No exacting criteria for Medical Assistance in Dying (MAiD) and no vetting of assessors providers, means we have empowered a group of self-selected individuals to kill at industrial rates, far exceeding most individual police, combat soldiers, or serial killers. Without thorough independent vetting of assessors, providers and processes, we invite the deadly problems and apparent gaming of the law that the slew of recent reporting is beginning to reveal.
Who are these people? Really.
Experimental ‘medicine’
vivisection | ˌvɪvɪˈsɛkʃn | noun [mass noun] the practice of performing operations on live animals for the purpose of experimentation or scientific research.
nostrum | ˈnɒstrəm | noun a medicine prepared by an unqualified person, especially one that is not considered effective. • a scheme or remedy for bringing about some social or political reform or improvement.
- Oxford Dictionary of English
Medical Assistance in Dying (MAiD), as formulated in Canadian law and practice, amounts to an uncontrolled mass experiment in which individual medical doctors and nurses assess and kill members of the public by lethal injection or prescription, under a set of broad conditions imposed by changes to the homicide and suicide sections of the Criminal Code.
MAiD was imposed under two sets of legal changes. It was allowed first for people whose natural deaths were very broadly interpreted to be ‘reasonably foreseeable’ (i.e., those with a terminal diagnosis on some non-specific timeline), and then for those whose deaths aren’t ‘reasonably foreseeable’ (e.g., a chronic condition or disability). It was implemented without carefully developing standards and oversight, or safetied trials, through study and live practise scenarios. Such trials would help to establish if it was possible to assess, approve, and kill patients, under those conditions, without error. There can be no margin for error in MAiD.
Questions are often raised by professionals about the quality of evidence and the concepts used to justify MAiD. But, it is very hard to find work that raises questions about the people and their supporters whom we have empowered to judge our lives and wield death.
Medical preparation and safeguards are typically strict across the healthcare system. Specialists undergo intensive classes and exams, long residencies, and often supervised field experience prior to certification. Failure is necessary, possible, and happens, to screen out the unsuitable. Surgeons may practise on cadavers before operating on living persons and rehearse complex surgeries throughout their careers. Psychiatrists first become doctors and then likewise undergo further training and certification. Doctors, nurses and pharmacists must know the qualities, side-effects, and contraindications of any pharmaceuticals that they use or prescribe. New drugs, surgical or therapeutic techniques or technologies require vast background work prior to testing on humans, and include a process of lab tests, tightly controlled trials, and independent validation.
All of this is done to avoid harming and killing patients, and yet mistakes still happen. No treatment, process, or person is perfect. There is always a real possibility of error.
Not so with MAiD, a very high-risk clinical practice, which has been exempt from these standard protocols.
In Canada, there are no expert practitioners (or ‘euthanists’) in assisted death because the ‘specialism’ has not been methodically developed and certified. There are no common national standards of training, assessment, data collection, or oversight of the practice. There are no multi-year rotational residencies, exams, or clear pathways for accountability. Instead, there are very broad Criminal code changes, CAMAP how-to webinars about slipping through cracks in the law and dodging ‘moral distress’, and local and individual ideological variation between self-appointed assessors and providers.
Only now, after seven years, CAMAP is tasked with developing a national training curriculum for assessors and providers. Until now, training amounted to whatever local guidance may or may not exist in different health regions, and CAMAP’s internal seminars. As the investigative journalist Alexander Raikin has evidenced, CAMAP’s seminars include non-clinical advice on how assessors can “shop around” for sanction, to ensure patient approval. Seminar attendees who raise ethical concerns about death – as when a patient seeks MAiD for socio-economic reasons like poverty and lack of disability supports – are informed that they may withdraw for reasons of conscience but must refer the patient to someone else who can ‘hopefully fulfil the request’.
Non-specialist clinicians therefore have a free hand in understanding and applying MAiD according to their own views and biases. CAMAP, composed of these clinicians, is also responsible for developing their training. When trainers, practitioners, and self-labelled specialists are all the same people, or part of a shared group, biases and approaches can become self-reinforcing, defensive, and cloistered.
Who are these assessors and providers?
We do not know who these people are. Really.
There are a few publicly vocal and increasingly familiar MAiD providers and an unknown and varying number of active providers outside the spotlight. These non-specialists are not independently vetted, as is the norm for other life-and-death or high-reliability occupations. Questions remain outstanding: Why do they want to kill and how do they reason this? What makes them think they are qualified to perform MAiD? Do their records show patient complaints, poor exam results and performance reviews, dismissals, or questionable conduct? What about their life-histories, personalities, and clinical and non-clinical experiences with death and illness? What implicit biases and latent fears do they hold?
Providers have said that they are offering a dignified, benevolent, or altruistic service. There is no one theory or philosophy, only a common outcome. Clearly, MAiD has many supporters, and cases like terminal illness for which it was originally intended are still the majority. Yet the questions above remain profoundly pertinent. All power positions can attract candidates who are ill-suited, underqualified, inappropriate or (un/intentionally) dangerous. That the number of such candidates may be marginal is hardly the point, given the lack of clear criteria, calls for rapid and unbridled expansion, and non-supervised settings like homes. Several individual practitioners have publicly acknowledged performing many hundreds of deaths, a noticeable percentage of the more than 31 000 MAiD deaths since 2016.
The comments and visuals in media and other interviews and some public-facing providers suggest that they gain gratification from killing. This is obviously a difficult, crucial issue given what is already known about others who commit sanctioned or criminal homicide. Why does a person choose to kill several (hundred) people – for any reason? Why do they seek to expand eligibility to those with mental illness, and or infants and children? (Indeed, there is already a MAiD activity book for children, and new hospital policies and procedures including scenarios where the parents would not be informed until after the child dies). Who is that person, and what is happening in these situations and settings? What would neural and physiological activity monitors show during the acts of assessing and killing – for both patient and provider?
Amateur, pseudoscience?
Part of the problem is hazy terminology, semantics, and rhetoric, such as where MAiD is variously defined and rationalised as assistance in dying, fostered suicide, suffering relief, dignity in death, care, patient choice, or euthanasia. Perhaps more complex is the subjective room for “feelings” or hunches that (uncertified but legal) providers allow themselves in determining what constitutes key conditions like mental illness, distress, and suitability for death. It is unclear how assessors and clinicians decide what key textual terms like ‘suffering’ or ‘intolerable’ mean, beyond impressions. The words on which life and death hang may be open to one’s own literary interpretation.
A billboard public figure here is Dr. Stephanie Green, an obstetrician turned MAiD provider, located on Vancouver Island, who has killed over 300 people, over one percent of all MAiD deaths since 2016, as of sometime in 2022. She is the President of the Canadian Association of MAiD Assessors and Providers (CAMAP), the closed industry group for MAiD practitioners and associates, and a member of the Clinicians Advisory Council of Dying with Dignity, Canada’s main pro-MAiD lobby group. She also holds a faculty appointments at the Universities of British Columbia and Victoria. In a brief she authored under CAMAP letterhead to the Canadian Parliament’s Special Joint Committee on Medical Assistance in Dying (AMAD), she writes,
‘Through our work we have seen evidence of the distinction between what others might hope to conflate- MAiD and suicide. Suicide is almost always a traumatic event, often violent, frequently impulsive, usually carried out alone or in secrecy, and it leaves devastation in its wake- for families, for first responders, often entire communities. By contrast, medical assistance in dying involves a legal framework, a rigorous process, the involvement of multiple health care practitioners and the option to involve many loved ones…the American palliative care physician Tim Quill so eloquently once stated- “suicide implies some form of self destruction, assisted dying involves a form of self-preservation". They are simply not the same.’ - Dr. Stephanie Green in CAMAP’s brief to AMAD
Here, Dr. Green uses a claim about the nature of suicide to distinguish it from MAiD to assert, in a circular logic, that MAiD is not suicide. For support, she cites a vague quote from a US palliative care physician and MAiD supporter. Her declaration of the non-suicidality of MAID seems to be from her and her colleagues personal impressions or opinions. Oddly, these guiding opinions and concepts are somehow not presented as clinical evidence obtained as part of a rigorous scientific study by trained experts in suicide, published in a peer-reviewed medical journal.
Indeed, CAMAP and Dying with Dignity are funding studies premised on supporting MAiD practice, as if nothing could be wrong, and seek the recruitment of more clinicians. This is not quite how the best science and medicine works.
In another instance, during her reported exchanges with Alexander Raikin, Dr. Green again promotes herself by claiming what appears to be an unverified ability to discern the difference between ‘active’ and ‘stable’ mental illness. Are these concepts her invention? In a text search of the nearly nine hundred and fifty pages of the main professional reference, Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5), for ‘active’ or ‘stable’ mental illness, these words appear only in the broader descriptions of ‘schizotypal’, ‘motor’, and ‘premenstrual dysphoric’ disorders.
‘…when I asked Stefanie Green how she decides whether a patient with a mental health condition has the competence to choose euthanasia, she said that she makes a judgment call about whether a patient has an “active” or “stable” case of mental illness. For “active” cases, she will consult a specialist; for “stable” cases, she proceeds on her own’. - Alexander Raikin’s interview with Dr. Stephanie Green in The New Atlantis
There is no comment in the article on the specialist with whom she consults. The identification of a new feature or type of mental illness, to be noted in revisions of the DSM, is the product of years of intensive empirical research and peer debate among the qualified psychiatric community. As Raikin points out, Green is ‘not a psychiatrist’.
Confidence in one’s personal ability to predict suicidality and not-suicidality was also voiced by Dr. Derryck Smith, a pro-MAiD psychiatrist in his appearance before AMAD and in the media. Though he is a psychiatrist, his predictive confidence does not seem to be shared by other provider-psychiatrists.
Elsewhere, on TVO’s The Agenda, provider Dr. Jean Marmoreo, like Dr. Green, has written a book about herself. She insists that her ‘feeling is that I provide care’ or a ‘service’ in killing her patients. Her homicides are also not, in her view, ‘assisted suicide’ or ‘euthanasia’. Assisted suicide and euthanasia must be for other clinicians and patients.
Dr. Arundhati Dhara, a family doctor and provider appearing before AMAD cited her friend’s idea to suggest any squeamishness about killing patients is somehow an indicator that it is actually the ethically correct thing to do.
‘The right thing to do doesn't always feel good. In fact, a friend of mine who's an ethicist said, ethics only really comes into play when everything makes you really uncomfortable.’ - Dr. Arundhati Dhara, Family Practitioner, to AMAD
Funding research to support MAiD, employing pet, unscrutinised, psychological or legal thoughts, feelings, or theories from your friend, to justify killing people, is not science or clinical medicine. Not even close.
Nowhere in the Constitution Act 1982, wherein the Charter of Rights and Freedoms is embedded, is the phrase Medical Assistance in Dying. MAiD is not an explicit universal right or freedom. It is a limited, unappealed court-rulings driven, amendment to the Criminal Code of Canada that effectively removes culpability for homicides and suicide assistance committed by two categories of clinicians, provided certain broad and poorly defined criteria are met. MAiD is a contestable attempt at constitutional alignment and is criticised for exceeding the limits of the court rulings upon which it is based. Yet, prominent MAiD clinicians, people who might be said to have a professional duty to understand the law under which they operate, claim MAiD is a clear Charter right.
‘MAiD is a charter right of Canadian citizens. And it seemed to me with that philosophy…that it was the health authority’s job…to bring the MAiD to the patient’
Dr. W. David Robertson, MAiD Director, Island Health, British Columbia
‘We’re now in the process of restoring a Charter right to psychiatric patients’
Dr. Derryck Smith, Professor Emeritus of Psychiatry, University of British Columbia
Privileged new doctors, who may lack substantial years of experience of in life and practice, can nonetheless sign onto MAiD with generic statements and a simplistic grasp of ‘autonomy’ that severs patients from the social determinants of their health or recovery prospects. What is being taught about MAiD in medical schools?
‘If someone has intolerable suffering and requests MAiD and has gone through the safeguards/alternatives and is still suffering, who am I to say they can't make that decision just because they're not terminally ill? That would deprive them of their autonomy.’ - Dr. Gurmeet Kaur Sohi, geriatric resident, Twitter
Here and other places, terms like ‘intolerable’ , which actually means ‘unable to endure’, are inarticulately defined in legal, bioethical, and medical senses.
intolerable | ɪnˈtɒl(ə)rəb(ə)l | adjective unable to be endured.
decompensation | ˌdiːkɒmp(ə)nˈseɪʃ(ə)n | noun 1 [mass noun] Medicine the failure of an organ (especially the liver or heart) to compensate for the functional overload resulting from disease. 2 Psychiatry the failure to generate effective psychological coping mechanisms in response to stress, resulting in personality disturbance.
- Oxford Dictionary of English
If a patient who is approved for MAID continues to live and retain coherence and assessed decision making capacity, are they tolerating their (maybe very difficult) suffering? Intolerable, by definition, is presumably closer in meaning to death or evidence of significant mental or physical decompensation. The Criminal Code is silent on such a key term, as it is others.
And so it goes, with the various publicly visible providers and supporters, employing as yet poorly defined, contrived, or misunderstood terms and concepts, to approve death and end lives.
If taken at their published words, it is hard not to argue that they decide death by divining from little more than their own ideas and politics, simplistic legal and sociological (mis)understandings, a request, and a brief eligibility checklist.
Meanwhile, psychiatrists, specialists with many years of training in assessing illness and suicidal behaviour, including some involved in CAMAP, often either stand opposed to MAiD or have very serious concerns about current and proposed applications. Legal experts likewise argue that the way MAiD was included in the Criminal Code extended beyond those rulings, and is certainly not a blanket Charter right or freedom.
MAiD, for some public-facing providers at least, with its odd mix of clinicians’ ‘feeling’ based care, a weak grasp of key or the use of dubious concepts, and the extracurricular use of lethal drugs, seems to be a nostrum reminiscent of deadly and ignorant crudity of early surgery.
Again, who are these people?
Familiar patterns
MAiD is fundamentally experimental. If it were a new drug, it has skipped the testing stages and randomised control trials and gone straight to market. The company has gamed the marketing, denied or spun away evidence of side-effects, buried internal memos of concern, and dismissed or assuaged critics. Any doctor or nurse practitioner can prescribe it, with only vague prospective guidance on dosages and use, and rhetorical promises that all shall be well. The issue here is not a philosophical discussion on a prospective right to choose one’s manner of death, but the inherent fallibility and corruptions of the system and people who may provide that death.
There are, of course, lawyers whose job seems to be pointing out the loopholes in the legislation, not to close them, but to allow more adventurous providers to approve the few requestors rejected by others. Those lawyers also jam fingers at the legislation and attack any naysayers. So, the new practice has defenders, but also enforcers to help push past red-flag wavers or whistle blowers.
The pattern here has many of the same key features that polluters, tobacco companies, pharmaceutical makers, law enforcement agencies, schools and universities, armed forces, and countless other organisations use to defend themselves when they’ve wrongly harmed or killed people. We’ve seen the stories of polluters, big tobacco, and the opioid crisis. Or, in Canada, instances like Thalidomide and Grassy Narrows, or more recently the Apotex clinical trial scandal, where Dr. Nancy Olivieri sounded the alarm and fought the fight.
These instances tend to involve some or all of the following features, which we also see in MAiD: 1) a thin, controversial, or invented justification for a product or service that starts hurting people; 2) industry-funded academic research to provide a veneer of scientific legitimacy; 3) in-house ‘research’ passed off as legitimate support; 3) lobbyists to sell the harmful product or service to government or key politicians; 4) lawyers and spin-doctors, who defend the thing and/or attack critics and whistle blowers; and, 5), an imperative to expand markets.
If there’s a sixth dimension, it might be the overlaps between the various actors and organisations, which could be called conflicts-of-interest in other circumstances. In MAiD, this includes those high body count, radical ‘autonomy’, or personal feelings-based clinicians with a foot in, CAMAP, Dying with Dignity, and even medical schools. Theirs is a preciously small club.
Mori Sect
In MAiD, the process of assessing and killing objectively disadvantaged people by lethal injection, we find a small group of self-appointed ideologues who are effectively amateurs, supported by a lobby group, industry funded academics, lawyers, and sympathetic politicians.
Clinically and scientifically, MAiD is a deadly experiment, lacking traditional development, controls and monitoring of clinicians’ ability to accurately assess and kill patients, with unprecedented and unchallenged changes to the Criminal Code. Socially, it conforms to patterns of well-resourced and well-connected groups introducing potentially harmful designs on poorly informed public and professional bodies, using its resources to defend itself and its product, and to attack its critics.
We should be wary of a cult of clinicians and acolytes who have built a new temple by rewriting a foundational text and inverting holy vows. Some, as clerics now, forsake science and reason for the fallacies of ‘privileged insight’ or ‘generalised expertise’ to kill the rich, poor, disabled, and sick, and to quicken the dying. Soon too maybe children and infants. Are they but the latest, in a line as old as time, of those among us who may be drawn to power through death, because of death, and anoint themselves magistrates of mortality?
Chris, you blocked me on Twitter because of religious 'bigotry'. I was pointing the inconsistency and hypocrisy of Christians such as Kevin Hay who cite the Hippocratic Oath but discard parts of the oath that don't align with their beliefs.
Would you be willing to reconsider this block? You have a couple of salient points against MAID as it is practiced in Canada and you're an academic yourself with no vested religious or organisational interest in the procedure other than a family experience. I very much looked forward to reading your Tweets and engaging with you on this topic. Many thanks.
You work with words, get them right. I have no patience for PR/social manipulation techniques.
The provider provides medical assistance in dying, assitance that has been requested. You're just equating it with "killing" to try and manipulate people (nice mention of serial killers btw). You and Cambridge Analytica. I wonder sometimes who people are supporting (or working for) when they don't get it. Big pharma? Keep 'em alive and keep them buying painkillers/mood enhancers/take your pick -- can't make money off someone who has already left this life. I'm done, dude. Adios & Namaste.