A Six-Week Exchange With the Euthanasia Prevention Coalition - Week 1

Medical Homicide for the Treatment of Mental Illness: The Role of Decisional Capacity. By Gordon Friesen, President of The Euthanasia Prevention Coalition.

Content and Support Notice

This exchange discusses mental illness, medical assistance in dying (MAiD), and suicide. These topics can be difficult or distressing for some readers.

If you or someone you care about is struggling, in crisis, or at immediate risk, help is available. In Canada, you can call or text 988 24 hours a day, 7 days a week. If you are in immediate danger, please call 911 or go to the nearest emergency department. If you are outside Canada, please consult local emergency services or a suicide prevention helpline in your country.

The following post is part of a structured, multi-week, simultaneously published exchange between Kim Carlson and Paul Magennis, authors of MAiD in Canada, and Gordon Friesen, President of the Euthanasia Prevention Coalition. These alternating messages will explore deeply divergent views on Medical Assistance in Dying (MAiD), and no mutual endorsement is implied.

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(N.B. Some readers may find the term “medical homicide” to be unnecessarily pejorative. I respectfully disagree. It is the taking of human life, itself, which causes such anxiety, not the words chosen to represent it.

“Homicide”, is a neutral, Latin, technical term. It may be “culpable”, or “non-culpable”. It is for advocates of so-called “medical assistance in dying” to explain why this allegedly “medical” instance should be viewed as one, rather than the other.)

On October 28, 2025, at our Euthanasia Prevention Coalition Parliamentary Press Gallery Conference in support of Bill C-218 (introduced to prohibit the practice of medical homicide for mental illness alone) I made the following statement regarding the decisional capacity reasonably required for such practice:

“the symptoms of mental illness often make that sort of (...free, informed, competent, adult) choice impossible.”

In a later critique of our Conference, Maid in Canada (M.I.C) responded:

“Some mental illnesses can impair decision-making in certain circumstances, but it is simply untrue that they always do — or even often do. In reality, most people living with mental illness retain the ability to make serious and informed decisions about their lives, including end-of-life decisions, most of the time.”

I do not disagree with much of this quote as written.

I do, however, consider it irrelevant to the question posed here: Does compromised decisional capacity provide a serious reason to oppose the practice of medical homicide, particularly for the treatment of mental illness alone? Clearly, I think it does.

In judging that claim I believe we must consider two things: first, the standard of decision-making capacity ethically required for medical homicide; and second, whether those people most likely to access medical homicide, for reasons of mental illness, actually meet that standard.

(Please note: it is not the case that we must prove capacity deficit in all sufferers of mental illness. We must only show that those people most likely to consider a recourse to medical homicide, are themselves, most likely to fall short of the exceedingly high capacity bar, which must logically be set for that practice.

For our concern is not with “most people ... most of the time (my emphasis)“. It is with the most severely afflicted people, in the worst possible times.)

As M.I.C. further notes, “capacity is always presumed unless there is a clear reason to question it”. And in a medical context, it is easy to understand why.

Since medical procedures are normally understood to be of great benefit, obtaining consent should be as easy as possible. But there are, indeed, times when society intervenes to deny decisional capacity, and hence, to deny the operation of autonomous choice. Basic procedure, in such cases, requires that capacity be proportional to the importance of the decision in review.

Traditionally, there is no decision considered more important than that of voluntary death (such as refusal, or withdrawal, of care). And contested autonomy will accordingly be most frequent in these. But, the medical homicide of a person suffering from mental illness, alone, is a much weightier choice than any typical removal of care. For in this case, there is no preexisting, organic, survival crisis. From a somatic perspective, the patient may be in excellent health.

Logically, then, it is the strictest possible standards of capacity ever seen in the treatment of mental illness --being those related to immediate prevention of suicide-- which should automatically apply to any request for medical homicide.

To be clear on this point:

1. It is clinical standard of care, for psychiatrists, to presume that suicidal desires result from cognitive distortions produced by mental illness. (And it is these distortions which are understood to impair decisional capacity.)

2. As for the claim that a desire for medical homicide is fundamentally different from common suicidality: The Canadian Association for Suicide Prevention denies any such distinction;¹ and the American Association of Suicidology --which once held a position differentiating the two-- has since withdrawn it.²³ Furthermore, most psychiatrists recognize that such a distinction (even if it existed) could not be clinically established.⁴

Finally, those who believe we might potentially tell the difference, between medical homicide request and ordinary suicidal ideation, base their suggestion on the hypothetical possibility of ruling out mental illness to begin with (a position, which ironically argues against any access to medical homicide for the mentally ill).⁵

(Yet, even were this a valid line of reasoning, psychiatrists frequently fail to detect serious mental illness. And depression has long been observed to exist in a large proportion of medical homicide deaths.)⁶

Taken together, these facts would seem to indicate: a) that the nexus of suicidality and capacity impairment presents an insurmountable clinical obstacle to any ethical scheme of voluntary medical homicide; b) that this difficulty becomes exponentially greater for persons with mental illness; and c) that it would be ethically unthinkable to permit medical homicide as a treatment for mental illness itself.

Impaired decisional capacity, therefore, is clearly a serious argument against the ethical practice of medical homicide (especially) for mental illness.

No medical homicide for mental illness. Support Bill C-218.

(Paul and Kim will respond on Jan 19th)

1. Canadian Society for Suicide Prevention , Statement on MAID for mental illness, December 2022 https://suicideprevention.ca/media/casp-issues-statement-about-maid-for-mental-illness/

2. American Association of Suicidology, Update on Physician Assisted Death Previous Statement https://suicidology.org/aas-update-on-physician-assisted-death-previous-statement/

3. Good Old News: In Early 2023, Suicidology Group Withdrew Statement NDY Protested, Not Dead Yet, July 10, 2023. https://notdeadyet.org/good-old-news-in-early-2023-suicidology-group-withdrew-statement-ndy-protested/

4. More Canadian Psychiatrists Respond: No MAiD For Mental Illness, Impact Ethics, November 28, 2023 https://impactethics.ca/2023/11/28/more-canadian-psychiatrists-respond-no-maid-for-mental-illness/

5. Abdi Sanati, Does suicide always indicate a mental illness? London Journal of Primary Care, 2009, https://pmc.ncbi.nlm.nih.gov/articles/PMC4222167/

6. Ganzini, Linda; Goy, Elizabeth R.; Dobscha, Steven K.; Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey, BMJ, October 7, 2008 (shows three of 9 deaths = 33%) https://pubmed.ncbi.nlm.nih.gov/18842645/