A Case for MAID (Medical Assistance in Dying) and the Humane Treatment of the Old Human Animal

On March 27, 2018, George and Shirley Brickenden died holding hands in bed after dining on lobster, salmon, and champagne. George, 95, and Shirley, 94, married since the final year of the Second World War, “flew away” (their words) to the strains of Mozart, Bach, and Scottish folk tunes. Surrounding their bed were the Brickenden’s four adult children, the Dean of Toronto’s St. James Anglican Cathedral, and two physicians. George’s last words to his family were, “I love you all.”[1] The Brickendens were very old, very frail, and very happy to end their lives with the help of their doctors, following a lengthy approval process for medical assistance in dying (MAID), under the provision of Canadian law.

Cue the scolding tongues. Tom Koch, a bioethicist, editorialized in Canada’s leading newspaper, the Globe and Mail, that “This tale of shared termination sets a dangerous precedent, not only for seniors but for all of us.”[2] The self-appointed morality police of the Anglican communion, “Virtue Online,” headlined its coverage with, “Couple Kill Themselves in Joint Assisted Suicide as Anglican Church Official Cheers Them On.”[3] Consistent with the doctrine that holds suicide, including euthanasia, to be a “mortal sin”, several Catholic websites condemned the Brickendens’ choice. News of the Brickendens’ deaths nearly broke the conservative Christian internet.

You may have seen the slogan, “Life is sacred, from conception to natural death” on bumper stickers and billboards. On the surface, it seems like a warm, fuzzy sentiment. Dig a little and the slogan morphs into a coercive judgement against abortion and MAID and people like the Brickendens who dare to live and die with intention. But why should life be compulsory?

And what exactly is a “natural death” anyway? The term is problematic. Doubtless, the sloganeers aren’t characterizing demise by raging appendicitis as natural death. Or measles, or post-partum hemorrhage, or congestive heart failure. The term “natural death” is nonsensical in the twenty-first century. Most of us will die in old age and our deaths won’t be “natural,” they’ll be medically managed.

Let’s place lifespan and mortality in broad historical context. Elders have always lived among us. In the olden days, if children survived to age five, they stood a reasonable chance of living long enough to play with their grandchildren.[4] Typically, the Grim Reaper took the elderly after a brief illness. There’s a tendency to credit medical heroics such as complex surgery for increasing longevity. However, much of the gain in human lifespan in the last century was achieved in the youngest demographic cohorts through advances such as immunization, antibiotic therapy, better maternal-child care, and public health measures such as provision of clean water.[5]

In the elderly, modern medical care is a double-edged scalpel. To be sure, an expertly inserted stent in a gunky coronary artery can give a person a new lease on life. On the other hand, modern medicine often keeps people alive into decrepitude, and often against their will. Canadians have one of the longest life expectancies in the world, but they endure, on average, about eight years of chronic ill health before they finally keel over, a figure that is echoed in other wealthy nations.[6] Nowadays, most of us rust away instead of falling apart quickly and dramatically as in generations past.

One might wonder, “Am I doomed to be spoon fed porridge by a distracted care worker as she checks her iPhone and sniffs that someone might need a diaper change?” Not necessarily.

Most people tacitly accept that we must pass through a drawn out, gray zone of misery and dependence prior to dying in old age. Well, stuff and nonsense. Imposing medical care on elderly people without offering them a painless means of escape is fundamentally cruel. With our practitioners’ counsel, each of us should have the right to rummage around in the palliative care chest and make plans for a healthy old age and swift expiration in the pattern of our forebears if that is what we want. MAID is an optional, new tool with application to this end.

In Canada, the Supreme Court over-turned a long-standing, loosely enforced ban against MAID in February 2015. In their judgement, the court stated that the ban had created a “duty to live” rather than upholding “a right to life” and that “leaving people to…endure intolerable suffering… impinges on their security of the person.”[7] In response to the ruling, the federal government passed Bill C-14 to legalize MAID in June 2016.[8]

To qualify for MAID in Canada, a person must be eighteen or over, cognitively sound enough to make informed decisions, aware of other care options, gravely ill or frail and nearing end of life, and have two physicians and/or nurse practitioners agree to his or her eligibility. After a period of reflection, the MAID procedure may be performed. Usually a health care practitioner administers lethal medications intravenously, and assisted deaths are peaceful and gentle. This practice differs from US states in which MAID is legal. In the US, patients seeking MAID obtain a prescription from a physician and self-administer lethal drugs orally.[9]

Last year, one percent of deaths in Canada were eased by MAID. The Brickendens’ deaths were two of approximately 3,000 assisted deaths in Canada in 2018.[10] George and Shirley Brickenden were trailblazers because they died as a couple and they qualified for MAID due to their generalized infirmity rather than an aggressive illness such as cancer or ALS. In time, more trailblazers will push the boundaries of qualification, and perhaps terminally ill, paediatric patients and people with dementia who have specified their end-of-life wishes in advanced care directives will have access to MAID as they do in Switzerland, Belgium and the Netherlands.[11]

Like the Brickendens, each of us should have the power to decide for ourselves how we will live and die. I believe the Brickendens have offered us a model, or at least a sketch, of one humane approach to dignified death in old age. So, I’m eating vegetables, walking or cycling to get around town, and avoiding crack cocaine. Some day, if I’m crumbly and miserable and sickness casts a terminally gloomy pall over my life, I plan to seek MAID. Yes, life is scared. Life is so sacred that we mustn’t leave decisions about its end in the hands of religious scolds; we should have the right to be the authors of our own stories.

[1] Kelly Grant. “Medically Assisted Death Allow Couple Married Almost 73 Years to Die Together.” Globe and Mail. (Toronto: 1 April 2018). https://www.theglobeandmail.com/canada/article-medically-assisted-death-allows-couple-married-almost-73-years-to-die/

[2] Tom Koch. “Age Alone Shouldn’t Be Considered a Justification for Physician Assisted Death.” Globe and Mail. (Toronto: 8 April 2018). https://www.theglobeandmail.com/opinion/article-old-age-alone-shouldnt-be-considered-a-justification-for-physician/

[3] Wesley Smith. “Couple Kill Themselves in Joint Assisted Suicide as Anglican Church Official Cheers Them On.” Virtue Online. (3 April 2018). https://www.virtueonline.org/canada-couple-kill-themselves-joint-assisted-suicide-anglican-church-official-cheers-them

[4] Lawson Greenberg & Claude Normandin. “Disparities in Life Expectancy at Birth.” Statistics Canada. (27 November 2015) https://www150.statcan.gc.ca/n1/pub/82-624-x/2011001/article/11427-eng.htm

[5] David R. Francis. “Why Do Death Rates Decline?” National Bureau of Economic Research. https://www.nber.org/digest/mar02/w8556.html

[6] Public Health Agency of Canada. “Health-Adjusted Life Expectancy in Canada.” (2012). https://www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/science-research-sciences-recherches/health-adjusted-life-expectancy-canada-2012-esperance-vie-ajustee-fonction-etat-sa

[7] Supreme Court of Canada. “Carter versus Canada (Attorney General).” Lexum. (6 February 2015) https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do?r=AAAAAQAGQ2FydGVyAQ

[8] Dying with Dignity Canada. “Get the Facts: Bill C-14 and Assisted Dying Law in Canada.” (2019). https://www.dyingwithdignity.ca/get_the_facts_assisted_dying_law_in_canada

[9] Death with Dignity. Frequently Asked Questions. https://www.deathwithdignity.org/faqs/

[10] Estimated figure based on Statistics Canada figure of 1,525 MAID deaths in Canada in last six months of 2017. Health Canada. “Third Interim Report on Medical Assistance in Dying in Canada.” (1 June 2018). https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-june-2018/medical-assistance-dying-interim-report-june-2018-eng.pdf

[11] Penney Lewis. “Assisted Dying: What does the Law in Different Countries Say?” BBC News. (6 October 2015.) https://www.bbc.com/news/world-34445715

References

Death with Dignity. Frequently Asked Questions. https://www.deathwithdignity.org/faqs/

Dying with Dignity Canada. “Get the Facts: Bill C-14 and Assisted Dying Law in Canada.” 2019. https://www.dyingwithdignity.ca/get_the_facts_assisted_dying_law_in_canada

Francis, David R. “Why Do Death Rates Decline?” National Bureau of Economic Research. https://www.nber.org/digest/mar02/w8556.html

Grant, Kelly. “Medically Assisted Death Allow Couple Married Almost 73 Years to Die Together.” Globe and Mail. Toronto: 1 April 2018. https://www.theglobeandmail.com/canada/article-medically-assisted-death-allows-couple-married-almost-73-years-to-die/

Greenberg, Lawson and Normandin, Claude. “Disparities in Life Expectancy at Birth.” Statistics Canada. 27 November 2015. https://www150.statcan.gc.ca/n1/pub/82-624-x/2011001/article/11427-eng.htm

Health Canada. “Third Interim Report on Medical Assistance in Dying in Canada.” 1 June 2018. https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-june-2018/medical-assistance-dying-interim-report-june-2018-eng.pdf

Koch, Tom. “Age Alone Shouldn’t Be Considered a Justification for Physician Assisted Death.” Globe and Mail. Toronto: 8 April 2018. https://www.theglobeandmail.com/opinion/article-old-age-alone-shouldnt-be-considered-a-justification-for-physician/

Lewis, Penney. “Assisted Dying: What does the Law in Different Countries Say?” BBC News. 6 October 2015. https://www.bbc.com/news/world-34445715

Public Health Agency of Canada. “Health-Adjusted Life Expectancy in Canada.” 2012. https://www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/science-research-sciences-recherches/health-adjusted-life-expectancy-canada-2012-esperance-vie-ajustee-fonction-etat-sa

Supreme Court of Canada. “Carter versus Canada (Attorney General).” Lexum. 6 February 2015. 2015) https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do?r=AAAAAQAGQ2FydGVyAQ

Smith, Wesley. “Couple Kill Themselves in Joint Assisted Suicide as Anglican Church Official Cheers Them On.” Virtue Online. 3 April 2018. https://www.virtueonline.org/canada-couple-kill-themselves-joint-assisted-suicide-anglican-church-official-cheers-them