What People Who Choose Assisted Death Actually Say

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0:21Coleman Hughes:Upfront payment of$45 for three-month plan, equivalent to$15 per month required. Intro rate first three months only, then full price plan options available. Taxes and fees extra. See full terms at mintmobile.com. Welcome to another episode of Conversations with Coleman. My guest today is Rupa Subramanya. Rupa is a writer for the Free Press who focuses on Canada. She has a weekly column aptly titled This Week in Canada. In this episode, we talk about Canada's assisted dying law, known as MAID, which stands for Medical Assistance in Dying. We talk about how a law originally intended for people with terminal illness has expanded to include lots of people with serious but not terminal ailments.

1:02Coleman Hughes:We also talk about the ethics and trade-offs involved in assisted dying laws in general. So without further ado, Rupa Subramanya.

1:17Coleman Hughes:On this show, we spent a lot of time having honest, unfiltered discussions around Israel, Zionism, and anti-Semitism. And if our conversations have made you more curious about any of these topics, I have a recommendation for you. Wondering Jews with Mijal and Noam is a podcast hosted by two of the leading Jewish voices of today, Noam Weissman and Mijal Bitan. On their show, Mijal and Noam are finding fresh perspectives on tough subjects. They've explored the war on Iran from the viewpoint of Persian Jews, they've poked fun at anti-Semitism with comedians, and they've asked prominent rabbis about the future of religion.

1:53Coleman Hughes:If you value nuance over hot takes and want to get past all of the noise, this show is for you. Search Wondering Jews with Mijal and Noam on Spotify, Apple Podcasts, or YouTube, and subscribe or find the link in the show notes. Okay, Rupa Subramania, thanks so much for coming on my show. Thanks for having me, Coleman. It's great to be with you. So the topic of this episode is medical assistance in dying. This is the phenomenon of the government allowing you to choose to euthanize yourself, essentially. It's a policy we've seen explode in Canada. We're going to talk specifically about the MAID policy in Canada.

2:39Coleman Hughes:But we're also going to talk, I think, about the phenomenon more broadly. We've seen different kinds of policies roll out in U.S. states, in Australia, in New Zealand, in Europe with different results. And I just want to acknowledge at the top, this is a tough topic for a lot of people. It has to do with death and dying. It, for many people, invokes, myself included, memories of the absolute worst moments in their life when you're watching someone you love most in the world suffer or die. And so, you know, it's understandable that people are provoked to very strong reactions and strong opinions.

3:30Coleman Hughes:And all of that, I think, makes the public policy conversation more difficult than on other topics, because the emotional stakes are so high. but you've been doing some incredible reporting on this including talking to many people um you know in in the weeks and months before they undergo a medically assisted suicide and uh you there's plenty in the free press and people can just search your name to read those articles i really recommend that but i first want to want to understand how did you get into reporting on this particular topic? Is it just because you're on the Canada beat? Or is there another reason why you ended up spending so much time talking to these folks?

4:21Thanks, Coleman. Well, I live in Canada. And what first drew me into reporting on Canada's MAID regime was I was seeing this growing disconnect between the way MAID was described initially when it was first legalized and the kinds of stories that were beginning to emerge. And Canada sold MAID to Canadians and to the world as a narrowly tailored system for the terminally ill, people who are within months and weeks of dying. It was billed as being compassionate and cautious. But as I began digging deeper into MAID back in 2022, that's when my first piece on MAID ran in the free press. We were called Common Sense at that time.

5:19I found that the system in Canada had rapidly expanded far beyond that original promise of compassion and caution. It was increasingly involving people with mental illness, people who were socially isolated, people who were homeless, people who were on disability, and people who just felt a great sense of despair. But, you know, I want to be clear about something up front. You know, I'm not opposed to the right to die. I feel that if you are of legal age, if you're of sound mind and you express a wish to die, and if that is available to you, I would defend that right. But I also understand there are cases, very tragic cases, of unbearable suffering where allowing someone a peaceful death.

6:17It can be an act of mercy and compassion, but we're talking about people who are within weeks and months of dying. But what's disturbing, even for someone like me who, and there are many people like me I've spoken to over the years, physicians and doctors who are generally would support the right to die, but they're disturbed at what is happening out there, especially in places like Canada, which is the rapid expansion of existing laws that go beyond terminally ill people and it's directed towards people who might have otherwise lived, perhaps for many years, if they had received the right kind of support, treatment and care.

7:00And also what alarmed me about all of my reporting on MAID was that how quickly all of the legal and moral boundaries had shifted, how rapidly that had expanded. So we have to go back to 2016. That's when MAID was legalized and it was limited to people whose debts were reasonably foreseeable. That's the legal expression. That's a legal term. And these are patients typically suffering from terminal illness or in the last stages of their life, that came to be known as TRAC-1 MAID. But in 2021, during the pandemic, Canada dramatically expanded this law through another piece of legislation, and it created what is now called TRAC-2 MAID, that is people who are not dying, but they qualify for euthanasia because they are deemed to be, their suffering is considered intolerable.

7:58So you could be in a wheelchair for the rest of your life. And if you find that suffering intolerable, you could be a candidate for MAID under this track two expansion. So suddenly you have people with years, even decades left to live, and they become eligible for euthanasia. And now where we're at right now is that Canada is debating the next expansion, in MAID. A committee is now studying MAID for mental illness, where the sole underlying condition is mental illness or psychological suffering. The implementation of this new track of MAID has been delayed many, many times. And the federal government, based on recent reports I've read, is reportedly preparing a legislation.

8:50They're prepared to table legislation that would pause the expansion of MAID, thereby pausing the expansion to MAID for mental illness. And this is because of, you know, perhaps stories like mine that have made a difference out there, where physicians, doctors and physicians, psychiatrists, healthcare officials have expressed deep concern. And when it comes to mental illness, the eligibility is just incredibly complex and difficult. And how do you assess irremediability in psychiatric illnesses? And all of that remains very, very uncertain. The fact that we've even arrived at this point here in Canada where we're seriously debating whether there should be made for mental illness alone, that this would have been unimaginable 10 years ago.

9:51But here we are.

9:54Coleman Hughes:Yeah. Okay. So there's a lot of things I want to say here. I mean, so first off, I think it's really important for me to acknowledge, similar to what you said at the outset, I fully support the right of people who have an actual terminal illness, meaning you are going to die. You have an illness, a disease that is understood well enough that we know you're not coming back from it. And you're in huge amounts of pain, and you don't want to spend your last month on earth in writhing agony, nor do you want to impose that trauma on your relatives to watch you suffer with no silver lining. And I've written in the free press about how this was my experience losing my mother to stage four metastatic bone cancer, that she had just a totally terminal diagnosis and had pain that was resistant to opioids.

10:59Coleman Hughes:And it was a really good thing that the doctors at the appropriate time allowed her to pass peacefully, right? Because the only alternative we were looking at is just another week of watching my mother writhe in agony, right? Right. So I think it's really important to flag at the outset, that is a case that we should approach with compassion and seriousness. And there's a huge amount of suffering to be alleviated in society if we can figure out how to create a transparent process for people to legally do that and circumscribe those situations and exclude other situations. the other situations that we i think i would want to exclude and i think i you and i probably agree on this rupa is really the moment you leave the territory of terminal illness you do open a door right the moment you make it make your eligibility for assisted suicide dependent on your subjective suffering alone, you lose any ability to complain when someone says, hey, I'm suffering too.

12:15Coleman Hughes:I'm suffering too. I may not have a physical disease, but I have a mental disease. I have depression. I have this. I have that. Once you open that door, you no longer have an emergency break. You no longer really have a principle to stand on to deny the next person. um and and this is when we we get into some of the cases that you've covered where people that are you know either in some cases like physically healthy or have you know physical ailments like you know you're blind right there's been plenty of happy blind people um but but nor can i deny that for you to be blind could really cause you to suffer should you be allowed to kill yourself?

13:01Coleman Hughes:Like, you know, legally using state dollars and hospitals and so forth. So, I mean, my first question in the case of Canada's law, which you said started in 2016, it seems to me that this track one category did not use the language of terminal illness. And that, at some level, to use what was the exact language, you said it was reasonably foreseeable? Death was reasonably foreseeable death. Right. So reasonably foreseeable, was that meant to be a synonym of terminal illness? Because it seems to me reasonably foreseeable is already looser than the concept of being terminally ill, which means you're on your deathbed.

13:53Coleman Hughes:Did they intentionally not use the phrase terminally ill? I believe they did. I haven't checked. It's been a while since I actually looked at the legal language behind Track One Made. But if I recall correctly, they did refer to terminal illness. In fact, That was the driving force behind track one MAID. And reasonably foreseeable death was as in you're within months of dying. And that was pretty clear under track one MAID. and there was no confusion about it. So you couldn't go into a doctor's office where you have type 2 diabetes or type 1 diabetes and tell your doctor, look, I just, you know, my debt is reasonably foreseeable.

14:48And the doctor would just laugh at you because that's not the case with these diseases. But so track one was pretty clear. Everybody agrees track one was not the problem. It's the expansion to track two. That's where the language gets

15:06a little tricky, right? When you say that your suffering is intolerable, it's a very subjective thing, right? One of the cases that I've written about, this young man recently died, died in January. We can talk about that a little later in depth. But, you know, he I spoke to the physician who euthanized him and she said to me, well, who are you to decide if this individual's suffering is intolerable? if you know a hypothetical person she was referring to a hypothetical person with a very similar condition as the person who had just died that if this person had type 1 diabetes if this person was blind or was in a wheelchair who who am i or who are you to say that their suffering is intolerable that's where the language um has has gotten quite um um controversial show because all you need to do is just tell your doctor at this point, as has happened to this young man that I wrote about, is that, look, I just can't live with this condition anymore.

16:16I do not want to be blind. I don't want to live as a blind person as I get older. I'm tired of dealing with my diabetes and also I have seasonal depression. So this suffering is intolerable to me and I just don't want to live with this anymore. And there are plenty of doctors out there in Canada who think that this is sufficient enough to approve an individual for MAID. Yeah.

16:46Coleman Hughes:I mean, so the obvious difference between someone like that and someone with a terminal illness is that, you know, we all know people in our lives or people, you know, who later become motivational speakers and we see, you know, you see David Goggins talking about how he was horribly depressed as a 20 year old and now he's David Goggins or any of these people, right? There are people that have attempted suicide, failed, and then gone on to live happy lives after some combination of personal growth, therapy, the right drugs. Increasingly with the psychedelic revolution that I think is coming, whether it's, you know, Ibogaine, MDMA, transcranial stimulation.

17:31Coleman Hughes:I mean, all of these things are on the horizon. Some of them are having fantastic results with people with certain mental illnesses. The notion that the government should be involved in canceling that life, which could go on to be a happy flourishing life, is totally different than someone who is going to die regardless in the next few months, right? So ethically, those are two different cases. And there should be an ironclad legal difference between those two cases. I'm curious, what is it about Canada's political culture? What beliefs and values are in the air such that so many people seem okay with the expanded policy, which most places on earth, I think, would be a non-starter.

18:22Well, I think this is a feature of a lot of Western countries. I'm originally from India, and I contrast so much of what I see here to what I've experienced in India. And I think one explanation that I've come to, I mean, there are several, but I can go through them. One is cultural. I think Canada has become, like many Western countries, an intensely individualistic society and places autonomy at the center of life. So suffering, once suffering, is no longer seen as something that you endure collectively or spiritually, but as a problem that needs to be solved through personal choice. and in this case with some help from the state.

19:18The other thing that is Canada-specific, I would say, is that our health care system here, our socialized health care system, state-funded health care system, is overstretched and often unable to provide timely care for people who are desperately in need. So when I write about Maine and I speak to doctors who are against medical assistance and dying, they'll say, you know, but the problem really here is that we don't have enough money for palliative care. The doctors who are empowered to carry out MAID are better funded than we are. So therein lies, there's an incentive system in Canada, a structure in place that perhaps incentivizes doctors who perform MAID as opposed to doctors who provide palliative care.

20:10And so if you're a vulnerable person, you sometimes feel that the state facilitates death faster than it can provide meaningful care. And I also think another part of this is ideological. The language surrounding MAID has shifted over time. As I mentioned earlier, the moral and legal boundaries have rapidly expanded. It went from something that is tragic and something that is exceptional towards, if you look at some of these right to die organizations, they will talk about dignity, they'll talk about empowerment, and they'll talk about the right to die. And that is about autonomy. And that autonomy becomes the highest principle.

21:03And so if unbearable, intolerable suffering justifies euthanasia for the terminally ill, why not for the chronically ill? if you can have made for physical suffering, why not for mental illness? And that's how the logic goes. And on autonomy, I was reminded of a point a Dutch professor of neurophilosophy made to me a few months ago. His name is Julian Kieberstein. And he said something very interesting about autonomy. And I'm not quite sure if I agree with him. But he said that we often speak about autonomy as though human beings are isolated. We're fully rational actors making these decisions entirely on our own.

21:53But in reality, our choices are shaped by our relationships with people in society. It's shaped by the environment that we're in. And it's shaped by economic conditions, whether we feel loved or loved, supported or abandoned. So so his argument is that autonomy is never fully independent because we make decisions within within all within this context. And so I think I think with Canada, it's it's and then you have a political class right in a place like Canada that is more than happy to enable all of these things. and so I feel like all of these things have come together in Canada, in the Netherlands as well.

22:41I would say the Netherlands is on a different path altogether where made for mental illness is legal in the Netherlands and so they're, you know, they have a very, very different perspective on dying in a way that would shock most North Americans and so I think a lot of it also has to do with the fact that Canada is more like a European country in that sense. You know, culturally, when it prizes autonomy over everything else.

23:16Coleman Hughes:So I remember when I looked into this for the piece I wrote for the Free Press, there was a strict separation between Canada, Netherlands, and Belgium on the one hand, which had these loose laws, you don't need terminal illness, and therefore had case after case after case of people in their 20s who are effectively sad for various reasons, offing themselves. There's a strict separation between that and the case of Oregon State, Australia, New Zealand, where there are death with dignity laws that are limited to those with terminal illnesses. And I really didn't see much reporting about people in their 20s.

24:07Coleman Hughes:I actually didn't see any people in their 20s without a terminal illness deciding to kill themselves. Is that an accurate picture in your view of what's going on? And if so, does it just come down to having the right law with the right restriction around having to have a terminal illness? So if I've understood your question correctly, you're saying that the laws are weak and that's why you're seeing people having this wish to die and therefore they're applying to die. Is that your question? Yeah, yeah, essentially. Yeah, because Oregon, I know Oregon has had a death with dignity law much longer than Canada has.

24:53Coleman Hughes:And all the horror stories that you've reported on and that I've seen, they all come out of the countries with the loose laws, right? With the Netherlands and Belgium and Canada. And it seems like they don't come out of the countries that have similar laws, but restrict it to the terminally ill. So is that the crux of... Sure. Yeah. As I mentioned, track two expansion did open the floodgates, so to speak, in terms of people just, you know, applying for MAID because they were socially isolated or they couldn't pay the bills or they were feeling despair. And certainly in the Canadian case, in Canada's case, the fact that TRAC2 came into being in the middle of the pandemic, that too, when people were especially vulnerable and young people especially so, that I absolutely would say that you can say it's all legal, But you have to then also question, well, where are we heading with this?

26:04You know, what are we doing? What's the end goal here? Do we want to make death, you know, do we want to make euthanasia so readily available? And under conditions, under any normal circumstance, common sense would suggest that, no, this person has many years to live, but that's not what's happening, right? Right. And so absolutely, I do I do think that the slippery slope argument, which is what a lot of people point to in Canada's case and in the Netherlands, for that matter, we're already there. And people say we're more like in a water slide situation right now. And that is that does come down to the law.

26:51Coleman Hughes:Yeah, so the slippery slope argument though, when I was looking into it, I was skeptical of this because it seems to me, and I would like to double check what the original Canadian law said, but you have cases like Oregon, Australia, New Zealand, where it's always been for the terminally ill only, and it's never slipped. And then when I looked at the original law in the Netherlands and the original law in Belgium, the original laws were not restricted to the terminally ill. Correct me if that's wrong, but that's what I found when I looked at the original laws in those two countries. And so it seems to me there actually hasn't been, perhaps Canada is the exception, but there hasn't been much slippage between the two kinds of laws.

27:46Coleman Hughes:There's just been laws that are rather capacious to begin with. And then, therefore, doctors have had this open door to creep through for years, and perhaps the practice has expanded. And then there's cases like Oregon, where it's just terminally ill, you've got six months to live, and it's never expanded outside of that. And I think, you know, I would caution against opposing all such laws because of the horror stories in cases like Canada, the Netherlands, and Belgium. Because it seems to me that you can have a law that is restricted to the terminally ill and doesn't creep outside of that. And that's important as well, given how much suffering people do experience who have terminal illnesses.

28:39Right. And we're seeing that in the UK right now with their assisted dying bill. I believe it was defeated a couple of weeks ago. But that was just geared towards people who are terminally ill. But because MAID has been so controversial in these other countries like Canada and the Netherlands, that people in the UK are watching this, watching these stories, they're hearing these stories and watching these developments in these countries. And they're like, you know, do we really want this here? And so the unfortunate thing about the expansion is that in countries where track one MAID for the terminal, it could be could be an option.

29:24and you do it under the rarest of circumstances for people who are literally within weeks of dying. And those things can be easily determined, I think. I'm not a physician, but I think when your doctor tells you you have four months to live or five months to live and there's really no other treatment option left because of fourth stage cancer or whatever, I think for those people, their suffering can be, you know, you could help them with a track one made like a program. But obviously, you know, expanding it beyond that becomes very controversial. And that's when you hit the slippery slope argument.

30:11And that's exactly what we're seeing in places like Canada and the Netherlands. And so, yeah, I mean, absolutely, any expansion is bound to, especially in a state, let me put it this way, especially in a place like Canada where the system generally seems to want to enable these physicians, right? There hasn't been a single doctor in Canada who's been reprimanded or they've lost their license because there have been concerns about the fact that they approved someone for MAID when that person could have lived. There's been no consequences for anyone. There's been, and so in a sense, the law actually protects these doctors and physicians who approve people for MAID.

31:05There's no real oversight, whatever oversight that exists in Canada. There's an incredible amount of pressure on these doctors to not ask questions. the Ontario Maid Death Review Committee is actually being kind of disbanded and they're going to put in doctors who are pro-maid to be on the oversight committee. This is an oversight committee that is going to be, that's going to have doctors who are generally on board with medical assistance in dying and they're going to get rid of the doctors who are not. So, you know, So you have a situation where it's not just the legal expansion of MAID, but you also have a state that is more than willing to go along with this.