Maine Writer

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Wednesday, January 18, 2023

Mentally ill are especially at risk when access to euthnasia is expanded

Should people with a mental illness be helped to die?

In 2019, 61-year-old Alan Nichols opted for an assisted death after he was admitted to a British Columbia hospital for suicide watch. 
On his application for MAiD, (Medical Assistance in Dying) the stated reason was "hearing loss".

More about the wrong minded and unethical movement to expand euthanasia puts the mentally ill at risk for preventable death.

"Dr. Madeline Li supports Canada's decision to pause the Maid expansion for mental health. She can recall the first patient she helped die, about one month after Canada first legalized euthanasia in 2016. 'I remember just how surreal it was', she said." BBCNews.

This echo essay is a response from Commonweal to the opinion published in The New York Times and blogged by Maine Writer at this link here.

Encouraged to Die? Canada’s euthanasia laws may be further liberalized. Echo report by Michael W. Higgins published in Commonweal Magazine.

When Ross Douthat wrote about Canada’s love affair with the “holiness of euthanasia” in a December New York Times column, he hit a nerve. His primary argument is reductionist, facile, and oracular but correct in its essentials: “What if a society remains liberal but ceases to be civilized?” Is Canada, in truth, Douthat’s moral dystopia, the inexorable endpoint of a corrupting liberal trajectory? A cautionary tale for an American society caught in an embattled landscape of irreconcilable philosophies?

Yes and no.

What provokes Douthat is the pending law before the Canadian Parliament that will expand its Medical Assistance in Dying (MAiD) legislation. In 2016, medical assistance in dying became legal in Canada as long as certain conditions were met, including the restriction that only patients with terminal illness were eligible. Indeed, the natural death of the patient must be deemed as reasonably foreseeable and the suffering irremediable. In 2019, a Quebec judge ruled that this legal restriction was unconstitutional and that Parliament needed to amend the MAiD legislation to include adults who didn’t have a reasonably foreseeable death. In 2021, the revised MAiD came into force and almost immediately there were cries for even further amendments, including the right for those suffering from mental illness to elect their time of death. Parliament imposed a two-year study period before any further alterations, with new legislation to be debated and most likely enacted in March.

But this appears to be a step too far for many Canadians—liberal creatures that we are—and pushback has been formidable. The Association of Chairs of Psychiatry in Canada—the lead psychiatrists of Canada’s seventeen medical schools—called on the federal government to delay the expansion of assisted dying to people with mental illness. These psychiatrists, and many others in private practice, are especially vexed over the law’s irremediable condition clause, arguing that it is very difficult, if not impossible, to predict accurately who will and who will not recover from a mental disorder. The Chairs Association makes the point that experts will need to find some common ground on “operational definitions of irremediability for different mental disorders” because no such consensus currently exists. In addition, many psychiatrists are disturbed by the simple clinical reality that physicians might find it challenging to distinguish between a client who is suffering from acute suicidal ideation, and one who is rationally seeking an assisted death as the final remedy for unendurable pain.

It is important to acknowledge that the primary concern of the psychiatrists is not the law per se, but its expansion to include mental-health candidates without any kind of training regimen established for evaluating these candidates. Medical school curricula need to be upgraded, safeguards put in place, and the full airing of contentious issues around prognosis assured before any expansion of the legislation is enacted.
Professional associations of psychiatrists aren’t alone in raising concerns. The executive director of the Canadian Association for Suicide Prevention, Sean Krausert, has cogently argued that “ending the life of someone with complex mental-health problems is simpler and likely much less expensive than offering outstanding ongoing care. This creates a perverse incentive for the health system to encourage the use of MAiD at the expense of providing adequate resources to patients, and that outcome is unacceptable.”

This use of MAiD as an option for those suffering grievously, and with little access to a timely and comprehensive health network, is more than unacceptable; it is outrageous. Nuala Kenny, a pediatric physician, bioethicist and Sister of Charity (Halifax)—and a vocal critic of MAiD from the outset—has watched with dread the persistent efforts to further liberalize the legislation:

Bill C-7 legislating medically assisted death is titled incorrectly Medical Assistance in Dying. Good medical and palliative care provide assistance in the process of dying. MAiD is assisted death. The legislation at the beginning provided safeguards for a ‘reasonably foreseeable natural death,’ professional medical assessments, a ten-day waiting period, and ongoing study of difficult issues. All this has now been overturned or liberalized. MAiD provides a quick, cheap, technological response to human, familial, social, and spiritual matters. It is the antithesis of compassion.

Although the number of known cases of unethical pressure on those burdened with great suffering to consider MAiD as a rational choice with an easily expedited protocol is low, such cases exist and are surfacing in the media. The most egregious have involved Canadian war veterans who were counseled to consider assisted dying. The public outcry forced both the veterans affairs minister, Lawrence MacAuley, and Prime Minister Justin Trudeau to assure Canadians that this was the recommendation of one misguided employee, now terminated—and that this is not government policy, nor will it ever be.

These official denials, however, are less than persuasive. The case of retired corporal Christina Gauthier, a former paralympian, highlights the insidious allure of the quick fix. Suffering from a deteriorating medical condition as a result of permanent knee and spine injuries incurred during military training, Gauthier testified to a House of Commons Veterans Affairs Committee that a caseworker from Veterans Affairs Canada offered her MAiD after her failure over five years to get a wheelchair ramp installed in her home. 

Although this may be a rare occurrence, as the authorities insist, it is a logical outcome in a society that finds itself with a stretched and cumbersome health-care system, that struggles to provide appropriate-level palliative and hospice care across a widely dispersed population, and that is, as a consequence of the Charter of Human Rights and Freedoms, willfully captive to the doctrine of personal autonomy.

There is liberal, and then there is liberal. The country that passed same-sex marriage legislation long before the United States, that has banned capital punishment for decades, that was one of the first nations to sanction South Africa over apartheid, and that welcomed more Syrian refugees than any other Western power is the same liberal nation that, under the rubric of compassion and free choice, is about to usher in an assisted-death law that knows no limits.

The Toronto Star recounted the story of a man suffering from a chronic but not terminal illness. His condition was exacerbated by social and emotional factors that included childhood sexual abuse, mental-health stresses, and poverty. His government allowance left him with only a couple of hundred dollars a month after he had covered his rent expenses, and he was unable to walk the two flights into and out of his residence. Under the current legislation he qualified for MAiD, was approved, and died last summer. Had the state seen to his needs, provided support for his various maladies, and given him a decent government income that allowed him to live with some dignity, he could have managed his chronic illness. MAiD was his escape, his solution, his free choice.

But was it really a free choice? William Sweet, professor of biomedical ethics and philosophy of law at St. Francis Xavier University, thinks it was anything but. “As for extending MAiD in cases of mental illness, reducing morality as a consequence to a matter of consent when that clear consent can be compromised by their condition shows minimum concern for the value of life and the dignity of the person. On this point many secular medical experts are in agreement with the majority of Catholic ethicists.”
Public outcry and protests from medical associations at the speed with which the government is moving has prompted it to delay indefinitely the March deadline until there is a greater consensus among parliamentarians and the experts.

It is clear that the government will not rescind the current legislation but will consider more carefully the extension of MAiD to those suffering from mental illness. Perhaps in the process they might listen to the advice of Theo Boer, a Dutch bioethics professor who cautioned the French government over its proposed assisted-suicide legislation by citing the experience of the Netherlands: its policy of legalized euthanasia was at the outset for mentally competent adults suffering from a terminal illness, but that has since been expanded to allow for young children to seek it as well. “If the most defined and controlled system in the world can’t guarantee assisted choice remains a last chance,” Boer wrote in Le Monde, “why will France do better?”

Or indeed, Canada.


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Saturday, January 14, 2023

Euthanasia is premature preventable death- Full Stop

Euthanasia “cannot be a default for Canada’s failure to fulfill its human rights obligations,” said Marie-Claude Landry, the head of its Human Rights Commission.

A New York Times echo opinion about death.
Will Euthanasia Be Secular or Sacred?
By Ross Douthat
(Maine Writer prelude- Unfortunately, this dangerous subject is as ancient as Socrates -died 399 B.C. Although Douthat does not make the clear correlation between the acceptance of euthanasia and, by extension, to the story about Socrates, he does make clear that society's response to ending life by suicide because of "whatever reason".....puts our culture at  risk for a return to paganism.)
Euthanasia is dangerous because the legalization of suicide leads to many innocent people becoming vulnerable to choosing preventable death.

Last month, Douthat wrote a harsh column about the Canadian euthanasia system, which has expanded rapidly over the past few years, with over 10,000 people ending their lives under its auspices in 2021. Now, he recommends two very different analyses of the Canadian experience.

The first comes from an article in the latest issue of The New Atlantis. Its author, Alexander Raikin, obtained internal material from Canada’s euthanasia bureaucracy showing its functionaries discussing in private what critics have charged publicly from the beginning: that a meaningful number of people who apply for euthanasia seem to be driven to it by poverty or difficulty accessing medical care as much as by physical or mental suffering, and that euthanasia providers can end up taking this for granted. 

To quote one of those providers, they might regret the “structural inequities” that influence who applies for euthanasia, but they don’t necessarily consider it their role to protect people “from the option of having an assisted death,” or to treat euthanasia as the “wrong outcome” just because the applicant might be having other issues.
Euthanasia creates the dangerous illusion that death is somehow saving others from having to care for those that are vulnerable to this method of suicide. 

Raikin goes on to consider two individual cases of people in such circumstances. One is Les Landry, a former trucker from Alberta with a history of suicidality who lost income from disability payments when he turned 65, and so he applied for medical assistance in dying (MAID) because he feels, in Raikin’s words, like “he no longer has the critical support he needs” to live his daily life. The other is Rosina Kamis, a chronically ill 41-year-old who was euthanized in September 2021: Her official reasons were physical pain from chronic leukemia, fibromyalgia and other conditions, but in private communications she told people that her suffering was more mental than physical, as much about isolation as pain: “I think if more people cared about me, I might be able to handle the suffering caused by my physical illnesses alone.”

As Raikin points out, both cases illustrate the tangle of motivations that might go into a decision for assisted suicide, and the impossibility of setting up a bureaucratic system that can reliably “distinguish a rational choice to die from a desperate cry for help.” Which suggests, in turn, that the more permissive and expansive your euthanasia regime, the more often a suffering person who is fundamentally asking for support will get approved for a lethal injection instead.

If Raikin’s article is a particularly vivid critique of bureaucratic euthanasia, Richard Hanania’s subsequent essay in defense of 

Canada’s euthanasia regime is a striking progression through different briefs in the system’s favor.

Hanania starts by defending the Canadian system in terms familiar from the moderate, cautious case for assisted suicide, which seeks to make it legal only as an exceptional form of end-of-life mercy, clearly separated from the way society attends to most forms of mental and physical suffering. He notes that even with the sharp increase in assisted deaths, the vast majority (❓) - I thought all of the victims were terminally ill (❓) of the people being euthanized are terminally ill 😡, and that the share of Canadian MAID recipients under 45 is still extremely small  😟😞— with the implication being that the cases discussed by Raikin are still outliers, exceptions to the normal rule.

Physician assisted suicide is a "slippery slope", preying on the emotions and the practice risks leading to the acceptance of euthanasia.

But Hanania goes further. First, he takes a more expansive libertarian position, critiquing any legal or medical presumption against assisting with a suicide, because it arrogates to the state the power to decide on “the right conditions” for making an exit from this life, instead of just letting the suicidal person make the decision for themselves. From this perspective, one might agree with Raikin that the health bureaucracy isn’t competent to determine Rosina Kamis’s true motivations for suicide — or anyone else’s for that matter — and still take the view that the state should err on the side of stated desires, and let personal liberty run its chosen course. So “the fact that the Canadian program is increasing rapidly does not by itself mean that anything is going wrong. It could just as easily indicate that people are too willing to infringe on individual liberty and force others to suffer against their will, and Canada is more morally advanced than the rest of the world in this area.”

And then — responding, in part, to some prodding from me on Twitter — Hanania goes further still, to a position that treats the suicides of people who might feel themselves to be “burdens on their family or the rest of society” as a not merely acceptable but potentially noble choice:

Since when do we denounce people considering how their actions will affect others? … I don’t like inconveniencing others, and for many parents the possibility that one day they could be a burden on their children scares them much more than death. I think this is a noble sentiment, and would gladly sacrifice myself when I’m old so that those I care about can live better and more fulfilling lives. If we’re going to talk about human dignity, I could think of nothing less dignified than ending a proud and successful life in diapers and with your brain rotting away, making your children miserable and preventing them from reaching their full potential … Suicide is in many cases a noble and heroic act, and it should therefore have state sanction.

What’s more, he concludes, lots of people agree with him on this, judging by both polls and pop-cultural depictions of assisted suicide: “The Romans had a concept of ‘patriotic suicide’ in which death was preferable to dishonor, and despite two millenniums of Christian influence we can still be inspired by the idea.”

There is a lot to be said about Hanania’s argument, but I just want to take the last line and run with it for a moment, because it ties together with points I made in my original column. That piece started by discussing the video that a Canadian department store produced to celebrate assisted suicide — a watery, holistic, spiritual tribute to a 30-something woman who killed herself to escape her suffering from Ehlers Danlos syndrome.
Part of my argument was that the video’s spiritual aspect wasn’t a coincidence, that the mass acceptance of euthanasia probably won’t replace the Christian prohibition on suicide with a libertarian or secular neutrality. Rather, a society that encourages euthanasia will eventually tend to sacralize it, reaching for pre-Christian or post-Christian narratives in which the decision to kill oneself is not just permissible but holy.

This point connects to one of my recurring themes — the idea that liberalism alone, liberalism as a pure procedural neutrality between competing worldviews, can’t really exist for very long as the exclusive ordering principle for a society. Instead, what we have called liberalism historically is really “liberalism-plus,” in which a constitutional order is framed with liberal principles, but then infused with some animating theology or ideology that orders lives, shapes politics and sets the terms of cultural debates.

In Hanania’s essay you can see a version of this play out just within the confines of a single piece of writing. He begins with a moderate argument that seems calculated to reassure people who want to be permissive on the edges, but also want the old Christian taboos on suicide to mostly be upheld. He moves from there to a more expressly libertarian perspective that sweeps biblical religion away entirely. And then he actively infuses this libertarianism with a kind of pseudo-Roman, pagan, pre-Christian case for suicide as a positive good, an appropriate service to the gods of the city and the hearth.

These gods need not be literal; I have no doubt that Hanania would disdain the woo-woo spirituality of the Canadian euthanasia video. But that kind of therapeutic, mystical post-Christianity and his refashioned stoicism are different versions of the same destination, two related examples of what de-Christianization yields — not just “free minds and free markets” and liberty for all, but a new theory of the good life, and with it a new set of conformist pressures.

This transformation is not a simple or rapid inevitability; a divided society can stay between worldviews, if you will, for quite a while. And Western society’s mixture of Christian, semi-Christian and post-Christian ideas helps explain the variation in euthanasia regimes across different developed nations — a variation that could last for some time, rather than everyone just converging on the Canadian approach.

But the fact that the old Christian taboos still have some restraining force should also make one a little skeptical of Hanania’s initial attempt at reassurance, his suggestion that the slope to 3 percent of all Canadian deaths may have been slippery thus far but you can rely on the native human preference for life over death to prevent developed nations from doing or accepting anything much worse.

This doesn’t reassure because you can see in Hanania’s own logic the potential for a much larger category of lives-not-worth-living:

In other words, the degraded life, the depressed life, the painful life, the financially burdensome life. (Or the chronically ill life, to cite the territory of despair that I know best.) And you can see in our society’s current trends, our “social recession,” the potential for many more lives to be lived in psychologically tenuous or disposable-seeming conditions — whether because of health problems, seemingly intractable drug or gambling addictions, various forms of social isolation and worklessness, a friendless and post-familial existence.

In this environment, the Canadian proffer that the medical system may not be able to help you feel better, but it can always help you die, does not seem to me like a particularly self-limiting innovation.

And if euthanasia is kept within limits or rolled back from its advances, I suspect it will be the old taboos and Christian prohibitions that make the difference, not a libertarianism, that so quickly and easily yields to pagan destinations.

Maine Writer post script - While blogging this echo opinion, I became horrified by the data from Canada. 10,000 people have opted for this end of life decision? Statistically speaking, it is impossible for all 10,000 to have had a terminal illness diagnosis whereby the patient has less than six months to live.  Statistically, many of those 10,000 people were victims of a movement that is working towards achieving the goal of making physician assisted suicide and euthanasia an acceptable alternative to providing compassionate end of life care, palliative care and hospice. 



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