MAiD Weapon

Autonomy and accountability when medically administered death is used to harm others

Several publicly documented medically administered deaths in Canada, including my father’s, have deliberately occurred on dates or in circumstances that are significant to people other than the patient. Such choices in at least two of these deaths were motivated in part by malice toward a target person. There are likely others out of public view. Unlike crimes or harmful actions involving perpetrators who remain alive, MAiD dead cannot be held accountable for weaponising their death. Assessing and providing clinicians also appear to wash their hands of this intended harm in the name of patient autonomy. The result is that no one is accountable when a patient uses MAiD to hurt others.

‘The patient's autonomy always, always should be respected, even if it is absolutely contrary, the decision is contrary to best medical advice and what the physician wants.’ 
- Dr. M.J. Kevorkian, late US euthanasia provider and convicted murderer

‘My job is to help them have a good life and a good death by their standards, not by mine or anybody else’s.’
- Dr. Ellen Wiebe, Canadian euthanasia provider

When my father was killed through Medical Assistance in Dying (MAiD), he chose to die on a family member’s birthday in an act of malice. I tried to stop him, but he became brusque and did not back down. At one point, he referred to his passing as a special birthday gift to remember him. His provider also noted the occasion but did nothing, and even cheerily acknowledged the day. To bear helpless witness to this remains one of the most horrifying, haunting, features of his death, and of my life.

Since then, I’ve learned that at least two other MAiD recipients chose to die on significant days in other people’s lives. Ray Cole, for example, died on his 47th wedding anniversary, and his death is covered in Avis Favaro’s CTV W5 piece. While it is not is not for me to know the dynamics of a stranger’s marriage, this choice of date left me uneasy.

I’ve also spent a little time (I can only stomach small doses) comparing statements from past public euthanasia advocates and providers, and one or two serial killers, to what we hear from today’s Canadian aficionados. One of them is the late ‘Jack’ Kevorkian, who was a US euthanasia provider and convicted murderer, and staunch advocate of a notion of Liberty read as patient autonomy. His words may offer some insight and draw out uncomfortable questions for Canadian medically administered death, as court-rulings have justified access to euthanasia in their interpretation of the Charter right to life, liberty, and security of the person.

How often do people choose their MAiD deaths at symbolic times?

There are many reasons people might pick an already notable date (or possibly location) for their death. One is ego and the desire not to be forgotten. At the end of their lives, some people worry about their legacy. Selecting a special routine occasion, like an anniversary or holiday, might reinforce their memory. Another reason may be to ‘share in spirit,’ by positive association, in such future events with loved ones.

A third reason is malice. Punishing others is a motivation in many suicides, including assisted suicide. Recently, Alexander Raikin’s article in The New Atlantis drew my attention to the very troubled life and MAiD death of Rosina Kamis. Told by an assessor that a MAiD death is ‘dignified’, she chose to die on her ex-husband’s birthday and wedding anniversary, an act clearly intended to emotionally harm him.

Ignorance or selfishness are maybe other reasons. Provider Dr. Ellen Wiebe killed Barry Hyman, a resident of a private Jewish nursing home, at his request because he wanted to die there. This occurred despite being asked not to by the management because the facility was also the home of Holocaust survivors. Wiebe insisted, however, that this would not be traumatic for the other residents and staff.¹

How many more such cases are there?

How are such choices made?

The selection of a significant death date may be premeditated, calculated, or impulsive. The varied emotions around impending death can alter personalities and judgements, even temporarily. Severe emotional or physical distress, or mental illness, can also produce distorted decisions.

Some providers and supporters celebrate autonomy and argue that a flexible option of death is liberating. Once approved for MAiD, a person can use it whenever they want, either immediately, months, or even years down the road. Approvals do not expire, and do not seem retractable. I was surprised to discover this in my father’s case; during his (ultimately halved) 90-day assessment period, he threatened to use his approval if we asked him to explain his decision or inconsistencies in his behaviour and claims.

How or when a person uses, or intends to use, their approval does not factor in determining their eligibility for MAiD, which is limited to flexible interpretations of suffering and clinical diagnoses. A MAiD approval amounts to a death-on-demand ticket that can be redeemed and used as a weapon of manipulation, harm, or for some other means than the ‘relief’ of suffering for which it is ostensibly intended.

What does it mean for potential targets?

Such harm can be deliberate and conscious. Unassisted suicides are often used this way, and the trauma for the target person or group can be severe and lasting. They can suffer profound emotional and psychological damage and some go on to also die by suicide.²

Deaths of ‘revenge’ or ‘resentment,’ falling on an important day to the target can be used to send a cruel message; to permanently link them with the death; to inflict guilt or responsibility for death; to imply culpability or neglect; or to saddle a celebratory occasion like a birthday with pain or regret. Trauma is prolonged through annual repetition, so the target is held hostage to negative anticipation. 

Regardless, survivors’ pain is often seen as the unfortunate by-product of an elective death. But they have no recourse, as the perpetrator is deceased. Aside from personal harm, their reputations or ongoing relationships may also suffer the blow of implication.

The residents and staff of the Louis Brier Home and Hospital, for example, some Holocaust survivors, had their autonomy dismissed by the provider who insisted they would not be traumatised, while she nonetheless embraced the patient’s autonomic wish for MAiD. Is the autonomy of the patient somehow more authentic or of greater importance than the autonomy of those impacted by the death?

Private motives cannot always be known, patient conversations with clinicians are secret, and target cases pose profound ethical dilemmas. Where harmful intentions are known or expressed, however, it should raise serious red flags.

Do providers have a say?

There is no requirement that a provider deliver MAiD. Providers can decline, and under law, no one can be compelled to kill another person. Yet many don’t refuse.

Providers kill patients even when they know, or ought to know, given readily discoverable information, that the death may be used to hurt other people. The reported internal seminars from CAMAP suggest that the safeguards, which are technically found in homicide and suicide law, are being gamed this way. Poverty, debt, and lack of resources, and punitive rationales are clearly acknowledged in the reporting.

What happens when requests for MAiD are refused?

Again, CAMAP’s internal communications seem to encourage clinicians to pass rejected patients around, until the ‘right’ assessors give them their two approvals. Current Justice Minister and Attorney General, Hon. David Lametti, espoused a complementary view: MAiD is a ‘more humane way’ of facilitating suicide, the reasons for seeking death notwithstanding. Most troubling here is the implication some assessors, even lawmakers, may regard assessments – and by extension, the Criminal Code homicide and suicide sections – as superficial pro forma, in what is generally a predetermined approval process.

What is the role of ‘autonomy’?

Autonomy, read as liberty, in most rights discourses and law, is limited to the point where its exercise infringes upon - i.e., harms - the autonomy of others. Yet the very concept of a ‘right to die’ acknowledges no such precondition. The reciprocal ‘right to life’ is likewise silent on how one uses their life, as it assumes life holds intrinsic value. To compensate, we have laws and institutions to hold accountable people who misuse their right to life by harming others. But since the abolition of capital punishment, the only exceptions to this fundamental right involves situations where lethal force is used to protect oneself or others. Even here, there is a formal investigation to determine if the deadly act was justified or an offence. No such accountability or responsibility is possible when exercising a ‘right to die’ through MAiD. The dead cannot be held accountable for misuse of their death, and clinicians and cases are not deeply reviewed.

Are some assessors and providers, and legislators, so beholden to a simplistic, idealised ‘autonomy’ that they are blinded to the fundamental principle of accountability that comes with a right to life?

‘You fail to understand that I said it was justified when she came to me.’ 

- Dr. M.J. Kevorkian on his killing of Sherry Miller

M.J. ‘Jack’ Kevorkian was an American pathologist who gained notoriety in the 1990s for illegally euthanising patients. He was eventually convicted of murder and imprisoned.³

In the above quote, and surrounding dialogue, Kevorkian describes a philosophical position where a patient’s request for death alone justifies its provision, as it is the patient’s view of their condition that is paramount.⁴ Pure, momentary, and individual expression of the desire for death is given primacy, and all other factors become extraneous. The assumption is one of clarity.

Here, autonomy is a sovereign concept, beyond self-governance. It is absolute, with no past or future, and no connection to anything or anyone. Following this logic, the potential for patient recovery, improvement, or the provision of supports are irrelevant, as are the patient’s socio-economic circumstances, relationships to others, or factors like coercion.

Kevorkian advocated Liberty above all, and his ‘autonomy’ signals total independence. In this view, every request for death is an isolated end-in-itself.

Yet that some people opt to die, in ways that harm or highlight other people, indicates that context and connections matter. Rosina Kamis’ case demonstrates that relationships were important factors in her death, and that the absence of ‘care’ was a principal motivator in turning to MAiD. ‘Anything can happen,’ she repeated, between approval and the date of death. Perhaps she was hoping for a vital intervention, in what she described as a physically non-terminal but lonely and unbearable situation. Ultimately, she used her death both to provoke and to ‘celebrate’ her loss and life.

Fanatical positions on autonomy and mortality are deeply disconcerting. A request for death may itself prove eligibility for MAiD. With this reasoning, a patient can change their mind, even improve their health, but still hold onto their approval, and use it if they feel suicidal, or malicious, at any future time. 

Dr. Kevorkian died in 2011. His name doesn’t appear much in current Canadian discourse, where only a few domestic activists and clinicians have emerged as far less controversial public figures. But it’s not hard to see his absolutist reasoning⁵ in the broad exemptions in the legislation, the approach adopted in CAMAP seminars and some visible practitioners, and the rhetoric of the federal minister responsible. 

Autonomy and accountability

The efforts of MAiD opponents centre on the finer points of the court rulings, legislation, the impact on at-risk communities, and AMAD testimony on the conceptual and risks problems with MAiD. They are premised on the importance of issues like relationships, health and social services, economic inequality, prognosis, care, and the intrinsic value of life. Arguments make use of such issues to question systemic problems of theory, practice, complication, legal loopholes, and ever-expanding access.

‘I’ve thought a lot about my autonomy.’ 

- My father, eagerly, to his MAiD provider minutes before she killed him

MAiD advocates emphasising choice and autonomy operate from a very different place. Theirs is a lineage of not just eugenics, but also of unfettered individualism, beginning with a philosophical view of personal choice. Yet the logical endpoint of a blanket ‘right to die’ and radical ‘autonomy’ narrative, is a right to contract or obligate the state, a medic, or someone else, to kill you for any or no reason.⁶

I don’t know how many MAiD providers draw ideological inspiration from Kevorkian, or would at least understand themselves as such. Clearly, some are far more willing to entertain that ‘right’ and kill than others, beyond risk thresholds might have been too much even for that euthanasia godfather. Providers doing this subordinate themselves to a doctrine of autonomy that, intended or not, clearly allows patients to use their death as they see fit, including to harm others.

Yet providers are also human, and therefore must have the same autonomy that they assign to their patients. They can choose not to entertain someone’s suicidal expression, investigate their circumstances, and work hard to provide alternatives to death. They do not have to approve or kill. They do not have to help someone use their state-provided death to transgress others' security of the person when the death results in harm.⁷

Cases of the weaponisation of MAiD beg many questions about autonomy and accountability in just what the right to die allows people to do. A few that come to mind are:

At what point do assessors and providers decide to surrender their own autonomy to the patient, and wash their hands of death and consequent harm? Why?⁸

Alternatively, do some clinicians, advocates, or patients, see MAiD as an opportunity to operationalise their autonomous, implicit or explicit, views of the disabled and sick now that the paper prophylactic of law is perforated for them?⁹

Finally, is there a point at which a patient, or assessor, or provider is formally accountable?

We haven’t found one yet.

In a fully developed bureaucracy there is nobody left with whom one could argue, to whom one could present grievances, on whom the pressures of power could be exerted.

- Hannah Arendt, ‘Reflections on Violence’, 1969

Notes

1. It need not be stated that these residents experienced the largest and most horrific exercise of eugenics and euthanasia policies in history. To argue they would not be traumatised is gross and absurd.

2. If or when mental illness as a sole qualification for MAiD comes into effect, MAID may beget MAiD for those diagnosed with grief and trauma disorders.

3. Kevorkian promised to starve himself to death in prison, engaged in a hunger strike, but in the event did not do so. He died much later, after release, of a thrombosis, at 83. Despite his willingness to administer 130 other deaths, nobody administered his and he did not take his own life.

4. In the same dialogue, Kevorkian states that he waited eighteen months to kill Sherry Miller to so he could be sure she was ‘incurable’ and ‘hopeless’ to ‘anybody with sense’. By Canadian standards, he was exceedingly cautious. Canadian law requires for the ‘not reasonably foreseeable natural death’ requestors only a 90-day ‘assessment period’ during which any two unstandardised ‘assessments’ must be passed. The actual time and effort spent on assessment in this period varies between regions and assessors, which seems in some public cases to amount to a single phone call. Assessors aren’t necessarily visiting and studying the patient, talking to other carers and family members, exploring non-lethal options, and pouring over records - trying to save life - for 90 days. For people assessed to meet the foreseeable natural death standard, there is no waiting period. Kevorkian at least wanted to be ‘sure’. Legally, Canadian assessors and providers are told they do not even have to be sure.

5. It is interesting to compare MAiD’s autonomy absolutism with the liberty-based reasoning in Covid-19 anti-vax and anti-mask ‘Freedom Convoy’ social movement. Both movements avoid reckoning with the harmful impacts of their exercise of autonomy on other people, in the latter these include the deadly risk to the immunocompromised and others by the unvaccinated and unmasked, and the harassment and denial of freedoms to the residents and workers of Ottawa’s city centre, or the risks to RCMP members and bystanders in Alberta from armed ideologues.

6. Canada still requires an illness and claim of suffering, even under the not reasonably foreseeable natural death (Bill C-7) criterion, for MAiD. Will someone, like Gladu and Truchon, attempt to challenge these criteria as discriminatory against the liberty of those who are in good health, but still wish to die?

7. Section 7 of the Charter of Rights and Freedoms reads, Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice. The Canadian government’s Charterpedia explainer states in reference to security of the person that (my emphasis), ‘the right is engaged when state action causes severe psychological harm to the individual (G.(J.), supra at paragraph 59; Blencoe, supra at paragraph 58; K.L.W., supra, at paragraphs 85-87). To constitute a breach of one's psychological security of the person, the impugned action must have a serious and profound effect on the person’s psychological integrity and the harm must result from the state action (Blencoe, supra at paragraphs 60-61; G.(J.), supra; K.L.W., supra. The psychological harm need not necessarily rise to the level of nervous shock or psychiatric illness, but it must be greater than ordinary stress or anxiety.’

8. Excepting, of course, the assessors’ and providers’ autonomous view that their brand of administered death, lethal injection, is ‘dignified’.

9. Here is Jocelyn Downie, the lawyer conducting those ‘you don’t have to be sure’ CAMAP legal seminars, praising a Substack post by US rightwing think-tanker Richard Hanania: ‘This thread. This piece on Substack. Antidotes to the recent waves of misinformation and flawed analysis of assisted dying in Canada.’ Hanania claims his piece was prompted by a request to ‘not to hide behind rhetoric of individual choice and acknowledge that I bring my own moral values to this issue’ and espouses a view that suicide is acceptable for those with ‘defective’ that is, disabled or ill, bodies, lest they be ‘burdens’ on society or families, and is a choice that he might make. He also claims that state should provide this death in the name of healthcare. Hanania’s is a eugenicist view of euthanasia, with at least one Canadian law professor suggesting it is hate speech. Indeed, a journey through his published material shows his take on MAiD sits among his broad range of anti-choice, transphobic, anti-’woke’, anti-feminist, anti-liberal, and other US ‘culture war’ stands, including complaints about censoring Tweets on the ‘genetic…black-white IQ gap’.