Advance?

Adam James Pollock writes:

Canada has seemingly decided to stop sliding down the slippery slope of assisted dying. On Wednesday, the country’s Justice Minister, Sean Fraser, revealed that the Liberal government would be indefinitely suspending its plan to legalise assisted dying for individuals whose only condition is mental. Before this, legislation had been passed which meant that, from March of next year, Canadians could apply to end their lives solely on the basis of mental illness.

This law has now been shelved, with Fraser stating that the government has decided there is no medical consensus on when mental illnesses become incurable or untreatable, and that subsequently it would be impossible to discern in which circumstances individuals could be allowed to end their lives. Psychiatrists had repeatedly been making this point, including earlier this year to a parliamentary committee, conveying that it is not possible to prognosticate on mental illness. At long last, the government appears to agree.

Yet since 2021, people can apply to end their lives in Canada even if their death is considered to be “reasonably foreseeable”, meaning that many people with lifelong conditions which are not considered terminal, such as multiple sclerosis, can die by euthanasia. This seems to reinforce the precedent that has long been put forward — whether implicitly or explicitly — by those who advocate for assisted dying, that the lives of disabled people simply have less value than their able-bodied counterparts.

This two-tiered society has been evident in Canada for several years now. Christine Gauthier, the Canadian Paralympian and army veteran, asked for state assistance in making her home more accessible through the installation of a wheelchair lift. Instead, she was offered euthanasia. Roger Foley, who has a degenerative neurological condition and remains in hospital, has repeatedly attempted to access self-directed home care, yet he is continually told by hospital staff that his only real options are to put up with his limited care or end his life. There are countless other examples. The solution, which the Canadian government has finally taken its first steps towards, is not widening the scope for people to die, but instead providing people with the requisite care to live as meaningful and dignified a life as possible. 

Disability campaigners have been highlighting this plight in Canada for years, and it is one that has been echoed in great detail in Britain over recent months. This year alone, legislation which would have legalised assisted dying in England, Wales and Scotland have all been rejected, in large part due to the worries of disabled people that they would essentially develop a duty to die. Legislators including Baronesses Grey-Thompson and Campbell, as well as Lord Shinkwin, revealed how they are frequently treated as second-class citizens due to their disabilities, and how this would translate to an increased vulnerability under an assisted dying programme.

Hopefully, Canada’s change in direction will inspire other countries where assisted dying for mental illness is already legal to follow suit. In the Netherlands, for example, there have already been tragedies where lives have been ended when the individual’s mental-health condition could have been treatable, such as the case of an autistic boy between the ages of 16 and 18 who was euthanised following a failed suicide attempt, with the justification being that he was suffering mentally because of his autism. This is precisely the kind of horrific case Canada has just avoided. The Netherlands could, and should, avail of this shift in medical and legislative viewpoint and repeal its legislation.

Canada has taken the right first step in ensuring that people with serious illnesses or conditions — mental or physical — are not disproportionately adversely affected by assisted dying laws. The next step back up the slippery slope is to reverse the other recent expansion of the law that allowed those for whom death is not reasonably foreseeable to end their lives. Assisted dying laws that were initially billed as being the exception to the rule have rapidly become the status quo, and any government that seriously cares about its citizens should seek to stamp this out.

And Darren Major writes:

The former Quebec premier who oversaw passage of Canada's first-ever medically assisted dying law says he now feels conflicted after seeing how far the practice has progressed since then. Quebec's National Assembly passed the law in 2014 outlining conditions under which terminally ill patients could formally request medical assistance in dying (MAID). While the bill was initially introduced by the Parti Québécois, it gained multiparty support while Philippe Couillard's Liberals were in government.

The former premier told CBC's The House that he sometimes questions his 2014 decision after seeing how MAID has expanded in Quebec and Canada since that first law was passed. "It was clearly reserved for terminal or pre-terminal conditions with a defined, unfortunate road to the end of life. And this is not the case anymore," he told host Catherine Cullen. "I'm not sure that I would have again voted for that law with the extension that we have seen in the recent years." 

Two years after Quebec passed its law, the federal government passed its own MAID legislation — prompted by a 2015 Supreme Court ruling that said a prohibition of medically assisted dying ran contrary to the Charter of Rights and Freedoms. Former prime minister Justin Trudeau consulted with Couillard before the 2016 federal MAID law was adopted. That federal legislation was struck down by the Superior Court of Quebec in 2019 because it was limited to those whose deaths were "reasonably foreseeable." The federal government passed a subsequent law in 2021 to fall in line with the court's ruling. Quebec took things a step further in 2024, allowing for people to submit advance requests for MAID before a person's condition, such as Alzheimer's, renders them incapable of giving consent.

Couillard, a former neurosurgeon, emphasized that the intention of Quebec's original law was to limit MAID to those solely suffering from a terminal illness. "I was warned about this by people opposing the law that told me, 'We see your motivation is good, but you will see, once you open the door you will not close it and it will open wider.' And this is what happened," he said. The federal government announced this week that, after deliberation in the wake of the 2019 court ruling, it wouldn't proceed with expanding MAID to people who are solely suffering from mental illness. (There are multiple cases before the courts arguing for further expansion to include people suffering from mental illness). 

Justice Minister Sean Fraser announced the government will not move forward with allowing medical assistance in dying (MAID) for those suffering solely from mental illness, angering some MAID advocates, but pleasing many in the medical community. "We need to create space for people to be able to provide consent when they know they're going to lose capacity in order to live out their remaining years rather than being put in a position where they fear they have to take that decision prematurely," Fraser said earlier this week. "We don't have the jurisdiction to create these services in the different provinces. We only have the jurisdiction to determine when a particular set of behaviours will be treated as criminal under Canada's criminal laws." 

Despite his current reservations, Couillard praised the passing of the original bill as "one of the best moments of democracy" during his premiership, noting that he allowed for a free vote within his Liberal caucus. But when asked, he said he does sometimes have regrets about passing the law. "In general, when this hits me, I think about specific patients that I've known in my medical career that were in such deep distress and pain that I think we did the right thing," he said. "But I hope we didn't go too fast. I hope we didn't take this as a trivial matter, which is certainly not the case."

But Sharon Kirkey writes:

Just as one debate over euthanasia is being settled, another is emerging over Canada’s plans to allow people to consent to medical aid in dying (MAID) at some future date when they are no longer of sound mind. In a surprise move this week, federal Justice Minister Sean Fraser announced the Liberal government is fine-tuning a bill to be introduced sometime this fall that, in addition to placing an indeterminate hold on MAID for mental illness alone, would decriminalize “advance requests” for doctor-administered death. Performing euthanasia on the basis of a person’s advance request “will mean that people will receive MAID when they no longer understand what is happening to them,” said Trudo Lemmens, a University of Toronto professor of health law and policy. 

Another thorny ethical concern: who makes the final call that it’s time to act on an advance request once the person has lost the capacity to decide for themselves? The Criminal Code generally requires that a person has the capacity to consent to receive MAID immediately before death is administered. The Liberal government is proposing to change that. Here’s a look at why that’s making some people nervous.

What are advance requests for euthanasia? 

Advance requests would allow people who have been diagnosed with a serious and incurable disease that will eventually lead to incapacity to draft a document outlining the specific conditions under which they would prefer to die, which would then be provided after they have lost capacity. In its report following a “national conversation” on the issue, the federal government offered the hypothetical example of a man named “Charlie” who, after being diagnosed with Alzheimer’s disease, “decides that should his health decline rapidly and he starts experiencing intolerable suffering after he has lost capacity to make health care decisions, he would like to have MAID provided.”  His advance request would set out conditions that, for Charlie, would constitute “endurable and intolerable suffering,” a formal criterion for MAID. That could include not being able to feed himself, get out of bed or recognize his children. 

If these conditions were to arise, the advance request would state that it would be his explicit wish to be provided MAID. The Criminal Code currently requires that a person have capacity to give explicit, final consent before death. The only exception involves people who are close to a natural death and have already been approved for MAID and have a date set, but are at risk of losing capacity before the scheduled date. In those cases, people can sign a waiver of final consent. In March, Alberta became the only province to explicitly ban advance requests for MAID. Fraser said it will be up to provinces to decide whether to allow people to make advance requests. 

On Oct. 30, 2024, Quebec joined the Netherlands in accepting advance requests for people diagnosed with dementia and other serious conditions that will lead to incapacity. However, as the Montreal Gazette’s Aaron Derfel has reported, with no amendment to the Criminal Code, many MAID providers in Quebec are anxious about being prosecuted, despite the province’s directive to criminal prosecutors that pursuing doctors who comply with the provincial law would “not be in the public interest.” Even then, about 3,000 advance requests have now been added to a Quebec registry; between 30 to 40 deaths have been performed under the directives so far.

What have Canadians said about advance directives? 

According to the federal government’s recently conducted national conversation on the issue, an online questionnaire completed by more than 46,000 adults between December 2024 and February 2025 found 69 per cent supported advance requests for people diagnosed with a serious or incurable condition that will lead to a loss of capacity. Twenty-six per cent said they oppose them. Some participants in roundtable discussions said final consent is “an essential guardrail. Without it they said that vulnerable individuals would be at risk,” according to the report. Some questioned how people can make a truly informed decision, given they don’t know for certain what they’ll be experiencing in the future.

Likewise, some wondered how to manage circumstances “where the person meets the conditions set out in their advance request but appears to refuse MAID after they have lost capacity.” “Euthanasia for people who are incapacitated is a very, very delicate matter,” Montreal family physician Laurence Normand-Rivest said this week at a press conference on Parliament Hill organized by the Euthanasia Prevention Coalition. “They don’t have the privilege to consent at the moment where we kill them,” Normand-Rivest said. “They show a lot of resistance. They need to be sedated. They don’t want an injection, and to have an IV … People think it will be a peaceful death but in fact we see a lot of struggle and battle when doctors euthanize incapacitated patients,” she said. 

Dr. Laurent Boisvert, a MAID provider and president of Quebec’s Dying with Dignity association, said that, in his experience, deaths performed under advance requests aren’t nearly so disturbing. He has personally performed three or four such MAID provisions. “I didn’t have this type of problem, but I know that at some point I can be in front of a patient who is quite aggressive, who doesn’t want to be touched and we need to sedate this patient” in order to insert the IV, Boisvert said. “But calling this a distressing procedure, I don’t think so.” People can appoint one or two trusted people — a spouse, an adult child — to make sure their advance request is respected, he said. In conversations with colleagues, “it seems that it has worked well (with) no big problems at this time,” Boisvert said. 

In a controversial 2016 Dutch case, a doctor ended the life of a 74-year-old woman who had been diagnosed with Alzheimer’s four years earlier, and who had drafted an advance euthanasia directive requesting euthanasia should she ever be admitted to a nursing home and no longer able to live with her husband. When her condition worsened, she was placed in a nursing home, where she began wandering the halls at night. “The nursing home doctor reviewed her case and decided that the woman was suffering unbearably, which would justify her wish to die,” Dutch media reported. 

On the morning of her death, the doctor secretly slipped a sedative into the woman’s coffee. She did not tell the woman she was about to die. Despite the sedative, the woman appeared to try to get up in the middle of the procedure and “resisted physically,” the doctor initially reported to the euthanasia committee. The woman’s son-in-law laid her back down so the doctor could inject her. The doctor was eventually acquitted of breaking Dutch euthanasia laws after a judge ruled the woman’s prior written request was sufficient and that there was no legal requirement for the doctor to verify the “current death wish,” BBC reported.

What do proponents say? 

Dying with Dignity Canada said the proposed legislation would only decriminalize advance requests in provinces and territories that also pass legislation permitting them, creating at best a patchwork system across Canada. “At worst, some people in Canada may never have access to advance requests in their province or territory,” CEO Helen Long said. Fraser, the federal justice minister, said advance requests would allow people at risk of losing their decision-making capacity “to live out their remaining years, rather than being put in a position where they fear they have to take that decision prematurely.”

What do opponents say? 

While he can understand the appeal they hold for some, psychiatrist Dr. Sonu Gaind said there are several unresolved concerns, including how people, once they lose capacity, could withdraw their consent. “Meaning that, if they change their mind, and they’ve lost capacity, what do you do? How do you deal with it? How do you know?” It’s a concern reflected in the coffee case in the Netherlands, he said. Advance requests are also based on what people think they would and would not want in the future. “We’re not very good at knowing how we’ll actually deal with things and cope with things” months or years later, said Gaind, a University of Toronto professor. Studies show people who suffer spinal cord injuries, for example, adapt in ways they never thought possible, he said. 

“How do we predict that for our future selves? We don’t know how we will actually adapt and feel in the future once something happens.” What’s not talked about enough, he said, is what gets “projected into the decision” to end a person’s life. “Once the person has lost capacity, then the agency for actually fulfilling their prior wishes falls on someone else,” Gaind said. “It’s inevitable, it has to: It falls on someone else to make a judgment that, ‘OK, have the conditions now been met’” to warrant MAID. 

It would fall onto an assessor, yet the MAID literature shows the personal views and values of the assessor influences the end-of-life decisions that are made, Gaind said. “You risk having an illusion that, ‘Oh, we’re compassionately fulfilling patient autonomy,’ but in fact are we now, in some of these situations, allowing internalized ableism of assessors to get projected onto these assessments of patients who’ve, at this point, lost capacity?” Others worry about coercion. “A court can undo a will that was unduly influenced,” Heather Campbell Pope, a lawyer and chair of Dementia Justice Canada, said in a statement. “But once MAID is provided, there is no meaningful remedy if we find later that the person was pressured to make the advance request” or pressured to go along with it, she said. “It is simply too late.”