all other options be made available and attempted first. In B & Nl, until recently the most liberal regimes, doctors have to agree that no other reasonable options other than euthanasia are available. In practice, this may sometimes come to the same, when you combine that with the right to refuse treatment, but as you discuss and know as a physician, an expert opinion about 'reasonable options' has an impact on what patients see as reasonable choices...
We should also be critical of 'evidence' presented to the joint parliamentary report, particularly if you rely on the report of the committee itself, which is problematically biased. An early paper shortly after legalization suggested that persons who asked for MAID were overall better-off, in relationships, with higher educational degrees. If you look at the data published by Health Canada, you see that a significant % of people who get MAID are now qualifying their suffering as intolerable because of loneliness (17%), being a burden to family, friends and caregivers (more than 30%!). We also see increased case-reports of people asking for MAID because of poverty, lack of adequate housing, etc. The data collected until recently do not capture enough of that to know how that is shifting. It is also clear, from evidence in B & Nl, that when you include mental illness as a sole basis, you will have in that population primarily people who struggle with a variety of social determinants of health. A final note: 57% of people say they suffer intolerably because of lack of pain relief or fear of that. As physician, you also would probably agree that it can't be the case that we had last year 5,000 people (half of 10k) whose pain could not adequately be relieved... That suggests to me MAID is clearly offered as a surrogate for the best available care... Not a last resort. Re the problems with the joint parliamentary report, see the letter of > 40 witnesses who testified before the committee: https://drive.google.com/file/d/1deorIQyVCXppcdROJaR3ZqcL0XUjdhwR/view
thanks for clarification. I read too quickly! You may be particularly interested in the discussion around MH and MAID. Happy to send you more about that by e-mail but you may already be on top of that literature!
It should be noted that 80% who received MAID in Canada had received palliative care beforehand: https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2021.html#table_4.4
One retort to this would that this doesn't specify the exact type of palliative care patients received (and it's true that it's a limitation of the report). At the same time however, there isn't an implication that the care received was sub-standard. When you look at Belgium, Oregon, and New Zealand for example (I don't know what the percentage is for patients in the Netherlands, Switzerland, Australia, or the other various US states that legalised MAID) you also see that the great percentage of patients who received assisted-dying underwent palliative care beforehand.
In Belgium approx 71%: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5758933/
In New Zealand approx 74%: https://www.health.govt.nz/our-work/life-stages/assisted-dying-service/assisted-dying-service-data-and-reporting
In Oregon approx 90%: https://journals.sagepub.com/doi/abs/10.1177/1049909111418637
I truly believe that given from all the evidence so far, that even if 99% of MAID applicants were receiving the very best palliative care most MAID requests wouldn't be rescinded. Why? Because pain isn't one of the top reasons why people request assisted-dying in the jurisdictions that have legalized it. Loss of autonomy, loss of dignity, and inability to engage in the activities they find to be enjoyable are by far and large the most common reasons. Palliative care is primarily about symptom management, which doesn't target this.
https://jamanetwork.com/journals/INTEMED/articlepdf/414824/ioi80188_489_492.pdf
DS, thank you for this perspective and these data, and for your civil comment.
Your point about palliative care is important. We need to know more about the care that was received at the end of life. I know more about mental health care and I don't think it's likely that patients received adequate mental health care before dying.
I agree with this point: "Loss of autonomy, loss of dignity, and inability to engage in the activities they find to be enjoyable are by far and large the most common reasons." However, this is where I part company with MAID advocates. I don't think becoming dependent means you lose human dignity. And I don't think assisted suicide should be a standard care for patients who do not want to become dependent or are losing the ability to engage in things they find to be enjoyable.
That's fair. I'm personally of the opinion that it isn't wrong to value autonomy or being able to engage in the activities that people find pleasurable in life.
All the best.
Understood.
I'm not suggesting that there is anything wrong with either autonomy or being able to engage in pleasurable activities. Better: both are critical to human well-being. I'm saying that we should draw a line such that doctors would not be permitted to assist suicide or perform euthanasia for those reasons.
I acknowledge that this will come at a cost for some people who want to die for those reasons. There are no easy solutions here.
No worries. Thanks for the clarification even though I personally disagree myself. Take care.
Thank you for this piece. The offer of MAiD by your oncologist reminded me of what appeared to be an approval based on a very limited and in some significant ways, completely wrong, knowledge of my father. I wrote the experience here. https://christopherlyon.substack.com/p/dying-indignity
I'm also concerned about who is attracted to providing MAiD. It's one thing to feel that ending the life of someone in extremis is perhaps a benefit to them, but quite another to want to involve themselves in ending the lives of people who are not dying and/or children, and who express personal gratification as a result. If we propose screening patients of suicidality and mental illness, we should do likewise for clinicians wishing to involve themselves in MAiD.
Thank you, Christopher. I look forward to reading your account.
Thank you for this helpful article on MAID including comments from your personal and medical experience. I was horrified that your surgeon suggested assisted-suicide based on his calculation of your life span (which was off by more than a few years!). Medical ethics need to be discussed and laws/ policies constantly reviewed, especially when they have life-changing consequences.
I came to your substack after reading "Eucharist ,Cancer, Love", your beautiful, poignant and insightful article in Comment Magazine, Winter 2023. May the Lord bless you for teaching us how to use each precious day of life well, in the centre of God's love.
Thank you for those kind words, Maria.
Excellent post, Bill. And 10,000+ instances per year seems to me to be quite persuasive evidence that this option is being overused.
Great article. In addition to personal awful circumstances (homelessness, poverty) I think I would add sense of being burden to family would prompt suicide. Offering by physicians legitimizes the choice when people are very vulnerable.
Insightful reflections. It rejoins a piece we wrote when Bill C7 was being debated. Canada's MAID system is unique in that respect. No other regulatory regime treats MAID as first line therapy available to be put on the table for any seriously ill or disabled person (i.e. everyone with serious illness, disease, or disability and has irreversible decline of capability (quite an ableist/ageist concept, in fact: who doesn't have that?) and who may be suffering intolerably. It's CAMAP's recommendation to explicitly introduce it to everyone who 'might qualify;, and the law doesn't prevent that and also doesn't require that all other options be made available and attempted first. In B & Nl, until recently the most liberal regimes, doctors have to agree that no other reasonable options other than euthanasia are available. In practice, this may sometimes come to the same, when you combine that with the right to refuse treatment, but as you discuss and know as a physician, an expert opinion about 'reasonable options' has an impact on what patients see as reasonable choices...
https://policyoptions.irpp.org/magazines/february-2021/how-bill-c7-will-sacrifice-the-medical-professions-standard-of-care/
Thank you, I will read this with great interest.
We should also be critical of 'evidence' presented to the joint parliamentary report, particularly if you rely on the report of the committee itself, which is problematically biased. An early paper shortly after legalization suggested that persons who asked for MAID were overall better-off, in relationships, with higher educational degrees. If you look at the data published by Health Canada, you see that a significant % of people who get MAID are now qualifying their suffering as intolerable because of loneliness (17%), being a burden to family, friends and caregivers (more than 30%!). We also see increased case-reports of people asking for MAID because of poverty, lack of adequate housing, etc. The data collected until recently do not capture enough of that to know how that is shifting. It is also clear, from evidence in B & Nl, that when you include mental illness as a sole basis, you will have in that population primarily people who struggle with a variety of social determinants of health. A final note: 57% of people say they suffer intolerably because of lack of pain relief or fear of that. As physician, you also would probably agree that it can't be the case that we had last year 5,000 people (half of 10k) whose pain could not adequately be relieved... That suggests to me MAID is clearly offered as a surrogate for the best available care... Not a last resort. Re the problems with the joint parliamentary report, see the letter of > 40 witnesses who testified before the committee: https://drive.google.com/file/d/1deorIQyVCXppcdROJaR3ZqcL0XUjdhwR/view
Thanks again, Trudo. Your point here is very important.
A point of clarification. I am a professor in the University of Ottawa Faculty of Medicine, but I am a psychologist, not a physician.
thanks for clarification. I read too quickly! You may be particularly interested in the discussion around MH and MAID. Happy to send you more about that by e-mail but you may already be on top of that literature!
Trudo, I would be grateful to read anything you send me.
email = william dot p dot gardner at gmail dot com