COVID-19 has taken a toll on our mental health. With more and more cases of depression, the deadly virus has made us more aware of our fragile existence. Perhaps, as a result, more attention is being paid to end-of-life issues, including hospice, and more controversially, euthanasia. Are we going down a slippery slope?
According to provisional 2020 year-end statistics, Alzheimer’s disease remained among the leading causes of death, increasing last year by almost 10%. Indeed, deaths from all types of dementia increased last year, accounting for many nursing home deaths and reflecting a lack of family visitation and stimulation. Canada was especially hard hit. A report by the Canadian Institute for Health Information found that as of May 25, 2020, 80% of COVID-19 related deaths were people in long-term care facilities and retirement homes, many of which instituted lockdowns and restricted or eliminated visits from family members.
Researchers found that the rates of loneliness and hopelessness in the aged increased during these lockdowns, causing ‘confinement syndrome,’ which resulted in more older people inquiring about Medical Assistance in Dying (MAiD). [1] While not a direct cause of increased euthanasia or assisted suicide, the lockdowns were considered an accelerant.
Nancy Holland
On October 20, 2020, with the prospect of another lockdown squarely in front of her, Canadian nursing home resident Nancy Holland had herself euthanized. Mrs. Holland, aged 90, was doing well for her age, but according to her daughter, “over the lockdown period her mental health and happiness severely declined.” There was nothing precisely medically wrong with Nancy, “who would regularly walk to the library, do her own shopping, and was a spry and social woman for whom social contact was like oxygen.”
But as weeks of intermittent in-room isolation imposed by her nursing home dragged on to months, she declined – physically and mentally. “Faced with a second round of lockdowns and isolation, Nancy made the decision “to seek … a medically assisted death.”
“Many who “met the criteria and [would have] wanted MAiD … are choosing to die sooner than they would otherwise because the … retirement lockdowns, particularly visitor restrictions, are so miserable.”
Dr. Susan Woolhouse, Canadian Association of Maid Assessors and Providers.
Originally, Canadian euthanasia legislation was limited to the terminally ill. At the time of Mrs. Holland’s death, according to Health Canada, MAiD was available if a physician had determined that an individual was:
“in an advanced stage of irreversible decline, experiencing unbearable physical or mental suffering … that cannot be relieved” and where one’s “natural death has become reasonably foreseeable.”
Nancy’s first request to her doctor was refused. But with the prospect of stricter isolation and Canada’s long winter, she deteriorated and developed concrete medical issues and once again considered MAiD. She made a second request, and this one was granted. Surrounded by family, she died on October 20.
“When you can’t look forward to getting out of your room, to having meals or doing activities with others, to even seeing your own families and loved ones, you can imagine for a person in the last few years of their life where these are the basic things that actually bring them joy and really defined what they would call their own quality of life, when you actually deprive a human being of these things, you can imagine that that can have significant psychological consequences that can really give people no real will to live anymore.”
Dr Samir Sinha, geriatric specialist at Mount Sinai Hospital.
Other countries recognized that the decline in long-term care residents was due to enforced isolation. The Netherlands, with one of the most permissive euthanasia laws in the world, found a balance between precautions and allowing activities and family visits. After a pilot project, the Netherlands officially permitted nursing homes to adopt a program allowing one visitor per resident.
But even as its older population died from COVID-19, Canada contemplated relaxing its MAiD regulations. Critics said that the proposed changes would make Canada’s law among the most permissive in the world. Bill C-7 was meant to give access to MAiD to people whose natural death is not reasonably foreseeable. Opponents to Bill C-7 contended that it endorses a prejudice that life with a disability has less dignity or is less worth living; transforming MAiD “from a procedure to facilitate dying into a terminal therapy for life’s suffering….”
Three weeks ago, on March 17, 2021, after a year of debate, Bill C-7 became law. Under the new law, a person’s natural death no longer needs to be reasonably foreseeable -- and both active euthanasia and medically assisted suicide are allowed. The necessary conditions are that the candidate is:
- Eighteen years of age or older.
- Have decision-making capacity.
- Have a grievous and irremediable condition - although not necessarily one destined for foreseeable death, and
- Two independent healthcare professionals need to evaluate and concur about the applicant's decision-making capacity and medical conditions.
The Global Push
Four days later, Spain legalized euthanasia, becoming the fifth country to do so. Here, too, terminal illness is not a required prerequisite, although “suffering from a serious or incurable disease or a serious, chronic and incapacitating condition,” which causes “intolerable suffering,” is required.
"Today we are a more humane, just and freer country. The euthanasia law, widely demanded by society, finally becomes a reality."
Spain's Prime Minister Pedro Sanchez
Portugal, too, is on the cusp of broadening its laws. (Its legislature enacted it, but their high court struck it down as imprecise. It is expected to be re-introduced.)
Yet even the most permissive MAiD regimes globally – including Belgium (where euthanasia accounts for 2.4% of all deaths), the Netherlands, and Luxembourg – treat MAiD as a last resort, available when no other options remain. But those who do not have a medical condition and are just “tired of life” and therefore don’t qualify for MAiD can still be “helped.” This comes by way of various Swiss groups, for example, Pegasos, and a perverse form of medical tourism. Dutch citizens seeking to end their life, but without a medical reason, can travel to Switzerland, where a Pegasos provides “the assist” for assisted suicide.
“Pegasos offers an assisted dying service to approved adults of sound mind, regardless of their country of origin/ residence.” Pegasos website
And while, under Belgian law, euthanasia for ‘tiredness of life’ is not permitted, “… doctors can circumvent the law by diagnosing ‘polypathology’ – a jumble of ailments which nearly every elderly person has, and amalgamated, are a sufficient “cause” for euthanasia.”
Not everyone, however, is supportive. Germany and Australia have put bills on hold or failed to pass them. The authors of a recent article in the Journal of Medicine and Philosophy article argued that “Belgian euthanasia law is broken ethically, administratively and legally.” A few months ago, UN human rights experts expressed alarm at a growing trend to enact legislation enabling access to medically assisted dying based largely on a disability or disabling conditions – supported by an aggressive and well-organized disability rights community. These experts claim that legislation allowing euthanasia for the non-terminally ill relies on “quality of life,” arguments often made by the disabled. The aged, who may feel subtly pressured to end their lives prematurely due to attitudinal barriers and the lack of appropriate services and support, are similarly vulnerable, although without powerful NGO advocacy on their behalf. And that brings us back to Nancy Holland.
Two months after Mrs. Holland took her life, vaccination changed the COVID-19 picture entirely. How many elderly who chose to die because they couldn’t face another lockdown would have chosen to live – if they could have seen around the corner to vaccination’s release from the bondage of isolation? We can only wonder.
[1] “Suicide” is the act of killing oneself. Assisted suicide, also called medical aid in dying (MAiD) or physician-assisted suicide (PAS), is committed with the assistance of another person, often a health professional, but the actual act is performed by the patient who self-administer drugs, usually, but not always, barbiturates. In euthanasia (also called "mercy killing"), another party brings about the person's death. The terms are often used interchangeably.
