00:00:00
I have a bunch of patients who are
waiting for it, right?
00:00:02
They've been approved—
00:00:03
They've not been approved.
00:00:04
They're waiting and hoping
to be approved.
00:00:06
These two doctors have
conflicting viewpoints
00:00:09
on euthanasia in their country.
00:00:11
I think Canada's approach to assisted
dying has been successful.
00:00:15
I am very concerned about medical assistance
00:00:19
in dying laws in Canada.
00:00:21
Euthanasia became legal in Canada in 2016.
00:00:24
They call it “medical assistance in dying”
or MAID for short.
00:00:28
Since then, the number of assisted deaths
in Canada
00:00:30
has risen to over 10,000 people in 2021.
00:00:34
That's more people by raw number
than any other country
00:00:37
where assisted dying is legal.
00:00:39
In 2021, eligibility for MAID expanded
to include people
00:00:43
who are not nearing the end
of their lives.
00:00:46
And starting next year...
00:00:47
that will include people
suffering solely
00:00:49
from serious mental conditions, too.
00:00:52
Our participants are here to engage in
a new kind of debate.
00:00:56
Yeah, that's where you and I
would disagree.
00:00:57
I know.
00:00:58
Where instead of fighting over
unvetted talking points...
00:01:01
we ask each expert to pick three facts
00:01:03
that their opponent would have to
concede are true.
00:01:06
Dr. Maher, do you agree that
these facts are true?
00:01:09
I do.
00:01:09
Dr. Green, do you agree that
these facts are true?
00:01:12
Yes, I do.
00:01:13
They'll present their facts and
they'll each get a chance
00:01:16
to respond with a footnote.
00:01:18
And after the fact exchange...
00:01:20
we'll also have four additional rounds
00:01:22
to further clarify their positions.
00:01:26
This is a fact-checked debate
about euthanasia...
00:01:29
in Canada.
00:01:31
Here we go.
00:01:37
In Canada
00:01:38
assisted dying is a rights-based issue...
00:01:40
resulting from constitutional court challenges.
00:01:44
The legalization of assisted dying
did not come about due to
00:01:47
voter initiated ballots, as happened
in some US states...
00:01:50
or because the government thought
it was a good idea.
00:01:53
Both of which can change with
shifting political winds.
00:01:56
Importantly, these court cases were
brought and won
00:02:00
by people with both terminal
00:02:01
and non-terminal illnesses.
00:02:04
It is true that court cases...
00:02:07
gave people who didn't have
terminal illness...
00:02:11
the right to have assisted deaths.
00:02:14
But one of the plaintiffs
in that key case...
00:02:17
Jean Truchon, who had cerebral palsy...
00:02:19
when he was considering
getting assisted death
00:02:23
what he said was that it was
the loneliness...
00:02:25
that was brought on by the pandemic...
00:02:28
that was leading him to
make that choice.
00:02:30
So I'm really concerned about
what that means
00:02:33
for people in Canada...
00:02:35
who will make choices to die.
00:02:38
Not for medical reasons alone,
or maybe not even primarily
00:02:41
because of medical reasons
00:02:43
but because of social reasons:
poverty...
00:02:46
isolation, loneliness.
00:02:49
That worries me a great deal.
00:02:50
Jean Truchon ultimately
led his challenge
00:02:53
to the new law for assisted dying...
00:02:56
because he was about to lose function
in his remaining limb.
00:03:00
That was his initial incentive.
00:03:02
Ultimately, this comes down to
a question of rights.
00:03:06
And who, if anyone,
controls our lives.
00:03:09
My name is Dr. Stefanie Green
00:03:11
and I'm a provider of assisted dying
in British Columbia, Canada.
00:03:14
I've always been taught about
the importance
00:03:16
of patient-centered care.
00:03:18
And I have found it to be
profoundly meaningful
00:03:21
to be involved at this time in their life...
00:03:24
and to provide and facilitate
their final wishes.
00:03:28
There are 15 countries that allow
00:03:30
some form of medically assisted dying...
00:03:33
Including ten US states and Washington, DC...
00:03:36
that allow people with a six month prognosis...
00:03:38
to self-administer a prescribed drug.
00:03:41
Canada is one of eight countries
00:03:43
that allows assisted dying for people
00:03:45
without a terminal diagnosis.
00:03:47
Next year, it will join most of these countries
00:03:49
in extending eligibility to people
00:03:51
whose only condition
is a mental illness.
00:03:54
In these countries, cases involving
00:03:56
primarily psychiatric conditions are rare.
00:03:59
In Belgium and the Netherlands...
00:04:01
they made up about 1% of all cases.
00:04:08
Canada's assisted dying laws
00:04:10
lack the safeguards that
other countries have.
00:04:14
There is no requirement
00:04:15
that all reasonable treatments
00:04:17
at least have been tried by the patient.
00:04:20
The doctors are able to
initiate the conversation.
00:04:23
There is no review process.
00:04:25
There's nobody looking to see
00:04:27
whether people in Canada licensed
to do this...
00:04:29
have in fact followed the law
and followed the rules.
00:04:33
Canada rejected paternalism in medicine
quite a few decades ago.
00:04:36
The Supreme Court decision states that a patient...
00:04:40
is not required to undertake medical treatments...
00:04:43
that are unacceptable to the individual.
00:04:45
We have long accepted that patients
can refuse medical treatment.
00:04:49
Even if the result of that refusal is death.
00:04:53
There's actually a very rigorous process in place
00:04:55
for this assisted dying model.
00:04:58
There's a number of eligibility criteria,
but once they are met
00:05:01
there are on top of that, a number of
procedural safeguards.
00:05:05
Of course, we're in complete agreement
00:05:07
that paternalism is not a good thing
00:05:09
and every Canadian is free
to make their own choices.
00:05:13
But when we're talking about assisted death
00:05:14
we're talking about choices made
at a point in time
00:05:18
when a person is profoundly vulnerable.
00:05:20
My name is John Maher.
00:05:22
I'm a psychiatrist with a community
mental health team
00:05:24
in Ontario, Canada.
00:05:26
My goal is to help my patients
00:05:28
live their lives the way they want...
00:05:30
and to do all we can to ensure
that mental illness...
00:05:34
and all that follows from that
doesn't keep them
00:05:37
from living full, rich lives.
00:05:44
There was an initial concern
00:05:45
that people would request assisted dying...
00:05:47
because they couldn't access palliative care.
00:05:53
But the data has put that fear to rest.
00:05:56
Over 80% of the people who receive MAID
in Canada...
00:06:00
are receiving palliative or hospice care
at the time of their death.
00:06:04
For those few who are not...
00:06:05
88% of them have access
to such care.
00:06:09
Compare that to the wider
Canadian population
00:06:11
and all causes of death
00:06:13
when statistics suggest
00:06:14
that only a minority of people
are receiving
00:06:17
palliative care before they die.
00:06:20
The data that you're referencing...
00:06:22
comes from the forms that are filled out
by the MAID providers...
00:06:26
and it tells us nothing,
00:06:28
nothing at all, about the quality
of the palliative care.
00:06:30
We also know from the data you're citing
that 21% of people who...
00:06:35
who received MAID had palliative care
for less than two weeks.
00:06:39
While it's true, we don't have
an objective marker...
00:06:42
for the quality of palliative care received.
00:06:45
What we do know from lots of data...
00:06:48
is that since MAID was legalized
in Canada...
00:06:51
we have a significant increase
00:06:53
in the funding for research for palliative care
and an increase
00:06:56
in the number of people receiving and
dying with palliative care at home.
00:07:00
The vast majority of people who
access MAID in Canada
00:07:03
are patients with a cancer diagnosis.
00:07:05
The next most common underlying
00:07:07
illness are end-stage organ failures.
00:07:10
So end-stage heart disease
00:07:11
end-stage lung disease,
end-stage liver disease...
00:07:14
and neurologic conditions,
they’re around the 10% to 15% range.
00:07:23
The wait times for MAID
in Canada
00:07:25
are shorter than the wait times
00:07:28
to get a lot of specialized services.
00:07:31
That might be pain clinics,
psychiatric care...
00:07:34
long-term care homes,
veterans’ benefits...
00:07:37
supportive housing, community-based care.
00:07:41
That's not right.
00:07:43
My job as a MAID provider
00:07:45
requires me by law to ensure
00:07:48
that my patients have been offered
the resources and services
00:07:51
that could potentially reduce their suffering.
00:07:54
I agree we need to
reduce wait times
00:07:56
but at some point when potentially
helpful resources...
00:08:00
are not reasonably available
00:08:02
we can no longer hold individuals hostage
to society's failings.
00:08:07
It seems to me that
the greatest failing
00:08:09
we're talking about here
is a society
00:08:12
that's willing to help its citizens die...
00:08:15
rather than provide the services...
00:08:18
that we know help,
that we know work...
00:08:20
that we know reduce suffering.
00:08:22
Killing people while
they're on wait lists...
00:08:25
is profoundly immoral.
00:08:32
National polls consistently show
00:08:35
that the Canadian public supports
assisted dying.
00:08:38
This includes people who self-identify
00:08:41
as religious and people
with disabilities.
00:08:44
These polls were conducted
before our law changed
00:08:47
to allow assisted dying,
00:08:48
in the first five years of legalized practice...
00:08:52
and in every year since the amendment
that extended eligibility
00:08:55
outside the end of life context.
00:08:58
Two polls that asked Canadians
00:09:00
about their views on MAID
for mental illness
00:09:02
came back with very different results.
00:09:04
One poll showed over 60% of Canadians in favor.
00:09:08
Another poll, one in particular looking
at MAID for mental illness
00:09:11
showed that only 31% of Canadians
support it.
00:09:14
I don't think Canadians have
a full understanding...
00:09:17
of what is happening.
00:09:18
But those organizations that are
focused on what's happening...
00:09:21
and drawing attention to it
00:09:23
namely the 137 disability organizations in Canada...
00:09:27
the national indigenous organizations...
00:09:29
the mental health organizations,
the United Nations...
00:09:33
everyone who is looking at this
and understanding
00:09:36
what is going on is gravely concerned...
00:09:39
about the discriminatory impact
of this legislation.
00:09:44
Canadians have been talking about
and debating
00:09:46
assisted dying since the 90s.
00:09:49
There are multiple reports,
multiple committees...
00:09:52
multiple news stories,
multiple court cases...
00:09:55
to suggest that Canadians are unaware
of what the issue is
00:09:58
is not exactly fair to
the Canadian public.
00:10:05
There is no consensus
00:10:06
among Canadian psychiatrists
00:10:08
on when any particular psychiatric illness
is incurable.
00:10:13
And under the law that comes into effect
in 2024 in Canada
00:10:17
a psychiatric illness must be incurable
00:10:20
and a person must be in a state
of irreversible decline.
00:10:24
But we can't say who that is.
00:10:26
Consensus in health care
is rarely required.
00:10:30
There is no consensus amongst doctors...
00:10:32
about whether they can
accurately predict
00:10:34
a prognosis of six months.
00:10:36
Yet it's an eligibility requirement
for assisted dying
00:10:39
in several countries, including
the United States.
00:10:42
However, in Canada, for MAID to proceed...
00:10:45
two independent clinicians
must be of the opinion...
00:10:49
that the patient's condition is incurable.
00:10:52
When someone has a terminal illness...
00:10:54
say cancer, we have
a pretty good idea...
00:10:57
of how long they might live.
00:10:58
May not be precise, but we have
a good idea.
00:11:01
In mental illness, we have no idea.
00:11:03
People get better after five years,
after ten years.
00:11:06
These are very, very different conditions...
00:11:09
very different circumstances.
00:11:11
Now, we'll move on to the additional rounds.
00:11:14
Questions.
00:11:15
Personal experiences.
00:11:17
Debunk.
00:11:18
Uncertainties.
00:11:21
Stefanie, can you ask
John a question
00:11:23
that helps clarify his position?
00:11:26
John, do you believe every person
00:11:27
with a mental health disorder
can be treated successfully?
00:11:30
Because if not and they have capacity...
00:11:33
should they not be allowed to access
the same legal health care
00:11:37
available to everyone else?
00:11:39
We both know the majority of people
living with mental illness...
00:11:43
have full capacity.
00:11:44
They can make their own
treatment decisions.
00:11:46
To answer your question,
can we treat everyone?
00:11:50
I don't think that's the right question.
00:11:51
The question is, can we
reduce suffering?
00:11:54
Can we help people cope
with suffering?
00:11:56
There are certainly going to be people
00:11:57
whose illness will not get better,
their physical illness.
00:12:01
But can we mitigate their experience
of their symptoms?
00:12:05
Can we bring support...
00:12:08
care, compassion, and love
to them in a way
00:12:12
that makes their life for them
worthwhile?
00:12:15
I'm not talking about denying anyone...
00:12:18
the option of choosing MAID.
00:12:21
To be frank, everyone can already
choose suicide.
00:12:26
What we're working to do is to ensure
00:12:29
that every person is treated
with respect, dignity...
00:12:32
provided with care and support...
00:12:35
that we know can help
reduce suffering.
00:12:39
Okay, John, would you like
to ask Stefanie a question?
00:12:41
Only one in three Canadians
00:12:43
have access to mental health care
who need it.
00:12:45
Only one in five children.
00:12:46
We know from disability organizations
across the country...
00:12:50
that disability supports are
completely inadequate...
00:12:53
to live a meaningful life.
00:12:55
People are suffering...
00:12:58
in ways that we can do
something about.
00:13:01
I'm asking you...
00:13:03
would you support providing MAID
to someone...
00:13:07
while they're waiting for treatment or care...
00:13:11
that could help them?
00:13:14
But it's down the road a bit.
00:13:17
I would happily stand with you
00:13:18
and call for our government to do better
than what it's doing.
00:13:22
I think it's a separate issue.
00:13:24
There can come a time,
on a case-by-case basis...
00:13:28
Every situation is individual,
every situation is unique
00:13:32
and every case needs to be
assessed in a unique way.
00:13:35
There may be a time
when a certain treatment
00:13:37
is available, too far away,
00:13:40
much too expensive, inaccessible to the patient.
00:13:43
In this case, we have to seriously consider
00:13:47
not holding them hostage to society's failing
00:13:51
and to consider offering MAID if it's truly what they need.
00:13:56
A tough situation.
00:13:58
I grant you that.
00:14:00
John, can you tell us something
from your personal experience
00:14:04
that has strengthened your conviction
on this issue?
00:14:07
As a psychiatrist...
00:14:09
who works with a community
mental health team...
00:14:12
supporting people with the most serious
mental illnesses...
00:14:16
We are becoming overwhelmed...
00:14:19
by what MAID has introduced...
00:14:23
into our clinical worlds.
00:14:25
I have patients who are already saying...
00:14:27
“I'm going to stop treatment.”
00:14:29
“I'm not going to keep trying.”
00:14:31
“I can die.”
00:14:32
Our efforts to help them stick with
the very challenging
00:14:36
and sometimes long-term treatment
required to heal and recover
00:14:40
is being undermined.
00:14:41
We're not just doing suicide prevention anymore.
00:14:44
We're doing MAID prevention.
00:14:46
I'm going to tell you about
a gentleman I’ll call Ray
00:14:49
who was 62 years old
with metastatic lung cancer.
00:14:53
And Ray had been asking for MAID
for quite some time.
00:14:57
And as he and I worked through
the rigorous eligibility criteria...
00:15:01
at some point, I was able
to sit in front of him
00:15:04
and tell him he was eligible
for this care.
00:15:07
And when I sat there and did that,
I saw in him...
00:15:10
a physical transformation, which I've learned
actually happens...
00:15:15
almost every time.
00:15:16
I saw his shoulders relax.
00:15:19
I think I saw him smile for
the first time since I'd met him...
00:15:22
and it was immediately followed by
an expression of gratitude
00:15:27
for the mere possibility.
00:15:28
He decided to proceed with MAID
00:15:30
and we held it not long after,
in the rooftop garden
00:15:34
of the facility in which he was living.
00:15:36
And as is required by law
00:15:38
I was seeking his final consent
00:15:40
before I administered the medication.
00:15:41
He was surrounded by his friends...
00:15:44
and as he gave me that consent
00:15:45
he reached out and grabbed my hand.
00:15:47
He looked at me and he said,
00:15:49
“I know this is going to
sound odd, Dr. Green
00:15:52
but I think you saved my life.”
00:15:54
And it reminds me all the time...
00:15:56
that for the people who actually need
and want this care
00:15:59
it is tremendously important.
00:16:06
Stefanie, what is one piece of
specific misinformation...
00:16:10
that you've heard about MAID
that you'd like to correct?
00:16:13
Recently, a number of eye catching headlines
00:16:15
have appeared in the news
about Canadians requesting
00:16:18
assisted dying due to the threat
of homelessness...
00:16:21
or the fact that they're
living in poverty.
00:16:23
And while it's true that
anyone can ask
00:16:25
for an assessment of eligibility for MAID...
00:16:27
and those unacceptable social inequities
00:16:30
might be contributing towards suffering.
00:16:32
The law is actually perfectly clear
and Canadians cannot access
00:16:37
MAID based on those factors alone.
00:16:39
John, would you like to clarify
a piece of misinformation?
00:16:43
Some MAID providers have argued that MAID...
00:16:46
for non-terminal conditions...
00:16:49
is not suicide.
00:16:52
For decades, suicide
has been defined
00:16:54
as taking steps to arrange
your own death.
00:16:57
Some have said that what makes MAID
different than suicide...
00:17:02
is that it's well thought out.
00:17:04
It's not impulsive.
00:17:06
But in fact, in one US survey of
over 1.4 million Americans
00:17:11
80% of people reported
00:17:13
that they thoughtfully planned
their suicide...
00:17:16
Which means that we have to consider
00:17:18
where it fits into all of our
suicide prevention efforts...
00:17:22
and whether it undermines those
very directly.
00:17:27
And now for a round called Uncertainties.
00:17:30
John, what is something
we don't know
00:17:32
about this issue that we need
more research on?
00:17:35
Canada currently collects data...
00:17:38
on the illnesses—
00:17:39
the physical illnesses that lead to
requests for MAID.
00:17:42
What we don't have is data...
00:17:44
that considers the socioeconomic reasons
people might request it.
00:17:49
And how significant an impact...
00:17:51
that might have on the request
00:17:53
and perhaps whether it drives it completely.
00:17:56
We don't know whether poverty,
homelessness...
00:17:59
being on a waitlist for treatment...
00:18:02
being refused disability benefits...
00:18:05
we don't know why...
00:18:07
people are choosing MAID
and we should.
00:18:10
On this point, John, I think we're
almost in agreement.
00:18:13
Canada has recently expanded
the type of data it's...
00:18:17
gathering on patients who
request and receive MAID.
00:18:21
And I'd be curious to see if it mirrors
what we know
00:18:24
from international jurisdictions.
00:18:26
Everywhere where this data
is collected elsewhere...
00:18:29
we know that it is the
socially advantaged...
00:18:32
who are accessing assisted dying
00:18:34
not the socially disadvantaged.
00:18:35
So I'll be curious to see
if that plays out
00:18:37
in the Canadian context, which is what
I expect to be frank.
00:18:41
That said, I think we do
have a good idea
00:18:44
of how people describe
their own suffering...
00:18:47
and therefore why they're requesting MAID.
00:18:49
Primarily, it's for people who can
no longer do the things
00:18:53
that bring meaning to their lives...
00:18:54
who no longer are able
00:18:56
to do what we call the
activities of daily living...
00:18:58
who've lost a sense of dignity
or independence.
00:19:02
And I think if we could find research
00:19:04
that would help us better understand...
00:19:06
what leads to that type
of suffering...
00:19:08
potentially there's a way
we can learn to treat it.
00:19:15
I'm concerned about this law...
00:19:17
having, I'll acknowledge,
the unintended...
00:19:20
but profoundly disturbing consequence...
00:19:23
of having people feel like
they're a burden
00:19:26
and that they should choose
death over life.
00:19:28
That they should no longer demand
00:19:30
of their government,
of their fellow citizens...
00:19:32
that care and support be provided.
00:19:35
Having spent time
00:19:37
with many suffering individuals,
I can tell you...
00:19:41
that Canadians are extremely grateful
for this option.
00:19:44
In a testament to the quality of care
being provided...
00:19:47
not a single person has been charged
with misappropriate action.
00:19:51
I think Canada's approach
to assisted dying
00:19:54
is more than adequate.
00:19:56
It is solid.
00:19:57
It is good, and for some,
it may be a model...
00:20:00
for considering care
in their own region.
