Mental health and dementia

Alan Nichols, a former school janitor in British Columbia, had battled depression for years when he was taken into hospital in June 2019.

His family had supported him throughout, his brothers visiting weekly and bringing him shopping. But he often stopped taking his medication, and after a neighbour raised concerns the police broke into his apartment one day and found him weak and dehydrated.

Initially, Alan wanted to be quickly discharged but his family persuaded him he should stay to recover. One month later, however, Alan’s family received an astonishing phone call from a doctor, telling them their brother would be given a lethal injection in four days’ time. Without informing anyone else, Alan had requested MAiD and been approved.

Shocked and confused, Alan’s family strove to find out on what grounds he had been approved, as he was not terminally ill and was also suffering from serious depression meaning his mental competency to choose euthanasia was strongly in question. But all their frantic inquiries were rebuffed on the grounds of patient privacy and they were powerless to stop their beloved brother being killed just days later.

“Alan did not fit the criteria. Alan was capable of talking, he was sitting up, he was eating, he was going to the bathroom, we were laughing, he was out of bed,” his sister-in-law Trish Nichols told a Canadian TV station. “I knew by looking at him that he still had living to do. He was not near the end of his life.

“How can you allow this with Alan, knowing his background of mental anguish and depression? We spent 50 years helping Alan live, and in one month they signed his death warrant.”

The Nichols family continue to fight for an investigation into Alan’s death, but Canada is already moving on. Soon, it is likely there will be many more people like him. Although at the time, people suffering from psychiatric conditions were not eligible for MAiD, in two years’ time the law will change to allow people with mental health problems to request euthanasia.

For years, Canada – like most societies – held firm convictions about suicide among those struggling with mental health problems. The authorities had compassion for those who feel like they want to take their own lives, and did everything in their power to stop them. Because everyone agreed suicide was never the right response to mental ill health.

But this is no longer the case. When the new MAiD law comes into force in 2023, not only will the state formally endorse the suicidal ideations of those with depression, anxiety, schizophrenia, bipolar disorder and a plethora of other conditions, it will actively facilitate it. Those who, like Alan, feel death is the only way out of their mental torment can no longer be confident their healthcare professionals will protect them from themselves. Instead, they could be assessed, approved and euthanised in less than a fortnight.

From the beginning of Canada’s experiment with assisted suicide and euthanasia, many were pushing for the inclusion of those whose problems were solely psychiatric not physiological. The initial MAiD law included a commission to study the issues of dementia and mental health. Some experts and politicians recommended the government make no distinction between those suffering from mental health conditions and those with physical illnesses. The media openly covered several cases of doctors agreeing to euthanise patients with dementia within a year or two of the law changing, despite MAiD requiring mental competency.

So when the government was forced to amend the legislation to abolish the requirement MAiD recipients be terminally ill and close to death following a court ruling, it also caved in on mental health. When the new bill passed into law in March 2021, it set a 24-month clock ticking. When that time is up, mental ill health will automatically be added to the list of reasons which make someone eligible to request MAiD.

Even aside from the devastating impact this will have on society’s efforts to prevent psychiatric patients from taking their own lives, it is also fundamentally illogical. Canada’s euthanasia rules require any eligible person’s condition to be “irremediable” – i.e., it cannot be treated and reversed. However, psychiatrists are almost unanimous in arguing that it is impossible to assess if a particular mental health problem is irremediable. The evidence shows it is simply not possible to accurately predict if a particular patient’s mental health will recover, or if it they will suffer for the rest of their life.

“Because we cannot predict irremediability, there is 100 per cent certainty that MAID will be provided to some people who could recover — there is no safeguard against that,” writes Kanudeep Sonu Gaind, an associate professor of psychiatry at the University of Toronto.

“We are poised to provide death for mental illness to potentially suicidal, non-dying marginalized people suffering from life distress who have the potential to recover — all based on less evidence than is required for the approval of any sleeping pill.”

Evidence from other countries confirms this. A Dutch study found assessors in one in five psychiatric cases of assisted suicide or euthanasia disagreed on whether the patient was likely to improve in the future. Despite this lack of consensus by the medical experts, all 66 people in the study were given euthanasia or helped to kill themselves regardless.

Dementia poses additional challenges. From the beginning of MAiD, elderly people suffering from dementia have been a significant proportion of those seeking an assisted death. Currently, the law requires any recipient of euthanasia to be mentally competent to consent to the procedure both when they make the request and again at the point of receiving their lethal injection. But practitioners and activists have pushed hard against these requirements, arguing it forces people who would like to be euthanised to seek it early, before their condition robs them of their faculties and thus the capacity to be approved for MAiD. They instead have demanded the law permit advance decisions — allowing someone with dementia to set out their wish to die in the future, while they retain the mental competence to do so.

In 2017, just one year after Canada introduced euthanasia, there were test cases of Alzheimer’s patients seeking to push the interpretation of the law to its limits. In the absence of laws permitting advance decisions, guidance from the Canadian Association of MAiD Assessors and Providers insisted it was somehow possible to consent to being assisted to commit suicide or euthanised even if your dementia had robbed you of critical faculties: “Just because a patient cannot remember that a sock goes on before a shoe, does not mean she is incapable of expressing a choice or appreciating the irreversible consequences of MAID.”

If activist doctors continue to push the envelope on MAiD eligibility or the government legislates to permit advance decisions, Canada will enter a new phase of its euthanasia journey. Doctors could be forced to euthanise dementia patients who are at the time happy and far from a natural death, simply because before they lost mental capacity they signed a MAiD request form. People’s fear of losing their faculties will result in their deaths by euthanasia, even though in reality millions live high quality lives, even with dementia.

If Canada does continue down this path, it will have ended up in a dangerous place. The focus will no longer remain on improving the quality of life for those with Alzheimer’s and reducing the suffering of patients undergoing cognitive decline. Instead, the attention (and inevitably, money and effort) will be driven towards ending the life of such people.

Simply passing MAiD into law is already changing people’s minds. In one study of carers in Quebec, 91% supported euthanasia for dementia patients who had made advance requests. Astonishingly, 72% were also in favour of euthanising even those without an advance decision. Almost three in four people who have been hired and trained to care for people living with dementia believe the state should unilaterally decide their lives are not worth living, and kill them. For the millions with dementia, many of whom already fear the rest of society will give up on them, this must be a terrifying prospect.

Canada’s early experience only mirrors that of other countries. When euthanasia becomes available for mental health conditions alone, it steadily becomes a bigger and bigger phenomenon. For why should we as a society bother doing the long, difficult work of walking with someone through their mental anguish and torment – trying to help them with the messy reality of therapy and other treatments – when they could simply be signposted towards an n intervention that would end it all?

Previously, people in the depths of grievous mental anguish – whether prompted by depression or dementia – could trust their doctors to try and relieve their suffering. But no longer. Previously, Canadian society had collectively signed up to do everything it could to prevent seriously ill people from making the destructive and tragic mistake of believing they would be better off dead. But no longer.