Abstract
I thank Dr. Smith for his response to the Perspectives article 1 ; I will respond to 3 points.
First, he states that I may have an undeclared “conflict of interest” on medical assistance in dying (MAID) in the form of a religious faith. Whilst I am not sure that a religious faith can be described as a conflict of interest in the field of ethical debates (rather, it may be a qualification), I do not hold a religious faith. My ethical critique is not theist; this may be of contextual interest to the reader, but I do not think this adds to or detracts from the arguments in the article.
Second, Dr. Smith argues that I have missed that Carter v. Canada (Attorney General) (2015) allows for mental illness as a sole eligibility criterion for MAID. I did not argue that Carter excluded mental illness and indeed noted that there may be a small number of people with psychiatric conditions that may fit Bill C-14 criteria. However, as I noted, the Supreme Court of Canada (SCC) did not hear evidence about psychiatric illness, stating at paragraph 111 that those conditions were not covered under the facts of Carter. Further, the SCC said, at paragraph 86, “The scope of this declaration is intended to respond to the factual circumstances of this case. We make no pronouncement on other situations where physician aid in dying may be sought.” 2 It is hard to read into that statement the inclusion of mental illness in Carter as Dr. Smith proposes.
Dr. Smith argues that the EF decision from Alberta is an unanswered precedent that is still the law in Canada. 3 He appears to suggest that this means that Bill C-14 may not be charter compliant. The status of the EF decision has been comprehensively reviewed by Lemmens et al., 4 who refute that position. I refer readers to that article for a comprehensive review of these issues. Ultimately, whether Bill C-14 is charter compliant will be adjudicated by expert legal minds, not psychiatrists.
Finally, Dr. Smith comments that I am primarily arguing from the perspective of a mental health clinician and ignoring that Carter is about patients’ rights to control their deaths, not physicians’ rights. It is true that I argue as an ethically concerned clinician. I respect and accept that people have a right to choose whether to live or die and understand that if someone is incapable of exercising that right or is at end of life, it may be ethically reasonable to ask for a physician’s assistance in their death. My point is that involving someone else in your death necessarily broadens the ethical analysis from one’s own autonomy interest to include the ethical burden on the other person. Autonomy does not entitle one to burden someone else with one’s death, except in extreme circumstances. Involving doctors necessarily invokes their ethical reactions, duties, and obligations. It is not only a debate about patient autonomy but also about the ethical duties and burdens of doctors.