A Six-Week Exchange With the Euthanasia Prevention Coalition - Week 2
Presuming Incapacity Is Neither Clinical nor Legal: The Case Against Categorical Exclusion. By Kim Carlson & Paul Magennis - MAiD in Canada
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.
The first installment was published by Gordon, President of the Euthanasia Prevention Coalition on Monday January 12, 2025. The entry below is by Paul Magennis and Kim Carlson from MAiD in Canada.
By Kim Carlson and Paul Magennis - MAiD in Canada
Medical “Homicide”
Gordon Friesen is free to use the term “homicide” as he wishes, but it cannot be defended as neutral. Acts that would otherwise constitute crimes are routinely transformed in law by consent and specific legal conditions. Describing MAiD as “homicide” is as indefensible as calling surgery “aggravated assault.”
Friesen admits to avoiding the term “murder” because of its rhetorical consequences, writing in December1 that “murder is just impossible to use. However, we know the truth.”
“Homicide” is offered not as a dispassionate technical definition—as claimed—but functions as a substitute that preserves Friesen’s moral claim while softening its impact.
Friesen’s opening remarks obscure the EPC’s frequently stated belief2 that MAiD is murder, raising questions about whether this exchange is being conducted in good faith.
Friesen’s Claims
Friesen’s argument rests on three claims: capacity in MAiD for mental illness is so impaired, too often impaired, or too difficult to assess that categorical exclusion is required.
Key Points
Friesen fails to understand the legal standard of capacity, to whom it applies, and how it is assessed.
All people are presumed to have capacity unless shown otherwise, including those with mental illness.
People who lack the capacity to give consent cannot have MAiD. Nothing in Friesen’s argument alters this rule. Rather, he suggests excluding those who are capable, despite the absence of any legal or clinical basis to do so.
The Canadian Psychiatric Association,3 in its position on MAiD for mental illness,4 affirms that assessing decisional capacity—including the stability, coherence, and durability of a person’s will in the presence of psychopathology—is a core psychiatric competency.
Capacity is Categorically Absent
At the EPC press conference,5 Friesen asserted that “obviously…euthanasia for the mentally ill does not fit [the description of a person making ‘free, informed, competent, and adult choices’]”.
This claim that people living with mental illness are categorically unable to make serious, potentially life-ending decisions is unsupported by case law, statute, regulatory standard, or accepted medical or ethical framework.
The Supreme Court of Canada was explicit in Starson6 that mental illness must not be conflated with incapacity, and “the presumption of capacity can be displaced only by evidence that a patient lacks the requisite elements of [decision-making] capacity…”.
If Friesen’s position is that people with mental illness, as a class, lack capacity to consent to MAiD, then it is his responsibility to explain why this should override a legal and clinical framework that rejects categorical assumptions of incapacity and requires individualized assessment.
Capacity Too Often Absent
Friesen concedes that people living with mental illness can have decision-making capacity, including for serious medical decisions. This undermines his argument.
Friesen’s assertion that “[he] 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” is incoherent. A claim about likelihood does not justify abandoning individualized assessment; it predicts ineligibility.
Individuals who do not have capacity cannot be eligible for MAiD.7 If someone “most severely affected…in the worst possible times” does not meet the capacity standard, that reflects the effectiveness of existing safeguards—not a failure of them.
Capacity Too Difficult to Assess
The difficulty of assessing capacity—regardless of diagnosis or seriousness of the decision—does not justify presuming incapacity or abandoning the effort. This claim is further undermined by evidence of high inter-rater reliability in psychiatric capacity assessments.8
Friesen does not demonstrate why MAiD for this one group requires a unique exception to this established framework.
MAiD Requests as Cognitive Distortions
Friesen asserts, incorrectly and without evidence, that psychiatrists presume suicidal ideation arises from cognitive distortions caused by mental illness. No such presumption exists, and clinical approaches do not equate suicidal thoughts with decisional incapacity. Even where distortions may be present, that would not justify abandoning individualized assessment.
People do not forfeit the presumption of capacity due to mental illness, cognitive distortions, or suicidal ideation.9
EPC Overstating References
We’ve noticed EPC has a tendency to overstate what their references support.10 Friesen claims that “most psychiatrists recognize” that a distinction between a desire for MAiD and suicidal ideation “could not be clinically established”, but the reference does not support that claim.
The article11 reflects the views of 43 psychiatrists—under 1% of psychiatrists in Canada12—which cannot reasonably be described as “most,” nor do the authors claim to speak for the profession. At most, Friesen’s reference supports the claim that some psychiatrists hold this view. Nothing more, and certainly not “most”.
Friesen’s Conclusions
Capacity assessments can be complex in the context of mental illness (as they can be in many other circumstances, e.g., infection or brain injuries). Where Friesen fails is his belief that the only acceptable response is to deny all—and only—people with mental illness as their sole underlying medical condition the same presumption of capacity afforded to everyone else, absent individualized evidence to the contrary. The high bar is not for recognizing capacity, but for justifying its denial—a burden Friesen has not met.
No MAiD for decisionally incapable persons. This is already law.
Starson v. Swayze, 2003 SCC 32 (CanLII), [2003] 1 SCR 722, https://canlii.ca/t/1g6p9>, retrieved on 2026-01-17
Starson v. Swayze, 2003 SCC 32 (CanLII), [2003] 1 SCR 722, <https://canlii.ca/t/1g6p9>, retrieved on 2026-01-17
A brief note on comments:
Kim and I have agreed with Gordon that we will not be participating in the comment threads during this exchange. That choice is intentional, and it’s meant to preserve the focus, structure, and integrity of the written dialogue itself.
That said, readers are very encouraged to discuss, critique, question, and debate the arguments raised here in the comments. We look forward to thoughtful engagement from all perspectives.
Once this exchange has concluded, we do intend to revisit the discussion and respond to points that merit further clarification or reply.
I've been assessed for MAiD for my MS. But because my family doctor indicated my lifelong struggle with mental illness, my assessment was done by a psychiatrist. A capacity assessment was done alongside the assessment.
The assessment notes:
"While this patient has a significant mental health history, [redacted], from our
assessment today, he is not acutely suicidal, and his mental health condition does not appear
to be impacting his capacity to make this treatment decision."
I can tell Mr. Friesen that, from experience, assessors take a comorbid mental illness seriously and take necessary steps to ensure patients have capacity to consent to something as serious as MAiD.