For skiers Canada may be known for its magnificent powder snows, stunning scenery and exciting downhill runs. But it is fast becoming infamous for an entirely different type of slippery slope: what opponents regard as the rapid and frightening expansion of the rules and ditching of safeguards around assisted dying.
That this is the inevitable result of legalising euthanasia is one of the main arguments against the Leadbeater bill that will be debated in the House of Commons a week today. In Canada, the Medical Assistance In Dying (Maid) has been in force since 2016. The Leadbeater bill’s opponents say in those 18 years the slippery slope has turned into an avalanche of death. The Catholic Caritas Social Action Network has warned: “In Canada... assisted dying now accounts for 4.6 per cent of deaths, with expanding eligibility criteria to include people with disabilities or mental health conditions. This raises serious ethical concerns about sending the message that some lives are less valuable than others. If legalised in the UK, there is a risk that similar pressures will emerge to broaden the law’s scope over time, putting the protection of vulnerable groups at high risk.”
In Canada some campaigners go even further, arguing the Canadian government has allowed the province of Quebec to get away with murder. Quite literally.
So before we dive into these arguments, let us look at what has actually happened.
1991 to 2010: The Canadian House of Commons and its committees debated six private member’s bills seeking to decriminalise assisted suicide. None was passed.
2009: Gloria Taylor was diagnosed with amyotrophic lateral sclerosis, a fatal neurodegenerative disease, and went to court insisting it was her right to be able to get help in dying.
2012: A judge in the Supreme Court of British Columbia ruled in Taylor’s favour, saying that “the prohibition against physician-assisted dying violates the (constitutional) rights of competent adults who are suffering intolerably as a result of a grievous and irremediable medical condition and concluded that this infringement is not justified.”
2015: The Canadian Supreme Court supported this judgment and ruled that sections of the criminal code “are void insofar as they prohibit physician-assisted death for a competent adult person who clearly consents to the termination of life; and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” They said the criminal law would need to change as those parts which prohibited medical assistance in dying would no longer be valid. They gave the government until June 2016 to do this.
2016: The Canadian parliament passed federal legislation that allowed adults facing “enduring and intolerable suffering” whose natural death is “reasonably foreseeable” to request medical assistance in dying.
2019: The Superior Court of Quebec decided the “reasonable foreseeability of natural death” eligibility criterion was unconstitutional.
2020: The minister of justice and attorney general of Canada introduced a bill to drop this qualification.
2021: Parliament passed a bill which loosened the criteria in two ways. For those with “foreseeable deaths”, “the patient’s written request for Maid would only have to be signed by one independent witness, rather than two. Second, the 10-day reflection period would be eliminated.” More importantly, “for individuals whose natural death is not reasonably foreseeable, the safeguards described above would apply in addition to... a minimum 90-day assessment period, a second eligibility assessment by a practitioner with expertise in the condition that is causing the person’s suffering and two clarifications of informed consent.”
2022: The exclusion of those suffering from mental illness, due to end that March, was extended until 2027 when it will be reviewed again.
2023: Quebec passed a law allowing people to sign advanced declarations of intent—that they want to be helped to die if certain conditions are met in the future, such as if they are no longer able to recognise their relatives.
In short, in 15 years, Canada has gone from a country where it was illegal for anyone to help someone kill themselves, to allowing this when their death from an incurable illness was “reasonably foreseeable”, to scrapping this criteria in favour of, in the words of the attorney general, one where there is “freedom of choice of all Canadians to decide for themselves when their suffering has become intolerable”. Between 2016 and 2022, almost 45,000 Canadian died in this way. And now Canada’s largest province has made it possible for some people to book their death in advance.
I’m not keen on the expression “slippery slope”. It’s both a cliché and a loaded partisan term. One can imagine campaigners against the English parliament’s ban on torture in 1640, arguing: “It’s a slippery slope, you know next it will be the stocks and pillory then flogging will go. Before long, you won’t even be able to beat your own children!” One man’s slippery slope is another woman’s primrose path.
Still, we are probably stuck with the phrase. So if there is such a thing as a slippery slope then, yes, this is it—indeed you would be battling strong headwinds up an icy incline to argue otherwise. It is clear there has been a gradual reduction of the restrictions and safeguards surrounding assisted dying, and what’s more these changes are driven by judicial activism—although both judges and politicians would claim what is behind the changes is an evolution of the public mood.
A government statement argued after one liberalisation: “The new law responds to feedback from over 300,000 Canadians, experts, practitioners, stakeholders, provinces [and] the testimony of over 120 expert witnesses”.
So if we accept as fact that Canada’s laws have become more permissive, the question is: is that a good or bad thing?
The changes were made to correct defects with the original law—flaws that worry me about the Leadbeater bill. In both the original Canadian law and the British bill, the main thrust of the arguments in favour of allowing doctors to help someone to die, intellectual and emotional, revolve around the prevention of terrible suffering. But this core contention is absent: there is nothing to help people whose lives may have become intolerable. In Canada that may have been an oversight. In the British bill it is deliberate.
The second worry is both practical and philosophical. The bill doesn’t even try to solve the conundrum that if I ever find my life intolerable, it may be, almost by definition, when I am not in a fit state to do anything about it. Quebec has decided to take the next logical step to address that. But what I’ve learnt about it so far makes me feel distinctly queasy.
But before we look at that, I wanted to get the view of the opponents of assisted dying about what is happening in their country. One of the fiercest critics is Amanda Achtman, who runs a project called Dying to Meet You. She’s in her early 30s, both earnest and enthusiastic. She tells me in a Zoom call that she first got involved in the debate as a young philosophy student and her reasoning still bears that hallmark. When she was growing up her grandfather lived with the family. He was in his eighties when these discussions were going on and that influenced her too. She tells me the slippery slope is inevitable.
“It cannot remain limited once legalised. It cannot remain limited because if it is presumed to be a good and sensible and compassionate thing then there’s no reason to restrict it to certain demographics. Why would you? If euthanasia is a compassionate means to end suffering, why wouldn’t we allow it for children? It seems rather cruel unless we say it’s about consent. But if it’s about consent then we see that it’s already been expanded to persons with dementia. So the way I put it is that euthanasia cannot remain limited once legalised. Once accepted as a sensible means to end suffering by a society then it will always be extended on the grounds of human equality.”
I suggest some would say that’s a good thing.
“If you believe it’s good, again, why would it be limited? I think it’s important for proponents of euthanasia to become much more transparent. I like to ask proponents of euthanasia, where would the limit be? I recently had a public event where I asked a Canadian euthanasia doctor whether he thinks there should be any limits whatsoever, and he specifically said to me: ‘I’m not comfortable saying there should be a limit.’ That question gets to the heart of whether it’s fundamentally a good practice, good medicine or not.
So it should never be done?
“That’s right, because you always prematurely end the person’s life and capitulate and concede either to the disease itself, without adequately treating it and rising to the challenge, or give in to the despair and what is essentially a kind of suicidal ideation. The fundamental reason why I oppose euthanasia across the board is because I believe that everybody deserves suicide prevention rather than suicide assistance. Legal euthanasia creates a two-tier society where some people get suicide assistance and others are offered suicide prevention.”
Quebec has decided to take the next step—in a way, the next logical step down Amanda Achtman’s slippery slope. Now in Quebec those with a serious, incurable condition can give “informed consent” not days but months or years before the condition takes a grip.
According to the government of Quebec, this means: “An advance request for medical aid in dying is made by a person who has been diagnosed with a serious and incurable illness leading to incapacity (for example, Alzheimer’s disease). The request must be made while the person is still capable of consenting to care, with a view to receiving medical aid in dying when they become incapable of doing so, if all the criteria set out in the Act are met. An advance request allows a person to give their consent in advance to receive medical aid in dying in the future, under certain conditions, when they will no longer be able to consent to receiving aid. The advance request form is available only from a physician or a specialized nurse practitioner.”
This report from CBC begins with one campaigner who is delighted by the change. Sarah Demontigny was diagnosed with early onset Alzheimer’s disease six years ago. She is now 43. She has three daughters and doesn’t want them to watch as she watched her father suffering before dying of the same disease at the age of 53, talking to himself in the mirror, crawling around on all fours, banging his head on the floor. She says: “It’s hard because you know you’ll just lose and lose and lose all the things you’re able to do… I feel like I finally have control over what’s left of my life.”
Some doctors are pleased, too. Georges L’Espérance is a neurosurgeon and president of the province’s association for the right to die with the dignity, Association québécoise pour le droit de mourir dans la dignité. He says he is delighted with the proposed legislation. “From what I've read, it’s the person who decides what their limits are,” he says. “For example, if they no longer recognise their children.”
But other doctors are worried, according to this report from AFP on the policy shift. It quotes one senior geriatrician, David Lussier, as saying: “What will be the most difficult will be to administer medical assistance in dying to someone who is not aware of it and who will not remember having asked for it.” Lussier added that if the patient makes a “gesture of refusal”, the doctor must cancel the procedure. But if a patient “resists, and it is part of their illness, we can still give it”.
Previously he had spelled this out in more detail in evidence he gave to parliament in 2022, saying: “Another important question arises regarding the situation in which the individual making an advance request refuses to cooperate when the time comes to administer medical assistance in dying. At an advanced stage, many individuals resist all contact and treatment and become aggressive when touched. As a result, they reject attempts to insert any intravenous device without previously being sedated or restrained. Even though patients, when they were competent, probably wanted to be sedated or restrained for the purpose of administering medical assistance in dying, are we to disregard their verbal or physical refusal when they are no longer competent? Many clinicians say they would find it very difficult to do so, especially if patients showed no signs of objectifiable suffering.”
This is both chilling and ludicrous. Chilling that any doctor might even toy with the notion of elevating a piece of paper above a patient’s distress at what is happening to them—even if they are no longer capable of rational judgement. Ludicrous that one’s past self could bind a future self to a death they no longer wished for. This is hard all round: of course it is possible to think “I couldn’t bear to live like that”, and then, when you arrive at that destination, still find some sort of joy in what once seemed a living horror.
As a matter of fact, Quebec’s new law makes it quite clear a patient can change their mind, even if it means filling in yet another form: “The physician or the specialised nurse practitioner must confirm that the person is capable of consenting to care, sign the form and make sure the request is withdrawn, as soon as possible, from the register provided for by law.”
But: “An advance request is not cancelled because a physician or a specialised nurse practitioner has concluded that they cannot administer medical aid in dying, unless this conclusion results from the refusal expressed by the person to receive such aid.”
Nevertheless, Claude Rivard, a palliative care doctor who carried out Quebec’s first assisted death and has administered euthanasia hundreds of times since then, is really worried. “When you’re going to come and try to insert the IV on a person who’s not capable of understanding what is going on, he will be hurt by that. I cannot start tying people up to insert [an] IV,” he said. “In the family’s mind, it could appear as an execution.”
One Canadian member of parliament, Garnett Genuis, said: “There has to be contemporaneous consent in the context of sexual consent. Why would we have a different and lower standard for someone consenting to die than for someone consenting to engage in sexual relations?”
That seems to me a schoolboy debating point (no nominative determinism then) rather than a valid argument, but there’s no doubt this whole business puts the federal government in a bind. It is clear that these plans are in breach of the criminal code, but it also doesn’t want a confrontation with this populous and potentially separatist French-speaking province. So it’s response is not to call them out or slap them down, but to consult on the wisdom of following their lead. The health minister Mark Holland said: “What we’re saying very clearly is that this is an incredibly difficult issue, that we need to take the time to have a national conversation that includes our provincial and territorial colleagues, that where these lines are drawn and whether or not the system is ready is a very important step.”
Amanda Atchman isn’t surprised. “This is basically a death for dementia policy—it is so dark and it is so dehumanising and furthermore it renders a diagnosis of dementia so much more tremendously fearful for both the person themselves and for their loved ones.” She argues children will be next as Quebec expands the scope of the law.
Campaigners like Achtman fear helping people take their own life is becoming just another tool in the medical kit box, and so just another way society has of dealing with its most problematic members. And from there to seeing suicide as normal is just a short slide down the slippery slope. Canadian newspapers are full of stories about the pressure vulnerable people have felt.
The Christian Institute quotes an unnamed 51-year-old woman from Nova Scotia on her way into cancer surgery. She was, the article claimed, fearful, shivering as she sat on a plastic chair waiting for her operation when a medic spoke to her. When the doctor asked if she knew about Maid, she said: “I don’t want to talk about that,” she recounts. “I was scared and I was alone and I was cold and I didn’t know what was coming. Why was I being asked about assisted dying, when I was on my way into what I truly believe was life-saving surgery?”
The woman stated that the repeated offers of euthanasia made her feel “like a problem that needed to be rid of instead of a patient in need of treatment”.
I put it to Achtman that although such stories abound, they rarely give enough detail to be trusted. She retaliated with: “Have you seen my video with Roger Foley? [I hadn’t, but here it is]. He’s a man living with several disabilities who’s in the hospital because he cannot get adequate home care. He says: ‘The doctor will come in and asked if I’m struggling with self-harm and if I say yes, I’m feeling suicidal, the doctor simply says: “Well, we have a programme to end your life if you’d like help with that.”’ If we don’t consider that a nudge and a push! I think it’s egregious that a person with disabilities who admits to temptation to self-harm would be offered euthanasia as the way out.’
I ask her if she cannot imagine being in such pain that even she would wish to die.
“As soon as you have someone who says, ‘Yes I am in such excruciating physical and existential pain I want I want to die,’ and then you have someone who says, ‘I'm in such physical and psychological pain but I don't really want to die,’ how is that second person really free and left any alternatives—medically, socially and culturally—to resist it?” she says. “It is a death sentence when you create pain as the threshold of what qualifies a person to prematurely have their life ended—it shatters all pretext of genuine choice for those in that situation.”
She says recent reports show what kind of suffering most leads people to request euthanasia. “It’s not being a burden, it’s not financial, it’s not pain or the fear of pain. The number one cited reason why people in Canada are asking for euthanasia is because they’ve lost the ability to engage in meaningful life activities. That is why I say that though there is a lot involved medically and health-wise in this subject matter, these are principally existential crises not medical choices.”
I interrupt: a choice is a choice. “If nine of 10 persons with Parkinson’s go for euthanasia and that one person out of 10 is not interested in it, I guarantee you that the pressure they will feel both on the part of the healthcare system and socially will be a form of coercion and pressure,” she retorts. “They will kind of be disqualified from existing.”
What would she say to British MPs preparing to vote next week?
“One of my biggest warnings would be at the very least euthanasia should never be doctor- or nurse-initiated. But I’ve read the bill very closely and it does not prohibit doctors from raising assisted dying with their patients. On the contrary it says they are free to and it’s at their discretion. That’s a disaster. The MP who introduced this bill is trying to say it’s got the strongest safeguards in the world and that it’s nothing like Canada, but it’s very, very, very, very much like Canada. Like Canada’s 2016 bill, where death needs to be ‘reasonably foreseeable‘. Okay, the only difference with hers is instead of ‘reasonably foreseen’ she says six months left to live. That is a mirage of precision: about half of the time doctors’ predictions on the six months left to live are wrong.”
A supporter of Leadbeater’s bill points out: “The Health and Social Care Select Committee concluded that no country that has a adopted a terminal illness only law has expanded the scope of that law. Those countries with broader laws adopted them at the outset, based on subjective criteria of ‘unbearable suffering’, which is not mentioned anywhere in Kim’s bill. The judicial revisions that have taken place in Canada could not happen here.”
Leadbeater herself told me: “When MPs come to vote on this very important piece of legislation they categorically will not be asked to consider an approach to assisted dying that in any way resembles that in Canada. I could not be more clear about this. The Canadian approach extends beyond terminal illness, whereas the title of my bill is very deliberately the ‘Terminally Ill Adults (End of Life) Bill’. I have had a number of difficult and sometimes upsetting discussions with people who would like it to go further, but the bill will apply only to those who are already dying with six months or less left to them and who want a better choice at the end of their life than they have now. Canada’s law was dictated by its Supreme Court. Here, both the domestic and European courts have said explicitly that it is for parliament and not the courts to decide what the law should be.”
At the end of writing and researching this piece, I feel more confused than ever—and still need to sit down and process all this information. My original headline was going to be “slippery when wet”—the argument being that the shortcomings in Canada’s original bill were weakness that inevitably led to reform. I haven’t changed my mind about that, but do wonder whether Quebec has gone too far, and in Canada assisted suicide has become just another lifestyle (deathstyle?) choice. And that makes me wonder whether the safeguards in the British bill are sensible, rather than too stringent. If I were an MP I would still have no hesitation voting for it—but would I then want to see it widened in scope. Quebec gives me pause.
I need more time to think—and your help. What do you make of the Canadian experience?
