Mr. S was rushed to the Emergency Department of Mount Sinai Hospital after a suspected suicide attempt. He had recently been diagnosed with metastatic pancreatic cancer and had taken a lethal dose of his prescribed pain medication, hydromorphone. The hospital staff were able to save his life and began assessing his eligibility for medical assistance in dying (MAiD).
It is important to note that Mr. S did not apply for MAiD and did not make any official requests for it. However, while he was recovering in the ER, two other physicians who were not connected to his primary care spoke to him about it. They learned that he had asked his family doctor about making a request for MAiD two weeks prior, but nothing had been initiated.
The physicians concluded that “this was sort of him taking matters into his own hands.” The situation turned into “query suicidality,” which is a medical term for an uncertain diagnosis in clinical reports. When the physicians met with Mr. S, they felt that he was making a capable request for MAiD.
University of Toronto’s
The case of Mr. S was presented in a public seminar series on March 24, 2021, as part of the University of Toronto’s Joint Centre for Bioethics. The seminar was attended by several clinicians, some of whom expressed discomfort with the assessment of MAiD eligibility in Mr. S’s case. One participant questioned why capacity for MAiD was assessed when the patient was experiencing untreated physical distress.
John Maher, a psychiatrist specializing in treatment-resistant mental illnesses and the editor-in-chief of the Journal of Ethics in Mental Health, criticized the situation. He described it as “bizarre” and shocking that MAiD was offered without addressing physical suffering or exploring potential psychiatric issues such as adjustment disorder or depression.
The Canadian Minister of Justice and Attorney General, David Lametti, had previously assured Canadians that there are waiting periods in place for MAiD, and that no one in a state of crisis would be given MAiD. Lametti emphasized that a person cannot simply walk off the street and request MAiD in a webinar for Dying with Dignity Canada in 2019.
The author of the article has been investigating the circumvention of MAiD safeguards for the past two years. The mistakes made when MAiD was first legalized were reported in 2017 by the National Post. According to Quebec’s College of Physicians, emergency physicians allowed suicide victims to die despite their treatable conditions because of MAiD.
The case of “Mr. S” was discussed in a public seminar held on March 24, 2021, by the University of Toronto’s Joint Centre for Bioethics. He was rushed to Mount Sinai Hospital after attempting suicide with a lethal dose of his prescribed pain medication following his recent diagnosis of metastatic pancreatic cancer.
Although he never applied for medical assistance in dying (MAiD) nor made any official requests, two physicians not involved in his primary care approached him while he was in the emergency room to discuss MAiD. They deemed his request for MAiD as capable, despite the fact that he had not yet addressed his physical distress.
This is not how MAiD is supposed to work, according to David Lametti, the Minister of Justice and Attorney General. In a webinar for Dying with Dignity Canada, Lametti stated that there are waiting periods and that no one in crisis would be given MAiD.
However, in the past two years, there have been reports of MAiD providers circumventing the safeguards put in place for the program. The National Post reported in 2017 that emergency physicians made mistakes in letting suicide victims die, despite their conditions being treatable.
Recently, it was revealed that some individuals in crisis following a suicide attempt have been given MAiD, despite claims from MAiD providers that attempting suicide disqualifies an individual from the program. The leading organization that trains MAiD providers was aware of this practice and privately endorsed it, even though a leading board member warned it could violate the law and the public’s trust.
Suicide and MAiD were intended to be separate, as ruled by the Supreme Court of Canada in the Carter case. The most recent expansion of MAiD created two tracks, and the procedural safeguard for Track 2 cases is a minimum 90-day assessment period. This safeguard will likely become even more important when people with only mental illnesses qualify for assisted suicide in the future.
University of Toronto’s
The University of Toronto’s Joint Centre for Bioethics held a seminar on March 24, 2021, where a patient’s case, Mr. S, was discussed. Attendees expressed discomfort with the idea of assessing Mr. S’s capacity for MAiD, a medical assistance in dying, while he had untreated physical distress. Psychiatrist John Maher reviewed the seminar and called it “bizarre,” adding that it was shocking to discuss MAiD without addressing physical suffering or sorting out any underlying psychiatric issues.
However, Canadian Minister of Justice and Attorney General David Lametti had promised that MAiD could not be performed the next day, and individuals in crisis would not be eligible. Despite this promise, there have been reports of MAiD being performed on individuals who attempted suicide. The leading organization that trains MAiD providers was aware of this practice and privately endorsed it, despite concerns that it would violate the public’s trust and potentially the law.
MAiD was initially intended to be separate from suicide. The Supreme Court of Canada ruled in Carter that proper safeguards could protect vulnerable persons from being induced to commit suicide. The Canadian government agreed, and the most recent expansion of MAiD created two tracks: Track 1, where a patient’s natural death has become reasonably foreseeable, and Track 2, where it hasn’t. In Track 2 cases, MAiD cannot be performed until the end of a minimum 90-day assessment period.
There are indications that suicide through MAiD may be occurring. Minister Lametti has caused controversy by suggesting that MAiD provides a more humane way of committing suicide for individuals who are physically and mentally unable to do so themselves. However, MAiD experts, including Stefanie Green, president of the Canadian Association of MAiD Assessors and Providers (CAMAP), maintain that suicide and MAiD are entirely different.
CAMAP represents the national body of MAiD experts and has been allocated $3.3 million by Health Canada to develop a national training curriculum for MAiD providers and assessors. In practice, much of the clinician training for MAiD already comes from CAMAP resources.
The article questions whether medical assistance in dying (MAiD) is being used as a substitute for suicide, despite denials from MAiD providers that attempting suicide disqualifies an individual for the program. The Canadian Association of MAiD Assessors and Providers (CAMAP), which is responsible for training MAiD providers, has received $3.3 million from Health Canada to develop a national training curriculum for MAiD providers and assessors.
Reasonably Foreseeable Death
The article delves into the definition of “reasonably foreseeable death,” which is used to determine eligibility for MAiD. The CAMAP training document defines it as a patient having a “death expected within x years” or having “a predictable trajectory to death.” Jocelyn Downie, a law professor who argued for decriminalization of assisted dying, argues that comparing suicide and MAiD is a logical fallacy because those who attempt suicide and survive do not qualify for MAiD.
However, an authenticated summary of a CAMAP case sharing session reveals that a person who suffered injuries from a suicide attempt and was left with pain and disability that led them to ask for MAiD received it under Track 1, without the required 90-day assessment period in Track 2. This case raises questions about whether MAiD is being used as a substitute for suicide.
The memo in question asks whether the risk of aspiration pneumonia from a suicide attempt or the risk of sepsis from quadriplegia caused by a car accident can be considered natural deaths, even if the coroner deems them not natural. This question is important because Track 1 of MAiD requires a “reasonably foreseeable” natural death. If a death is not natural, any clinician involved could face criminal charges.
The memo ultimately affirms that the right decision was made in the case of patients who had refused treatment for aspiration pneumonia or sepsis, as their deaths can be considered natural deaths that meet the NDRF (natural death is reasonably foreseeable) requirement, despite the coroner’s report.
However, Jonathan Reggler, another MAiD provider and co-chair of the Clinicians Advisory Council for Dying with Dignity Canada, expressed concern about the risk of the case being seen as suicide completion and the potential for a court case or negative public perception. Reggler urged other CAMAP members to consider the optics of such cases and the potential consequences for MAiD clinicians and supporters.
CAMAP and its president, Stefanie Green, as well as Reggler, did not respond to requests for comment. The RCMP could not confirm or deny if the case discussed in the memo is being investigated.
The author of the article interviewed Jocelyn Downie, a professor of law and medicine at Dalhousie University, about the Medical Assistance in Dying (MAiD) law in Canada. Downie clarified that her comments in a memo to the Canadian Association of MAiD Assessors and Providers (CAMAP) were not a “legal interpretation,” but rather an explanation of the law in relation to a specific question asked. Downie also stated that there is no contradiction between her comments in the interview and the CAMAP memo. She explained that when a person presents with a suicidal state, that state must first be attended to before MAiD can be considered.
The issue of suicide is relevant when considering the “optics” of MAiD. The Supreme Court of Canada decriminalized assisted suicide based on the “harm avoidance” argument, which maintains that giving individuals the choice to end their life through a physician is necessary to save lives. However, the data shows that in Canada, the number of MAiD cases has increased significantly between 2016 and 2020, while the number of suicides has remained essentially flat since at least 2003. This trend is contrary to what has been observed in other countries. As a result, Canada’s suicide rate, including assisted and unassisted suicides, is among the highest in the Organization for Economic Co-operation and Development (OECD), at 30.1 suicides per capita.
I presented the data to Trudo Lemmens, a law professor at the University of Toronto, for his insights. However, Tyler Black, a supporter of MAiD and a suicidologist, did not respond to my interview requests. According to Lemmens, the Supreme Court’s claim that legalizing MAiD would reduce suicides lacked evidence. He noted that while it may seem appealing in theory, the data does not support it.
Starting next year, Canadians with mental illnesses may qualify for MAiD. The Expert Panel on MAiD and Mental Illness, led by psychiatrist Mona Gupta, recommended to Parliament that no additional legal safeguards were necessary. Gupta previously stated that these patients would have received psychiatric care for years before being eligible for MAiD. She added that individuals who have difficulty accessing care are not eligible for MAiD.
In June of last year, I asked Gupta about cases where suicide attempts resulted in MAiD. She explained that it is a clinical judgment issue as to whether someone who has attempted suicide should eventually be eligible for MAiD, and how far into the future that should be. Gupta also noted that some individuals who survive suicide attempts refuse treatment and die as a result.