Canada Wants To Let Dementia Patients Consent to Euthanasia in Advance
· Reason
Patients diagnosed with progressive dementia may know exactly how much deterioration they are willing to endure. They can articulate their wishes, discuss alternatives, and put their instructions in writing. Should losing the ability to repeat those instructions invalidate them?
Canada is preparing to address that question. On October 23, its Justice Department announced planned rules that would allow adults diagnosed with an incurable illness expected to destroy their decision-making capacity to consent in advance to assisted suicide (or, as Canada calls it, medical assistance in dying (MAID)). Ministers will discuss the proposal on October 27, but it must pass both houses of Parliament and receive formal approval from Canada's governor general before becoming law. Parliamentary committees can hear testimony and consider amendments along the way. The announcement promises safeguards but offers few details. Those details will determine how well the proposal respects patients' choices.
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A free society recognizes individuals as sovereign over their own bodies provided they respect the rights of others. That freedom includes deciding how much suffering they are willing to endure. A competent adult's decision deserves respect even when physicians, relatives, or public officials would choose differently.
Competent adults should be free to choose clinician-assisted suicide or clinician-administered euthanasia, provided they give fully informed, voluntary consent and those assisting them do so willingly. That freedom should include planning for the loss of decision-making capacity. A patient's loss of decision-making capacity should not automatically grant the government authority to override instructions given while the patient was competent.
Physician-assisted deaths are now authorized in 13 states and Washington, D.C. Twelve states and the district enacted laws; Montana permits it under a state Supreme Court ruling. American statutes generally follow the Oregon model: Patients must have decision-making capacity, have a terminal illness expected to cause death within six months, and self-administer the medication.
These restrictions exclude people who suffer greatly but cannot meet the government's timetable or physically perform the final act. Progressive dementia creates another barrier. By the time patients reach the condition they hoped to avoid, they may no longer qualify.
In 1999, Michigan convicted Jack Kevorkian of second-degree murder after he administered lethal drugs to Thomas Youk, a patient with amyotrophic lateral sclerosis ("Lou Gehrig's disease") who had consented to the procedure. As I wrote in Reason, patients' bodily autonomy includes the freedom to request a willing physician's assistance in ending their lives. Requiring patients to administer the medication themselves denies that choice to people whose illnesses have stripped them of the physical ability to act. Dementia raises a further question: whether an informed decision can survive the loss of the capacity to express it.
Other countries give patients more latitude. At least a dozen countries permit some form of assisted dying, though their rules vary considerably. Canada does not require a terminal prognosis. In the Netherlands, euthanasia is permitted for unbearable suffering with no prospect of improvement, subject to statutory safeguards.
Some countries also recognize advance requests, though under different conditions. In the Netherlands, a written advance request can replace an oral request once a patient loses the ability to express a choice, including in advanced dementia. The remaining legal requirements, including unbearable suffering without prospect of improvement, still apply.
Belgium permits advance requests more narrowly, only when a patient becomes irreversibly unconscious. Patients who lose decision-making capacity due to dementia while remaining conscious cannot obtain euthanasia under an earlier directive.
Respecting a patient's earlier wishes raises difficult questions. How clearly must patients describe the circumstances in which they want assistance? Who determines whether those circumstances have arrived? What happens if a patient who can no longer understand the directive resists the procedure or appears content with life?
Legal scholars, working with clinicians and patients, must help lawmakers answer these questions. Finding the right answers is difficult, but the obstacles are not insurmountable. Lawmakers must develop careful safeguards that respect patients' choices rather than impose a blanket refusal to honor decisions made while patients were competent.
Patients already use advance directives to refuse life-sustaining treatment after losing decision-making capacity. Authorizing someone to administer life-ending medication requires additional legal consideration. But the principle of planning ahead deserves the same respect: People should have a meaningful say over what happens to their bodies when illness prevents them from speaking for themselves.
The law has a legitimate role in protecting patients from coercion, fraud, and life-ending procedures they never consented to. Before another person intentionally helps end a patient's life, the law must require reliable evidence that the patient gave informed, voluntary consent and that the applicable conditions were met. Neither a relative's preferences nor a clinician's assessment of whether a life remains worth living can substitute for the patient's decision.
Participation must also remain voluntary. Clinicians and private institutions should be free to decline participation on moral, ethical, or professional grounds. Respect for autonomy extends to all involved.
Oversight should focus on compliance with the law. An independent body could audit cases retrospectively, publish anonymized findings, and refer credible violations to investigators. It should not require patients to obtain bureaucratic approval for individual decisions, nor should it have the authority to rewrite eligibility standards.
Eligibility should hinge on a serious, incurable condition causing enduring, intolerable suffering and on reliable evidence of informed, voluntary consent. A six-month prognosis gives the government too much power over how long patients must endure suffering they consider intolerable.
Canada's proposal deserves careful examination once its details are available. A law that honors clear advance instructions while protecting patients against violations of those instructions would expand their control over the course of an incurable illness. A law that allows others to substitute their preferences would undermine the autonomy it purports to protect.
Dementia can rob people of their memories, judgment, and ability to communicate. The government should not use those losses to erase choices they freely made while competent. Patients who leave clear, informed instructions deserve laws that let willing clinicians honor them. Their bodies belong to them, even when they can no longer say so.
The post Canada Wants To Let Dementia Patients Consent to Euthanasia in Advance appeared first on Reason Magazine.