Full Comment - Killing off the sad and the poor with MAID

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00:01:58.720 Hello, I'm Anthony Fury.

00:02:05.120 Thanks for joining us for the latest episode of Full Common.

00:02:07.680 Please consider subscribing if you haven't already.

00:02:10.720 Medical assistance in dying, MAID as it's called, is expanding in Canada.

00:02:16.220 In ways that a lot of people are perhaps not even aware of.

00:02:20.080 Laws were first introduced permitting MAID in Canada just over five years ago.

00:02:23.540 But in early 2021, the categories and situations were broadened in ways that are concerning to a number of experts.

00:02:31.620 Do we really know what we're getting into here?

00:02:34.020 Shouldn't we perhaps talk this out a little bit more as a nation?

00:02:36.940 To help us understand the complexity of these issues, where we're at in this situation here in Canada, and where we may be going awry, we're joined today by Dr. Sanu Gand.

00:02:46.720 Dr. Gand is a professor at the University of Toronto and the head of psychiatry at Humber River Hospital, where he is the physician chair of the Medical Assistance and Dying Committee.

00:02:55.620 Dr. Gand, thanks so much for joining us today. We appreciate it.

00:02:58.880 My pleasure. Thank you both for having me and also, more importantly, for your interest in this challenging and complex topic.

00:03:07.300 Yeah, challenging indeed. And there's definitely a lot of perspectives, both professional perspectives, but also very raw opinions out there that a lot of people are sharing.

00:03:17.600 I'm kind of surprised to find us so suddenly back at this conversation, as I know it was a national conversation about five years ago, following a court ruling.

00:03:25.520 A lot of people said, well, it's a slippery slope. Watch out.

00:03:28.940 We said, well, OK, you know, take it one step at a time.

00:03:31.180 But it looks like recently we have gone a further step, which I guess requires a subsequent conversation.

00:03:37.060 Yes, and this is why I'm so appreciative that you're taking the time to look at this issue, because I honestly believe that the vast majority of Canadians are completely unaware of just how far things have gone and in such a short time.

00:03:56.320 So I think there are a lot of misconceptions out there about where our current expanded policies are going and how we've come to be where we are.

00:04:06.060 Well, can you explain to us how things first sort of developed back around 2016 when there was, I guess, a court ruling saying medical assistance in dying would be allowed to end the suffering of terminally ill adults?

00:04:20.560 What were the confines of that? How did that sort of work practically?

00:04:25.000 So what happened was in 20, the court ruling was from 2015, and it led to laws that were implemented in 2016.

00:04:33.920 And the ruling was in a case called Carter versus Canada.

00:04:38.800 And in that case, there were two plaintiffs, two people who were, they were fighting for the ability to have a medically assisted death.

00:04:49.080 And each of those people had what we call a neurodegenerative illness, meaning an illness that has known progression and a known course to it, and it was known that they would not be able to improve.

00:05:04.880 One of them had ALS, and the other had spinal stenosis.

00:05:09.160 So what the Supreme Court found in that case was that the up until then blanket prohibition the country had against assisted dying, that the blanket prohibition violated our charter.

00:05:22.300 And what that means is they said that you can't just say that you're unable to provide assisted dying in any situation.

00:05:31.040 It may be suitable in some situations.

00:05:33.480 Now, keep in mind, that prohibition was actually in the criminal, in our criminal law, is the law that needed to change.

00:05:41.100 So what changed in 2016 to conform with that ruling was that the government brought in Bill C-14, which allowed for assisted dying in certain circumstances.

00:05:55.180 And one of the safeguards that was required was that a medical condition that was grievous, meaning really serious, and irremediable, meaning it will not get better, that we can predict it won't get better, that you needed to have a grievous and irremediable medical condition.

00:06:14.040 And one of the safeguards was that natural death needed to be reasonably foreseeable.

00:06:19.660 And so that's what the initial framework was based on in 2016.

00:06:26.640 What was the response among the medical community to this ruling?

00:06:30.060 Was there the sense that, yes, we need to provide these opportunities for people, that this is a gap?

00:06:34.800 So there was, I don't know if relief is the right term, but a general agreement with this?

00:06:38.500 Was there anxiety?

00:06:40.580 What was the level of acceptance to resistance, would you say?

00:06:43.400 It's a controversial area in some ways, but I do think that the ruling at that time, which was framed in the context of providing assisted dying when someone is already dying, that's a key distinction, because death needed to be reasonably foreseeable.

00:07:02.340 There has been a shift towards greater acceptance that that is appropriate in some situations.

00:07:10.520 And it's not a universal shift.

00:07:12.040 I don't think there's 100% agreement on either side in this complex debate.

00:07:17.440 But it is something that shifted over time.

00:07:19.580 And to put that in context, you know, there had been a previous Supreme Court ruling in a case about 20, in the 1990s, in 1993, a different case challenging the same law.

00:07:33.600 And that was a case also of a woman, Sue Rodriguez, who had ALS.

00:07:37.700 And in that ruling, the Supreme Court upheld the existing law through a split decision.

00:07:42.740 And in the 2015 ruling, the Supreme Court unanimously ruled that the law violated the charter.

00:07:51.680 So even that represents some sort of shift in what society and people seem to think was acceptable.

00:08:00.420 The concern became, though, that some people did not agree with it.

00:08:07.000 And it did allow the option for people to be what are called conscientious objectors, meaning if somebody did not want to participate on the medical side, that they shouldn't be compelled to.

00:08:21.260 But there were others who were not conscientious objectors, but they had concerns about further expansion.

00:08:28.560 And that's the category I fall in.

00:08:30.620 I'm not a conscientious objector.

00:08:32.400 I actually, as you mentioned, I chair our, I'm physician chair of our hospital MADE team.

00:08:38.480 I've seen the potential benefit and value that MADE can bring in appropriate situations.

00:08:46.260 I have also been sensitized to what I think are the dire dangers of providing assisted suicide in inappropriate situations.

00:08:56.560 That is where I believe we're heading.

00:08:58.120 And Dr. Gand, this position, physician chair of this committee, can you break down what that is, what you do in that capacity?

00:09:07.100 So we have developed policies.

00:09:09.240 Every site would have done this to develop policies to allow for assisted dying under the existing laws.

00:09:19.140 And part of my role in that committee has been to assist the hospital and the team in developing those policies.

00:09:25.840 And there's also a role of oversight of the actual cases and applications that come through for assisted dying.

00:09:34.260 Now, I'm a psychiatrist.

00:09:35.700 My background is psychiatry and psycho-oncology.

00:09:39.660 In other words, when patients have cancer as well.

00:09:43.200 And the MADE laws that we have had up until now, because that reasonably foreseeable death, safeguard had been there, and mental illnesses on their own do not, by and large, lead to death, sole mental illness conditions have not been things that have really been open for getting MADE for.

00:10:06.640 So people could apply for MADE if they have a mental illness, plus another condition that had been leading to foreseeable death.

00:10:15.300 But mental illness conditions alone generally would not qualify for that.

00:10:20.060 And as a result, in terms of my role, we haven't had applications for sole mental illness.

00:10:26.620 So as a psychiatrist, I wouldn't have a role in doing the clinical assessment of whether somebody's ALS is irremediable, for example, or whether their lung disease is irremediable.

00:10:38.080 So it's more of an oversight role where we would review things as a team.

00:10:42.540 But again, we so far have not had MADE for sole mental illness, by and large.

00:10:48.540 So now we're in a situation, March 2021, the law further amended by Bill C-7, which has expanded the situations and categories where MADE is made available to patients.

00:11:03.120 In what sort of scope has this now changed?

00:11:06.940 So if I can take a second, I'll rewind a little bit.

00:11:10.820 Yeah, please.

00:11:11.280 In order to get to that question, because you mentioned at the beginning that some people had concerns there could be a slippery slope, and others were saying, no, there's no need to worry about a slippery slope.

00:11:23.340 Right.

00:11:23.860 You know, in my opinion, I would say that we have not actually experienced a slippery slope.

00:11:32.900 There's no slope.

00:11:33.720 There's a cliff.

00:11:34.980 And I believe our MADE laws are falling off that cliff.

00:11:38.480 And I'll tell you why I say that.

00:11:39.840 So before even getting to the expansion in C-7 from 2021, before getting there, let's just talk for a minute about what has been happening with MADE under the old system, when death needed to be reasonably foreseeable.

00:11:55.680 And this is part of what I think many people don't understand.

00:11:59.420 When death needed to be reasonably foreseeable, it did not mean that you only had two weeks or two months or even two years left to live.

00:12:07.440 It was generally acknowledged through other case law that occurred during that time, that even if someone had up to a decade to live, up to 10 years to live, that could qualify and would qualify and did qualify for getting MADE.

00:12:22.880 So we're not talking about people right on death's doorstep, even under the old system.

00:12:28.040 I wasn't aware of that, to your point about Canadians not really understanding.

00:12:31.780 I did not know that part.

00:12:32.620 Yeah, and so what that means, quite literally, is that even age ended up becoming a potential quote-unquote qualifier, because the issue of age and frailty did come into play.

00:12:47.440 And so if you could say to anyone that, yeah, we think it's reasonable that you might have 10 years or a bit less to live, they actually would have qualified under the old system without expansion.

00:12:58.460 Now, under the old system, let's look at briefly what the numbers were, that the country gets national statistics.

00:13:06.560 The way we've compiled them, there's always a bit of a delay in the national reporting.

00:13:12.660 So I'm going to give you two years of national reporting.

00:13:15.280 The latest national reporting we have is from 2020.

00:13:19.040 In other words, pre-expansion of C7.

00:13:22.800 But I'm going to talk first about 2019.

00:13:25.320 So in the year 2019, which was just a few years after MAID came in in 2016, in that short time, our national death rate from MAID was 2%, meaning that 2% of all deaths in Canada by 2019 were by MAID.

00:13:44.520 Some provinces were quite a bit higher than that.

00:13:48.060 So Quebec was at almost 2.5% and BC at about 3.3%.

00:13:53.380 Over the next year, so into 2020, again, before expansion of C7, the death rate in every single province went up.

00:14:03.140 They quite remarkably called the term a growth rate.

00:14:05.680 They called it a growth rate in the death rate by MAID.

00:14:09.300 And so by 2020, 2.5% of all Canadians dying that year died by MAID.

00:14:15.720 And Quebec had gone up to over 3%.

00:14:19.900 BC had gone up to over 4%.

00:14:22.160 And we know that even within there, there are pockets that are even higher.

00:14:27.140 It's reported that Vancouver Island's death rate by MAID is over 7%.

00:14:33.280 And it's been dubbed the MAID capital or assisted dying capital of the world.

00:14:38.660 Now, all of that is before Bill C7 expansion.

00:14:43.180 Now, let's look at what happens with Bill C7 expansion.

00:14:46.040 Can I just ask you one question, though?

00:14:47.920 Because I imagine some advocates of this would say that that increase in rates is an indication of what people have always wanted anyway.

00:14:55.340 And that it's, while maybe not good news, these are people who are avoiding the great pains that they anticipated at what would be a more natural end of life, where they are allowed a death with dignity now.

00:15:08.320 And that that number is something, again, not to be celebrated, but that people got what they wanted.

00:15:13.560 How do you respond to that position, which I've heard advocated?

00:15:16.680 And I've heard people say, I've heard the MAID advocates for expansion or expansionists, I've heard them say precisely that, that, oh, that's a good thing.

00:15:27.480 The more MAID, the better. 0.99

00:15:29.140 And in fact, I've literally heard them say...

00:15:30.780 The more than better.

00:15:31.700 Pardon me.

00:15:32.460 What a lie.

00:15:33.700 I'm not trying to be facetious.

00:15:36.320 I've literally heard that.

00:15:37.860 I've also heard them say that the problem is not that the rate is high in some provinces, it's that it's low in others.

00:15:45.000 And that that reflects that there's not enough availability of people to get MAID.

00:15:49.900 Now, before kind of saying which way should we fall on that, I have to point out that people need to realize, especially as MAID laws expand, they affect different people and different populations in different ways.

00:16:06.220 And we'll hopefully come back to this near the end, because I think this is really a key, key point.

00:16:14.660 But when we look at the number of people dying by MAID, we also need to look at who are those people who are dying by MAID and why are they getting it.

00:16:25.920 There is a pocket of people.

00:16:27.880 There are some people who get MAID because they want to die with dignity.

00:16:33.220 They've lived a life of autonomy, and they want to preserve their dignity and autonomy and die with dignity.

00:16:40.440 As we expand MAID laws especially, there is also a second group of people, and evidence shows this, who it's not that they're seeking death with dignity.

00:16:50.820 They're seeking an escape from life suffering.

00:16:53.860 And life suffering includes social suffering.

00:16:56.280 When we look at who's actually been getting MAID when death is foreseeable, right, so if death is predictable and foreseeable, that group does actually tend to be, according to the research, that group tends to be more privileged.

00:17:13.040 They have had higher education.

00:17:14.720 They come from higher socioeconomic status, and they tend to be white.

00:17:19.380 That's the description in the terms of the researchers in multiple places that have looked at this.

00:17:24.980 But when you expand MAID, which is now what we're doing, when you expand MAID for conditions beyond death being foreseeable, in other words, when you expand MAID to people who are not dying, then a different group starts to be affected, and they seek it for different reasons.

00:17:43.720 They seek it because they are suffering from things like poverty, loneliness, isolation.

00:17:49.460 You also see, and I'll talk about this a bit later, a gender gap emerging with twice as many women as men getting MAID for psychiatric euthanasia in the European countries that allow it.

00:18:03.080 So it's not just a population number of 2% or 2.5%.

00:18:08.100 It is who is getting MAID for what reasons, and then who keeps getting it as we expand the laws more. 0.98

00:18:15.140 And to me, that shifts the question from not, well, where do we think the perfect balance is?

00:18:22.020 It shifts the question to which mistakes do we want to make?

00:18:26.020 Do we want to say that somebody, to preserve their autonomy, we want to make it even easier for them to get it, even if they have more than 10 years left to live?

00:18:35.020 But by doing that, we also change the goalposts, and we know that others are now going to get it because they've had life-suffering society refuse to help them with.

00:18:48.520 Is it preferable to have MAID available for someone who otherwise, and I can't think of a more diplomatic way to say this, would otherwise have just had a messier suicide?

00:19:05.020 When we look at the actual evidence, and that is something that the expansion advocates have, or activists, have said is an issue.

00:19:18.180 Oh, we're trying to avoid people from having, in the terms you're using, a messier or painful suicide.

00:19:25.680 The evidence does not support that.

00:19:27.920 What we actually find is this, that in the, so if we look at psychiatric suicide and suicide attempts, it's an interesting statistic, which is universally, this is repeatedly found, that by a two-to-one ratio, more women than men attempt suicide.

00:19:48.920 So they try to end their lives when they have, when they're suffering from a mental illness.

00:19:54.820 And the vast majority of them do not end up taking their lives.

00:20:00.040 So the initial suicide attempt, they end up surviving it.

00:20:04.260 And most do not try again.

00:20:06.500 And this is a clear thing we see with the suicide research, that in the vast majority of cases, suicide, in those contexts, is something that there's a lot of ambivalence about.

00:20:19.560 But people may have that ambivalence for a prolonged period of time.

00:20:23.740 It's not that it's only there for one day or two days.

00:20:26.440 It can be for a long period of time.

00:20:28.080 And if they get to the point of acting on it, that's when they have a suicide attempt.

00:20:33.540 What we're doing with MAID is we are changing a transient suicidality in those situations into a permanent death.

00:20:41.640 Because when you look at the European countries that provide psychiatric euthanasia, you see that exact same two-to-one ratio of women to men who actually get their lives ended.

00:20:51.480 So in other words, something which they might otherwise have a suicide attempt and survive and then not try again and go on to live meaningful lives.

00:21:02.380 We're now making it easier for them in that initial period to actually have their lives ended by us.

00:21:09.000 So the data shows that suicide attempts, many of them are cries for help.

00:21:14.340 So let's help them.

00:21:15.880 So in terms of cries for help, I mean, the person really is suffering.

00:21:23.320 It's not that they're doing something to, you know, manipulate the situation.

00:21:29.320 That's not at all what I would mean in terms of cry for help.

00:21:33.100 But it is a sign that they need help.

00:21:35.280 And the help they need, the help they need is help with their illness and help to live.

00:21:42.100 And in fact, I've spoken with many people who have said, you know, people who've struggled with chronic depression, who've said, at that point in my life, in the past, I was competent.

00:21:55.400 I still had capacity.

00:21:56.720 So people still usually retain capacity to make decisions, even when they have mental illness.

00:22:02.560 But the decisions they make change.

00:22:04.780 Right.

00:22:04.960 Think about it.

00:22:05.460 Anyone who's been depressed knows this.

00:22:06.900 When we're depressed, we think differently.

00:22:09.600 And this is also backed up by evidence and research.

00:22:12.680 We have what's called a cognitive triad of I am bad, the world is bad, and the future will be bad.

00:22:19.300 It changes how we think.

00:22:20.960 Think about how that makes you feel about whether you want to be here in the context of suffering from mental illness and poverty and loneliness.

00:22:28.720 And so in that context, somebody may actually want to end their life and they can't see anything else.

00:22:37.460 My role as a psychiatrist has always been to say, you know, I actually know from the evidence and from experience that we actually can help you.

00:22:47.580 And I think that's what our role should be.

00:22:52.260 There's one fellow who, I won't say his name, but he does talk publicly about this.

00:22:58.640 It's actually a bit painful for me to even say.

00:23:01.400 I always get a little emotional thinking about this.

00:23:03.780 But he struggled with mental illness for many years, chronic depression, sometimes getting better, other times worse.

00:23:10.640 And it did have suicidal thoughts for much of that.

00:23:16.640 And he tells the story.

00:23:20.200 He tells the story of standing on a bridge.

00:23:24.000 And he was planning, contemplating jumping.

00:23:29.540 And literally somebody in a crowd behind him said, said, jump, jump, if you can believe that.

00:23:35.780 And somebody else pulled out their hand, held his collar and just pulled him back.

00:23:44.000 And he came back and he didn't instantly recover.

00:23:48.060 It's not that.

00:23:49.080 But he did recover.

00:23:50.960 He got better.

00:23:52.120 He lived and is living a meaningful, fulfilling life.

00:23:55.640 He's actually become a mental health advocate.

00:23:57.360 And I don't want to be the person on that bridge that doesn't say, we're going to help you live and find a way to live a meaningful life again.

00:24:07.380 And that is what the evidence actually shows the risk is with expanded, made, and psychiatric euthanasia.

00:24:14.080 We'll be back with more full comment in just a moment.

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00:25:01.900 Dr. Gan, in response to the expanding legislation, would your perspective be that we just need to think this through more and maybe not go ahead with this?

00:25:11.520 Or is it that we need different safeguards involved to act as further checks and balances?

00:25:17.640 You know, that's an excellent question.

00:25:20.860 And one of the fundamental issues here is that if you bypass the fundamental safeguard, no other safeguard means anything.

00:25:30.760 And what I mean by that is this.

00:25:32.900 One of the fundamental safeguards, this is embedded in our legislation.

00:25:37.360 This is what Canadians have been told and sold that MAID is about.

00:25:42.820 They've been told that MAID is for a grievous and irremediable condition. 1.00

00:25:47.840 That is something which for mental illnesses is a fallacy to be able to apply to MAID laws. 1.00

00:25:54.700 Because mental illnesses can be grievous and absolutely can lead to terrible suffering, as bad or worse suffering than physical or other medical illnesses.

00:26:05.040 However, what you cannot do with any mental illness is predict when it won't get better.

00:26:11.340 So, the issue of it being irremediable, that's actually impossible to predict.

00:26:17.360 And that's not me saying this.

00:26:18.720 This is something which every group that's actually looked at this has reached that conclusion.

00:26:24.500 That that's what the national and worldwide evidence shows.

00:26:28.560 That in any individual case, you cannot predict when the person will or will not get better.

00:26:37.300 CAMH has said this.

00:26:38.680 They've said it very bluntly.

00:26:40.140 The American Psychiatric Association does not support this sort of expanded MAID.

00:26:46.460 The Australians don't. 1.00

00:26:47.620 The Canadian Mental Health Association doesn't.

00:26:50.820 And so, this idea that we're telling people that, oh, yeah, I think you're not going to get better.

00:26:57.100 That is not based on any scientific evidence.

00:27:00.400 And in fact, the scientific evidence shows we can't make those predictions.

00:27:03.580 So, my question is, if we are not providing MAID for when the condition can't get better, when it's irremediable, what are we providing it for?

00:27:13.660 And then it opens the door to all of that other life and psychosocial suffering.

00:27:18.420 Even groups that support MAID for mental illness, even they acknowledge and admit that you cannot make these predictions.

00:27:32.160 So, the Quebec Association, the Quebec Psychiatrist Association, the AMPQ, this was in a paper that was written by their group.

00:27:42.580 And it included the author, or as one of the authors, the same person who's currently chairing the federal expert panel on mental illness.

00:27:54.760 And that group actually literally said, regarding irremediability and mental illness, it is possible that a person who has recourse to MAID, regardless of his condition, could have regained the desire to live at some point in the future.

00:28:10.700 And then they remarkably, in my opinion, remarkably, go on to say that, well, regarding, you know, the certainty and eligibility criteria, assessors will have to answer this ethical question each and every time they evaluate a request.

00:28:25.640 And, you know, our law is not that somebody has a grievous and irremediable medical condition if in the ethical opinion of each and every assessor they do.

00:28:35.360 So, that opens it up to such non-scientific, non-evidence-based judgments that place our patients at risk of premature death when they're in a state of suicidality.

00:28:49.620 Dr. Gant, I want to get your take on a CTV news story from November 2020 that I've never forgotten.

00:28:57.580 It surprised me and shocked me for a number of reasons.

00:29:01.320 I'm sure you're aware of these incidents.

00:29:03.180 There's a few of them.

00:29:03.920 The headline is, Facing Another Retirement Home Lockdown, 90-Year-Old Chooses Medically Assisted Death.

00:29:12.340 And you go through the story and it explains this lady, 90-year-old Nancy Russell, died surrounded by friends and family.

00:29:19.220 It was what she wanted.

00:29:20.340 It was the exact opposite of the lonely months of lockdown she had suffered through in a retirement home where she had lived for several years.

00:29:26.580 The story goes on to talk about her life.

00:29:29.120 It says the lockdowns were so crushing for her.

00:29:33.540 And there's so much that can, of course, be said about our treatment of elderly, long-term care homes, retirement homes, pandemic rules, which were legitimate, which weren't.

00:29:42.240 But when I read this story, I remember a year and a half ago, I thought I didn't think this was what medically assisted dying was for.

00:29:51.100 How did this all come about?

00:29:52.600 I appreciate that she's a 90-year-old beyond normal life expectancy, but she was also not facing an imminent death from a deteriorating health issue.

00:30:02.060 Yeah, you know, I actually, I think you've struck the nail on the head.

00:30:07.960 How did this come about?

00:30:09.680 Because this is not, it's not what I signed up for when I got, when I actually believed in the value of assisted dying in some situations.

00:30:20.960 It's not the sort of thing that I think most people, most Canadians would think made should be for.

00:30:28.040 And unfortunately, that actually is what this expanded made is exposing people to.

00:30:36.060 And I believe the way we got here is, you know, there are a number of myths that have fueled what has led to expanded made.

00:30:45.920 As I said at the beginning, most people don't even realize that even before expansion, if somebody had even up to 10 years of life left, they probably would have qualified.

00:30:56.980 But I think the key myth that allows this to perpetuate, and this is very sad to me.

00:31:03.520 I see so many of the expansion activists repeatedly saying that, oh, made is about autonomy.

00:31:11.040 They're telling people it's about your autonomy.

00:31:13.000 Well, and that's very appealing, because people say, of course, autonomy is good.

00:31:19.240 And if we have more autonomy, all the better.

00:31:22.700 Well, when we actually look at the stories you're talking about, about who are some of the people getting made, and this is from work that continues to come out.

00:31:33.000 This is from December of 2021, looking at psychiatric euthanasia.

00:31:38.240 What kind of suffering is actually leading to these people getting it?

00:31:42.260 There's a range of it, but it includes things like perceived failures to live up to the expectations of others, and societal standards and norms.

00:31:50.900 Feeling a burden to society.

00:31:53.080 The accumulation of several misfortunes, life misfortunes, and perceived difficulties leading to a so-called culmination point.

00:32:00.060 And we've already had headlines.

00:32:03.220 You know, I was on a podcast with Canada Land, I think it was, in October.

00:32:08.140 And the heading of that podcast was a woman in our country, in B.C., saying, I die when I run out of money. 0.94

00:32:15.020 The, this has, as it should, it's attracting international attention.

00:32:23.660 You know, Canada prides itself, as a Canadian, I like to pride our country as being one that's on the forefront for social justice.

00:32:31.740 In this area, I think we're taking a huge step backwards, and to be blunt, I think we're implementing policies of privilege that actually embed ableism, ageism, racism, and sexism, and expose the most marginalized to unnecessary premature deaths for this autonomy myth.

00:32:52.560 And I'll get back to that in a second, but in terms of the international headlines, there was a piece in the UK Spectator, just in the past week or two, titled, Why is Canada Euthanizing the Poor?

00:33:05.380 And it goes through some of the things there now.

00:33:08.280 Now, in terms of autonomy, as I mentioned before, you will have a group that has lived well, and now will have the chance potentially to die more on their own terms.

00:33:25.400 Although I honestly think that even in that group, most people don't realize that they would have been able to get made even if they had 10 years of life left, even before, before expansion.

00:33:34.980 But let's say, let's say the expansion does increase the autonomy for some who have lived well, and now want to die well.

00:33:44.160 Well, these other things I was talking about, about people getting it for life suffering, that's not autonomy.

00:33:51.000 That is seeking an escape from life.

00:33:54.320 It's not seeking a dignified death.

00:33:57.240 And so this myth of autonomy, it's a specific type of autonomy.

00:34:01.180 It is what I would call privileged autonomy.

00:34:04.980 Dr. Gand, I must say, I myself am conflicted on this, because I have always approached so many life choice issues from a very libertarian perspective, where I say, ultimately, even if it's something that I don't agree with, I wouldn't do myself, I wouldn't want people I love doing it.

00:34:21.640 Who am I?

00:34:22.860 What place do I have to tell a consenting adult what they can and can't do?

00:34:28.840 And this issue, hopefully, we are dealing with poverty issues so that nobody even has that thought.

00:34:34.760 Hopefully, we are dealing with mental health challenges. 1.00

00:34:37.120 Hopefully, we are providing all the other exit ramps.

00:34:39.600 But ultimately, if someone has thought through this, hopefully thoroughly, hopefully at length, who am I ultimately and who are we as society to ultimately limit this option?

00:34:48.540 How would you respond to people such as myself who are conflicted because of that very thought process?

00:34:56.180 Well, I do understand that conflict.

00:34:59.040 And I agree with you that when people have true autonomy, we should support them in the decisions that they make.

00:35:06.420 The problem is that the things that I make as my decisions in any society, they can also affect other people.

00:35:15.040 And the laws that we implement affect different people in different ways.

00:35:18.880 So it is questionable whether it's truly an autonomous decision for somebody who's in a state of depression, whose mental illness is affecting how they think.

00:35:29.580 They're still capable, you know, they still have legal capacity and competency.

00:35:35.820 But as I mentioned before, their thoughts are being affected by I am bad, the world is bad, future will be bad.

00:35:41.740 And there are known biological correlates that lead to the sense of hopelessness and despair in depression.

00:35:50.960 And suicidality is a symptom of mental illnesses.

00:35:55.160 It's actually one of the core symptoms of some mental illnesses.

00:35:57.600 And so in that state, to facilitate somebody to end their life, when we cannot even say to them that they won't get better, but we pretend that that's what we're giving it to them for, for an irremediable condition that we can't predict.

00:36:12.160 To me, that is morally wrong, because we know from the evidence that most of those people actually will get better and will themselves regain the will to live.

00:36:23.220 So it's not about imposing somebody's external autonomy on anyone.

00:36:26.820 It's about recognizing that, well, as I expand my quote unquote right for made under all of these other circumstances, it is exposing a different group of marginalized or vulnerable people who are suffering from all sorts of life suffering, who actually most of whom would get better.

00:36:47.860 But in their state of transient wishes for death, we'll be facilitating and fueling those.

00:36:53.840 That's how I would answer that.

00:36:55.120 You know, there's, and this was actually in the UK spectator piece that I mentioned to you before.

00:37:03.560 But there's a quote from a French poet, I think he was, many years back, and I'll just read it to you and you can kind of figure it out for yourself.

00:37:16.300 But it's Anatoly France, and he says, the law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread.

00:37:30.140 Pointing out that it's the same law, but obviously it affects people in different ways.

00:37:36.500 You're probably not going to have too many people who are rich needing to sleep under bridges or beg in the streets.

00:37:42.460 And if Anatoly France was alive today, I actually think the ghost of Anatoly France would say this about Canada's current made laws and expansion, that Canada's made law in its majestic equality helps the poor as well as the rich to die for life suffering.

00:38:02.160 To me, that's not autonomy.

00:38:03.800 Dr. Gann, when you talk about vulnerable persons, one category of individuals most people agree are in more vulnerable positions, our youth, our children.

00:38:13.500 And when we talk about expanding medical-assisted death, a lot of concerns right away gravitate to what degree does this or does this not involve children or a phrase that's used in the medical context, mature minors, usually referring to teenagers.

00:38:31.000 What are your concerns about that category?

00:38:35.900 It's very similar to the last question you asked about, well, if somebody in that moment is deemed to have capacity, shouldn't we respect their wish and their autonomy?

00:38:48.700 And that argument has been extended to mature minors to say, well, it shouldn't matter what age they are.

00:38:56.300 If you've got a 12-year-old who understands what they are asking for and we deem them to have legal capacity or competency, they should be able to get it.

00:39:07.560 There are made expansion activists who are seeking precisely that.

00:39:11.980 I am highly concerned about that because, once again, I think what it does is in a very, I would say this is an artificial, this entire thing is often an artificially narrow focus on, oh, it's just that person's individual autonomy and it excludes everything else.

00:39:32.360 So, let's look at youth for a second.

00:39:34.400 We know that the brain, the human brain, continues to develop in terms of specific things that are necessary for decision-making into our third decade.

00:39:47.460 So, by the age of even 25, it may not be fully, the frontal cortex and other key parts of our brains that are involved in decision-making are not actually fully developed in terms of where they eventually will be going.

00:40:05.560 I remember that was a concern around legalizing marijuana, the concerns that 18 to 25 bracket there.

00:40:11.700 Yeah, that's exactly, I was actually going to go exactly there, that, you know, I find it striking that in our society, I don't have a problem with this other stuff I'm talking about.

00:40:23.100 When I say striking, I'm talking about the contrast.

00:40:25.560 But I find it striking that in our society, nobody raises concerns, or I won't say nobody, but people generally accept that we can have a legal age for drinking.

00:40:37.220 We can have a legal age for voting, we can have a legal age for marijuana, but we can't have a legal age for when we are going to help a non-dying teenager or less end their life. 1.00

00:40:54.620 I find that remarkable.

00:40:55.980 And the science and evidence completely doesn't support that, but again, if the only issue that people are paying attention to is, oh, it's that individual's autonomy, let's provide them what they're asking, it's such an artificial argument.

00:41:14.540 Dr. Gand, to your point, there are activists who are pushing still for further expansion of this, and also to one of your very beginning points, a lot of Canadians aren't even aware of what's going on now, and weren't even aware of exactly what the 2016 laws brought about.

00:41:31.040 You've talked about this being beyond a slippery slope, but are we still falling?

00:41:36.040 Do we still potentially have more to go?

00:41:38.660 Well, I think that opening it up to mature minors, opening it up to sole mental illness conditions that we are pretending we can predict to be irremediable when we can't, I think that those are bridges we should not be crossing.

00:41:55.600 So we do have ways more that we could go, but I don't think we should.

00:42:00.980 You know, this is actually pretty unusual, I'm pretty sure, for a podcast, but I wonder if you would bear with me for me to read you a two-minute poem that I wrote the night that Bill C-7 passed.

00:42:15.680 Yes, please.

00:42:16.740 Okay.

00:42:16.980 So just to put this in context, this was in March 2021, March 11th, and Bill C-7 passed with what they called the Sunset Clause that meant that within two years, made for sole mental illness will be provided.

00:42:34.620 And incidentally, that Sunset Clause, remarkably, you know, for a year, the government had said we're not going to have made for sole mental illness.

00:42:45.120 In the initial draft of that bill, the Attorney General, Minister Lamedi, was giving those assurances repeatedly.

00:42:51.720 And then less than a month before this date, in March, the government changed its mind.

00:42:59.900 They put in the Sunset Clause that had been recommended then by the Senate Committee.

00:43:05.040 And after one evening of debate that the government foreshortened with, I believe, what they call a closure motion or something like this.

00:43:13.200 So literally, one evening of debate, this bill with Sunset Clause passes.

00:43:20.040 The political background is interesting because the vote was largely along party lines.

00:43:26.320 Almost all the liberals voted for it.

00:43:28.420 The bloc voted for it.

00:43:30.760 But the people who voted against it, it was actually left and right united in voting against it.

00:43:36.340 So the NDP and conservatives and greens, independents, and a smattering of liberals voted against it.

00:43:42.440 And I was very disturbed that, I have to say, and I was really upset because I could see where things were going to be going.

00:43:49.380 And I could picture the headlines that we're now seeing about I die when I run out of money.

00:43:56.160 And so I wrote this that night.

00:43:57.480 And it's called Last Rites, Ode to C-7. 0.58

00:44:00.660 So, O Canada, my brave new world, glorious and gore-free, will soon become the land of death on demand, full autonomy, at least for me.

00:44:12.840 I've been granted good life, good friends, good wealth.

00:44:17.360 Thank you, C-7, for dealing me good, easy death. 1.00

00:44:20.740 My last rites, my last rite, easing suffering at my choosing, sanitized, beautified, the choice will be mine, my death so peaceful, ready for prime time.

00:44:33.340 I hear whispers in the background warnings to not short the price of tomorrow's mornings, that the cost of my saving grief will be those seeking relief from a life lived without my privilege, not dying, but only trying to get by in life.

00:44:51.840 Those we won't help live, but will now give, enticed escape from strife.

00:44:59.320 But whispers I can ignore if they fall on the shores of those who whisper louder, experts reassuring me prouder.

00:45:09.500 It's their task to know full well, but I don't ask and they don't tell.

00:45:15.640 And besides, it's not entitlement, consider the enlightenment of those non-white, non-wealthy, and wise, of those marginalized, to finally have a choice to die well, when in life they had no voice, their only choice was living hell. 0.92

00:45:34.700 So thank you, Canada, powers that be, for ensuring that our smooth passings will reflect the privilege of our life trappings.

00:45:43.000 I will soon be free, without anxiety, knowing that with ease I can choose the time of my going.

00:45:50.960 And any poor souls sacrificed on this altar of my choice, my voice, there will be no way of knowing.

00:46:00.840 Wow.

00:46:03.380 Those would be powerful words to end by, but I want to talk about a couple more issues before we go, Dr. Gand.

00:46:11.460 And one of them relates to what you said about the vote on all of this, the legislation being a bit more aggressive than it needed to be.

00:46:21.980 I know we haven't invited you on as a political analyst, but what is your sense of what people think they're trying to accomplish in bringing in these laws?

00:46:33.960 Because, to your point, we're not just following best practices getting up to global standard.

00:46:38.140 We're now the cutting edge, if you can call it that, for most jurisdictions.

00:46:44.040 It's not something that everybody out there is saying, we need this, we need this.

00:46:47.920 Are they, do they think that this is following social progress and just something that inevitably must be done?

00:46:55.580 Is this catering to some special interest groups?

00:46:58.200 I mean, how did this all come about?

00:47:00.160 I appreciate the technicalities or a Supreme Court ruling five years ago, but more broadly, how did we get to this point?

00:47:07.340 Again, you know, I think that's a really important question, because when we get to this point, when any country gets to a point like this on issues of national importance, you kind of hope that due diligence has been done and that different things have been looked at and weighed before decisions are made.

00:47:27.860 That hasn't happened here, so I can't speak to the reasons why, but I can tell you what has happened.

00:47:34.380 And, you know, I think there are a couple of important points along this path.

00:47:40.660 You know, when the initial law came in, and keep in mind, that was through a different attorney general, right?

00:47:46.640 That was back when it was Minister Jody Wilson-Raybould, who brought in the initial law.

00:47:52.000 So when the initial law came in that had reasonably foreseeable natural death as a safeguard in 2016, and then that was challenged in 2019 in what was called the Truchon ruling in Quebec.

00:48:04.940 So this was a provincial court, and in that ruling, ruled on by one single judge, she overturned or said that the naturally foreseeable reasonable death safeguard is overly restrictive.

00:48:22.000 And the country has to eliminate it.

00:48:24.260 Now, very unusually, the government did not appeal that.

00:48:29.700 By then, the attorney general had changed.

00:48:32.340 But it's pretty unusual.

00:48:34.340 I'm not a lawyer, but my understanding is that it's pretty unusual for the government not to appeal such provincial rulings to the Supreme Court.

00:48:43.460 And they did not do that.

00:48:45.520 You know, it's ironic.

00:48:46.320 I don't even know what this was on, but two days ago, I think it was, yesterday or two years ago, driving home.

00:48:52.000 I heard on the radio that there was some provincial ruling on some other issue, and immediately the government has said, we're appealing to Supreme Court.

00:49:00.200 In this case, they didn't even appeal it.

00:49:02.120 So it never went through that.

00:49:03.740 The government did not do a five-year review that it was supposed to, and that mandated review was also bypassed.

00:49:12.120 And so in that sense, due process hasn't been done, I think.

00:49:19.760 And I will also say that, and I regret saying this, but I honestly believe it's true.

00:49:26.700 You know, I'm a past president of our National Psychiatric Association.

00:49:30.240 I'm a past president of the Canadian Psychiatric Association, and I've had significant concerns about the input of my own association in this, because I don't think it's contributed necessary evidence in making these decisions.

00:49:45.900 And I say this as a past president.

00:49:47.560 So unlike the American Psychiatric Association, or the Irish one, or the Australian and New Zealand one, the Canadian Psychiatric Association's input, they basically framed it purely as an issue of discrimination, in my mind.

00:50:04.080 And they said patients with a psychiatric illness should not be discriminated against, and nobody wants to discriminate.

00:50:10.400 But then they link it to the assumption that it would be discrimination unless they have the same options available regarding MAID as available to everyone else.

00:50:20.140 And they admitted that they had not looked at whether you could predict whether psychiatric conditions could or could not get better.

00:50:27.520 And most concerningly to me, you know, throughout this whole process of whatever it was, a year before the C7 consultations or during that public consultation process, in all of that time, in the written and oral submissions from my own expert group, the number of times they even mentioned mental illness, suicide risk, mental illness-related suicide risk, suicide prevention, even said the word suicide literally was zero.

00:50:56.480 And to me, and to me, that's like a respirology association, doing public consultations on lung health or lung disease, and never mentioning smoking.

00:51:07.040 It's baffling.

00:51:08.160 But what it does mean is that the necessary input into making these decisions wasn't made.

00:51:16.960 And, you know, you made the comment about, and I am linking a thread here, you made the comment about, oh, we're at the forefront, you know, kind of, you know,

00:51:26.460 kind of whether we want to be or not.

00:51:27.920 One other point I want to make is that, unique to Canada, nowhere else in the world actually has this.

00:51:33.920 We have a provision that says that somebody can get made, they can apply for and get made, even if they've never had any attempts at treatment.

00:51:44.820 Think about that, especially in the context of, say, mental illness, but even in general.

00:51:49.940 So, and the reason for that is there's a qualification in there that things that could make the situation better, they need to be acceptable to the person.

00:52:00.400 Now, nobody's talking about forcing treatment.

00:52:02.460 I'm not saying that at all.

00:52:03.900 But I am saying that if we're now telling people, oh, yeah, we know you're not going to get better, and they may have never even had access to treatment, that's pretty shocking to me.

00:52:15.400 In other countries that have previously been considered to be more expansive with MAID, so some of the European countries, even there, there's a requirement that reasonable efforts at treatment have been made before you can say that something won't get better.

00:52:30.480 We don't even have that here.

00:52:32.480 So, what that means is, rather than helping people live dignified lives in the community and providing them the supports that they may need to do that, in a state of immediate suffering and immense suffering, rather than helping somebody live, we might say, we're going to, you know, help you end your life.

00:52:52.100 And that obviously has financial consequences.

00:52:54.300 You know, this has been looked at pre-expansion and estimates made post-expansion.

00:52:59.560 The Parliamentary Budget Office was tasked with doing estimates on how many hundreds of millions of dollars, actually less it costs to provide MAID than to provide medical care.

00:53:11.540 And that doesn't even count the social supports that are no longer needed to help a disabled person live in the community with dignity.

00:53:21.020 So, what I'm saying is that whether people consciously are thinking about these levers or not, they are all there.

00:53:33.120 And in terms of even these financial implications on a strained healthcare system, I mean, you can do the math yourself.

00:53:42.820 Yeah. Wow. Dr. Gant, I have learned so much during this conversation right now.

00:53:50.400 And it all goes back to your original point that perhaps we are not having an informed national conversation.

00:53:56.280 Canadians are not fully apprised of what's going on with this issue.

00:53:59.280 Whatever opinions they have, whatever views they end up holding about it, that we need to probably hash things out a bit better as a nation.

00:54:06.720 So, I hope our conversation today can at least be helpful in some small way in heading in that direction.

00:54:12.600 Dr. Gant, thanks so much for joining us today.

00:54:15.380 And thank you so much for your kind of thoughtful consideration of these issues and openness to thinking about the various perspectives.

00:54:24.400 Thank you.

00:54:25.700 Full Comment is a post-media podcast.

00:54:27.920 I'm Anthony Fury.

00:54:29.040 This episode was produced by Andre Pru with theme music by Bryce Hall.

00:54:33.020 Kevin Libin is the executive producer.

00:54:34.780 You can subscribe to Full Comment on Apple Podcasts, Google, Spotify, and Amazon Music.

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00:54:47.120 Thanks for listening.

Full Comment - May 23, 2022

Killing off the sad and the poor with MAID

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