A fact-checked debate about euthanasia（A fact-checked debate about euthanasia）

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I have a bunch of patients who are waiting for it, right?
They've been approved—
They've not been approved.
They're waiting and hoping to be approved.
These two doctors have conflicting viewpoints
on euthanasia in their country.
I think Canada's approach to assisted dying has been successful.
I am very concerned about medical assistance
in dying laws in Canada.
Euthanasia became legal in Canada in 2016.
They call it “medical assistance in dying” or MAID for short.
Since then, the number of assisted deaths in Canada
has risen to over 10,000 people in 2021.
That's more people by raw number than any other country
where assisted dying is legal.
In 2021, eligibility for MAID expanded to include people
who are not nearing the end of their lives.
And starting next year...
that will include people suffering solely
from serious mental conditions, too.
Our participants are here to engage in a new kind of debate.
Yeah, that's where you and I would disagree.
I know.
Where instead of fighting over unvetted talking points...
we ask each expert to pick three facts
that their opponent would have to concede are true.
Dr. Maher, do you agree that these facts are true?
I do.
Dr. Green, do you agree that these facts are true?
Yes, I do.
They'll present their facts and they'll each get a chance
to respond with a footnote.
And after the fact exchange...
we'll also have four additional rounds
to further clarify their positions.
This is a fact-checked debate about euthanasia...
in Canada.
Here we go.
In Canada
assisted dying is a rights-based issue...
resulting from constitutional court challenges.
The legalization of assisted dying did not come about due to
voter initiated ballots, as happened in some US states...
or because the government thought it was a good idea.
Both of which can change with shifting political winds.
Importantly, these court cases were brought and won
by people with both terminal
and non-terminal illnesses.
It is true that court cases...
gave people who didn't have terminal illness...
the right to have assisted deaths.
But one of the plaintiffs in that key case...
Jean Truchon, who had cerebral palsy...
when he was considering getting assisted death
what he said was that it was the loneliness...
that was brought on by the pandemic...
that was leading him to make that choice.
So I'm really concerned about what that means
for people in Canada...
who will make choices to die.
Not for medical reasons alone, or maybe not even primarily
because of medical reasons
but because of social reasons: poverty...
isolation, loneliness.
That worries me a great deal.
Jean Truchon ultimately led his challenge
to the new law for assisted dying...
because he was about to lose function in his remaining limb.
That was his initial incentive.
Ultimately, this comes down to a question of rights.
And who, if anyone, controls our lives.
My name is Dr. Stefanie Green
and I'm a provider of assisted dying in British Columbia, Canada.
I've always been taught about the importance
of patient-centered care.
And I have found it to be profoundly meaningful
to be involved at this time in their life...
and to provide and facilitate their final wishes.
There are 15 countries that allow
some form of medically assisted dying...
Including ten US states and Washington, DC...
that allow people with a six month prognosis...
to self-administer a prescribed drug.
Canada is one of eight countries
that allows assisted dying for people
without a terminal diagnosis.
Next year, it will join most of these countries
in extending eligibility to people
whose only condition is a mental illness.
In these countries, cases involving
primarily psychiatric conditions are rare.
In Belgium and the Netherlands...
they made up about 1% of all cases.
Canada's assisted dying laws
lack the safeguards that other countries have.
There is no requirement
that all reasonable treatments
at least have been tried by the patient.
The doctors are able to initiate the conversation.
There is no review process.
There's nobody looking to see
whether people in Canada licensed to do this...
have in fact followed the law and followed the rules.
Canada rejected paternalism in medicine quite a few decades ago.
The Supreme Court decision states that a patient...
is not required to undertake medical treatments...
that are unacceptable to the individual.
We have long accepted that patients can refuse medical treatment.
Even if the result of that refusal is death.
There's actually a very rigorous process in place
for this assisted dying model.
There's a number of eligibility criteria, but once they are met
there are on top of that, a number of procedural safeguards.
Of course, we're in complete agreement
that paternalism is not a good thing
and every Canadian is free to make their own choices.
But when we're talking about assisted death
we're talking about choices made at a point in time
when a person is profoundly vulnerable.
My name is John Maher.
I'm a psychiatrist with a community mental health team
in Ontario, Canada.
My goal is to help my patients
live their lives the way they want...
and to do all we can to ensure that mental illness...
and all that follows from that doesn't keep them
from living full, rich lives.
There was an initial concern
that people would request assisted dying...
because they couldn't access palliative care.
But the data has put that fear to rest.
Over 80% of the people who receive MAID in Canada...
are receiving palliative or hospice care at the time of their death.
For those few who are not...
88% of them have access to such care.
Compare that to the wider Canadian population
and all causes of death
when statistics suggest
that only a minority of people are receiving
palliative care before they die.
The data that you're referencing...
comes from the forms that are filled out by the MAID providers...
and it tells us nothing,
nothing at all, about the quality of the palliative care.
We also know from the data you're citing that 21% of people who...
who received MAID had palliative care for less than two weeks.
While it's true, we don't have an objective marker...
for the quality of palliative care received.
What we do know from lots of data...
is that since MAID was legalized in Canada...
we have a significant increase
in the funding for research for palliative care and an increase
in the number of people receiving and dying with palliative care at home.
The vast majority of people who access MAID in Canada
are patients with a cancer diagnosis.
The next most common underlying
illness are end-stage organ failures.
So end-stage heart disease
end-stage lung disease, end-stage liver disease...
and neurologic conditions, they're around the 10% to 15% range.
The wait times for MAID in Canada
are shorter than the wait times
to get a lot of specialized services.
That might be pain clinics, psychiatric care...
long-term care homes, veterans' benefits...
supportive housing, community-based care.
That's not right.
My job as a MAID provider
requires me by law to ensure
that my patients have been offered the resources and services
that could potentially reduce their suffering.
I agree we need to reduce wait times
but at some point when potentially helpful resources...
are not reasonably available
we can no longer hold individuals hostage to society's failings.
It seems to me that the greatest failing
we're talking about here is a society
that's willing to help its citizens die...
rather than provide the services...
that we know help, that we know work...
that we know reduce suffering.
Killing people while they're on wait lists...
is profoundly immoral.
National polls consistently show
that the Canadian public supports assisted dying.
This includes people who self-identify
as religious and people with disabilities.
These polls were conducted before our law changed
to allow assisted dying,
in the first five years of legalized practice...
and in every year since the amendment that extended eligibility
outside the end of life context.
Two polls that asked Canadians
about their views on MAID for mental illness
came back with very different results.
One poll showed over 60% of Canadians in favor.
Another poll, one in particular looking at MAID for mental illness
showed that only 31% of Canadians support it.
I don't think Canadians have a full understanding...
of what is happening.
But those organizations that are focused on what's happening...
and drawing attention to it
namely the 137 disability organizations in Canada...
the national indigenous organizations...
the mental health organizations, the United Nations...
everyone who is looking at this and understanding
what is going on is gravely concerned...
about the discriminatory impact of this legislation.
Canadians have been talking about and debating
assisted dying since the 90s.
There are multiple reports, multiple committees...
multiple news stories, multiple court cases...
to suggest that Canadians are unaware of what the issue is
is not exactly fair to the Canadian public.
There is no consensus
among Canadian psychiatrists
on when any particular psychiatric illness is incurable.
And under the law that comes into effect in 2024 in Canada
a psychiatric illness must be incurable
and a person must be in a state of irreversible decline.
But we can't say who that is.
Consensus in health care is rarely required.
There is no consensus amongst doctors...
about whether they can accurately predict
a prognosis of six months.
Yet it's an eligibility requirement for assisted dying
in several countries, including the United States.
However, in Canada, for MAID to proceed...
two independent clinicians must be of the opinion...
that the patient's condition is incurable.
When someone has a terminal illness...
say cancer, we have a pretty good idea...
of how long they might live.
May not be precise, but we have a good idea.
In mental illness, we have no idea.
People get better after five years, after ten years.
These are very, very different conditions...
very different circumstances.
Now, we'll move on to the additional rounds.
Questions.
Personal experiences.
Debunk.
Uncertainties.
Stefanie, can you ask John a question
that helps clarify his position?
John, do you believe every person
with a mental health disorder can be treated successfully?
Because if not and they have capacity...
should they not be allowed to access the same legal health care
available to everyone else?
We both know the majority of people living with mental illness...
have full capacity.
They can make their own treatment decisions.
To answer your question, can we treat everyone?
I don't think that's the right question.
The question is, can we reduce suffering?
Can we help people cope with suffering?
There are certainly going to be people
whose illness will not get better, their physical illness.
But can we mitigate their experience of their symptoms?
Can we bring support...
care, compassion, and love to them in a way
that makes their life for them worthwhile?
I'm not talking about denying anyone...
the option of choosing MAID.
To be frank, everyone can already choose suicide.
What we're working to do is to ensure
that every person is treated with respect, dignity...
provided with care and support...
that we know can help reduce suffering.
Okay, John, would you like to ask Stefanie a question?
Only one in three Canadians
have access to mental health care who need it.
Only one in five children.
We know from disability organizations across the country...
that disability supports are completely inadequate...
to live a meaningful life.
People are suffering...
in ways that we can do something about.
I'm asking you...
would you support providing MAID to someone...
while they're waiting for treatment or care...
that could help them?
But it's down the road a bit.
I would happily stand with you
and call for our government to do better than what it's doing.
I think it's a separate issue.
There can come a time, on a case-by-case basis...
Every situation is individual, every situation is unique
and every case needs to be assessed in a unique way.
There may be a time when a certain treatment
is available, too far away,
much too expensive, inaccessible to the patient.
In this case, we have to seriously consider
not holding them hostage to society's failing
and to consider offering MAID if it's truly what they need.
A tough situation.
I grant you that.
John, can you tell us something from your personal experience
that has strengthened your conviction on this issue?
As a psychiatrist...
who works with a community mental health team...
supporting people with the most serious mental illnesses...
We are becoming overwhelmed...
by what MAID has introduced...
into our clinical worlds.
I have patients who are already saying...
“I'm going to stop treatment.”
“I'm not going to keep trying.”
“I can die.”
Our efforts to help them stick with the very challenging
and sometimes long-term treatment required to heal and recover
is being undermined.
We're not just doing suicide prevention anymore.
We're doing MAID prevention.
I'm going to tell you about a gentleman I'll call Ray
who was 62 years old with metastatic lung cancer.
And Ray had been asking for MAID for quite some time.
And as he and I worked through the rigorous eligibility criteria...
at some point, I was able to sit in front of him
and tell him he was eligible for this care.
And when I sat there and did that, I saw in him...
a physical transformation, which I've learned actually happens...
almost every time.
I saw his shoulders relax.
I think I saw him smile for the first time since I'd met him...
and it was immediately followed by an expression of gratitude
for the mere possibility.
He decided to proceed with MAID
and we held it not long after, in the rooftop garden
of the facility in which he was living.
And as is required by law
I was seeking his final consent
before I administered the medication.
He was surrounded by his friends...
and as he gave me that consent
he reached out and grabbed my hand.
He looked at me and he said,
“I know this is going to sound odd, Dr. Green
but I think you saved my life.”
And it reminds me all the time...
that for the people who actually need and want this care
it is tremendously important.
Stefanie, what is one piece of specific misinformation...
that you've heard about MAID that you'd like to correct?
Recently, a number of eye catching headlines
have appeared in the news about Canadians requesting
assisted dying due to the threat of homelessness...
or the fact that they're living in poverty.
And while it's true that anyone can ask
for an assessment of eligibility for MAID...
and those unacceptable social inequities
might be contributing towards suffering.
The law is actually perfectly clear and Canadians cannot access
MAID based on those factors alone.
John, would you like to clarify a piece of misinformation?
Some MAID providers have argued that MAID...
for non-terminal conditions...
is not suicide.
For decades, suicide has been defined
as taking steps to arrange your own death.
Some have said that what makes MAID different than suicide...
is that it's well thought out.
It's not impulsive.
But in fact, in one US survey of over 1.4 million Americans
80% of people reported
that they thoughtfully planned their suicide...
Which means that we have to consider
where it fits into all of our suicide prevention efforts...
and whether it undermines those very directly.
And now for a round called Uncertainties.
John, what is something we don't know
about this issue that we need more research on?
Canada currently collects data...
on the illnesses—
the physical illnesses that lead to requests for MAID.
What we don't have is data...
that considers the socioeconomic reasons people might request it.
And how significant an impact...
that might have on the request
and perhaps whether it drives it completely.
We don't know whether poverty, homelessness...
being on a waitlist for treatment...
being refused disability benefits...
we don't know why...
people are choosing MAID and we should.
On this point, John, I think we're almost in agreement.
Canada has recently expanded the type of data it's...
gathering on patients who request and receive MAID.
And I'd be curious to see if it mirrors what we know
from international jurisdictions.
Everywhere where this data is collected elsewhere...
we know that it is the socially advantaged...
who are accessing assisted dying
not the socially disadvantaged.
So I'll be curious to see if that plays out
in the Canadian context, which is what I expect to be frank.
That said, I think we do have a good idea
of how people describe their own suffering...
and therefore why they're requesting MAID.
Primarily, it's for people who can no longer do the things
that bring meaning to their lives...
who no longer are able
to do what we call the activities of daily living...
who've lost a sense of dignity or independence.
And I think if we could find research
that would help us better understand...
what leads to that type of suffering...
potentially there's a way we can learn to treat it.
I'm concerned about this law...
having, I'll acknowledge, the unintended...
but profoundly disturbing consequence...
of having people feel like they're a burden
and that they should choose death over life.
That they should no longer demand
of their government, of their fellow citizens...
that care and support be provided.
Having spent time
with many suffering individuals, I can tell you...
that Canadians are extremely grateful for this option.
In a testament to the quality of care being provided...
not a single person has been charged with misappropriate action.
I think Canada's approach to assisted dying
is more than adequate.
It is solid.
It is good, and for some, it may be a model...
for considering care in their own region.