Research identifies key concerns with expanding access to MAID to mature minors
In December, the Council of Canadian Academies (CCA) will report to Parliament on whether to expand access to medical assistance in dying (MAID) in three major areas: to mature minors, to those with mental illness as the sole underlying medical condition, and by advance directive.
The CCA reports will not make recommendations, but the reports will include available evidence on expanded access to MAID in these three areas and consider how the evidence informs our understanding of MAID in the Canadian context.
The EFC submitted a brief which outlines academic research and opinion that expressed key concerns about expanding MAID in these ways.
Here is an excerpt from the backgrounder to the EFC’s brief, which summarizes some of the reasons not to expand access to MAID to mature minors. This excerpt is written in the more formal style required of these kinds of briefs, but we thought it was important to share this information as widely as possible. We are always available to answer your questions.
The Evangelical Fellowship of Canada (EFC) is the national association of evangelical Christians in Canada. The EFC upholds respect for human life and care of vulnerable persons. Expanding access to euthanasia and assisted suicide (EAS) would place the most vulnerable Canadians at risk and further undermine societal respect for life.
Mature minors
The EFC absolutely rejects the idea that MAID should be made available to minors. Children are a vulnerable population. Children are influenced and may be pressured by adults in numerous ways. As this article in the Journal of Medical Ethics noted, “even a small amount of pressure by an authority figure will typically have disproportionate actual force on any child, particularly a sick child… Children rightly merit extra protection because they are generally more sensitive than adults.”[16]
Canada’s first priority must be to provide high quality medical care for children. To consider expanding MAID to mature minors in the absence of widely available, high quality mental health services and palliative care would be unethical. In Canada, less than 25% of children with mental health disorders receive specialized treatment services.[17]
There is no agreement about whether minors have a capacity to consent to EAS. One study on adolescent decision-making states: “Given that the psychological and neurological data have already been interpreted to support opposing conclusions on this question, it seems prudent at least to reserve judgment about what the data actually reveal about the quality of adolescent decision-making.”[18] It goes on to state: “We haven’t yet agreed on a stable definition of capacity in this population, much less a reliable instrument for measuring capacity.”[19]
The law sets an age at which Canadians may make significant decisions, such as the right to vote or to purchase alcohol or cigarettes. It is only appropriate and reasonable that a life-ending decision should be restricted to a similar age.
At the Special Joint Committee on Physician-Assisted Dying, Dr. Dawn Davies of the Canadian Paediatric Society stated that no consensus exists on an age of consent to treatment. She went on to say:
In general, the less weighty the outcome of the decision, the more we allow the minor to play a role in that decision. For example, for a very young child, it may be asking which arm they would like their intravenous started in because the risk of harm is so low. However, a child not wanting potentially life-saving chemotherapy if they have a good prognosis or not wanting any further treatment if they have just suffered from a terrible car accident, for example, are the cases that are much more difficult to assess.[20]
In general, the less weighty the outcome, the more a minor plays a role in the decision. MAID cannot be undone or mitigated, it is intended to kill, and thus it cannot be considered like any other type of medical treatment over which minors may have legal decision-making power.
As an article on euthanasia and children states, “The weightiest decision of all is the choice to die. Virtually all other choices can be reversed or mitigated.” [21]
Another article explains: “Making a decision to administer antibiotics differs from making a decision to end a life. In the former case, recovery from a misguided decision is possible, and the very goal is to respect and preserve natural life. This cannot be said of the latter case”[22]
There is a moral and ethical difference between refusing or withdrawing treatment and MAID. In cases where a minor participates in a decision that results in his or her death, the minor is refusing treatment, not consenting to a lethal injection. Hastened death is categorically different than end of life care, including palliative or continuous sedation in the last days or hours of a patient’s life. The intention to end a life, rather than to alleviate pain, makes euthanasia and assisted suicide fundamentally different than end of life care.
As Dr. Mary Shariff of the Canadian Paediatric Society explained to the Special Joint Committee on Physician-Assisted Dying:
… the argument is being made that the law has already allowed mature minors to make medical decisions even if doing so would result in their death. But let's think about that a little more closely. In those death cases, the decision is about rejection of treatment whereby if the child rejects treatment, the child runs the risk of dying. This is an entirely different consideration for children than is children being expected to consent to lethal injection.
… we also see from those cases in the Canadian case law that if the odds of survival are good with treatment, the court will override a minor's refusal.[23]
Conclusion
The EFC opposes all euthanasia and assisted suicide. However, in a context in which these practices are legal, we advocate for stringent safeguards to provide the strongest possible protection for vulnerable Canadians and to minimize the potential for abuse.
This brief summary points to compelling evidence of numerous problems with expanding access to MAID to mature minors, to those with mental illness as the sole underlying factor, and by advance requests. To expand access to MAID in these ways would place some of the most vulnerable Canadians at unacceptable risk.
Our focus as Canadians must be on extending and improving high quality palliative care and treatment for mental illness.
(See the EFC’s submission to the CCA and the full backgrounder to the EFC’s submission.)
Endnotes
[16] Kaczor, Christopher. “Against Euthanasia for Children: A Response to Bovens.” Journal of Medical Ethics: Journal of the Institute of Medical Ethics 42, no. 1 (January 2016): 57–58.
[17] Waddell, Charlotte, Kimberley McEwan, Cody A. Shepherd, David R. Offord, and Josephine M. Hua. “A Public Health Strategy to Improve the Mental Health of Canadian Children.” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 50, no. 4 (March 2005): 226–33.
[18] Salter, 34. [Salter, Erica K. “Conflating Capacity & Authority: Why We’re Asking the Wrong Question in the Adolescent Decision-Making Debate.” Hastings Center Report 47, no. 1 (January 1, 2017): 32–41.]
[19] Ibid., 35.
[20] “Evidence, Special Joint Committee on Physician-Assisted Dying (42-1) - No. 11 - Parliament of Canada,” February 3, 2016. http://www.parl.ca/DocumentViewer/en/42-1/PDAM/meeting-11/evidence#Int-8779514.
[21] Kaczor, “Against Euthanasia for Children.”
[22] Liao and Chan, 182. [Liao, Lester, and Daniel Chan. “Physician-Hastened Death in Young Children: Getting to Underlying Assumptions.” Paediatrics & Child Health 21, no. 4 (May 2016): 181–82.]
[23] “Evidence - PDAM (42-1) - No. 11 - Parliament of Canada.”