Advance requests for MAID: A conversation with Dr. Tim Holland

News & Updates | February 2, 2024 | Sarah Dobec

Home / News & Updates / Advance requests for MAID: A conversation with Dr. Tim Holland
A headshot of Dr. Tim Holland

Currently, advance requests for MAID are not legal in Canada; we require an amendment to the Criminal Code to set out a framework for this addition to our MAID legislation. Dr. Holland shares with us his research on the topic and how he thinks it could work.

Dr. Tim Holland has been passionate about the right to die movement in Canada since before 2016 when medical assistance in dying (MAID) became legal in our country. 

“I became an assessor and provider in 2016 and soon after was elected as the Chair of Ethics for the Canadian Medical Association (CMA); we oversaw the redrafting of their current MAID policy. I joined the Canadian Association of MAID Assessors and Providers (CAMAP) in the early days when it grew out of the “MAiD in Canada” listserv. After medical school, I pursued my Master of Arts in Philosophy, and my thesis topic was advance requests for MAID in the setting of advanced dementia. I am now the Head of the Department Bioethics at Dalhousie University and the chair the working group at CAMAP for advance requests for MAID.” 

Currently, advance requests for MAID are not legal in Canada; we require an amendment to the Criminal Code to set out a framework for this addition to our MAID legislation.  

The final report from the Special Joint Committee on MAID made three recommendations in support of advance requests for MAID including Recommendation 21: that the Government of Canada amend the Criminal Code to allow for advance requests following a diagnosis of a serious and incurable medical condition disease, or disorder leading to incapacity. 

2023 Ipsos polling indicates that 82% of people across Canada support an advance request for MAID for individuals diagnosed with a grievous and irremediable condition. Support for advance requests without a grievous and irremediable diagnosis remains high at 72%. 

“This is something we know many people across the country want in place for themselves and for their loved ones. From a philosophical perspective it draws in all our concepts of metaphysics of personal identity and what makes us human as well as the classic bioethics tension between the right autonomy and consequentialism (e.g., beneficence/non-maleficence). It’s an important issue to address for many reasons.” 

One of the next steps in legalizing advance requests for MAID is to develop a framework for administration. While some are concerned that this will be very complex, recording future wishes for an assisted death is not new; advance requests for MAID have been a legally enshrined option in end-of-life frameworks in The Netherlands, Luxembourg, Belgium, and Spain. 

“In populating the CAMAP advance request working group, I was intentional in inviting people with different opinions, and we’ve been able to work through our task list quite effectively. When you first look at the task at hand it seems overwhelming, but the way we are approaching it gives me confidence that drafting a workable framework is feasible. I am optimistic that we can create a framework that will provide clinicians with a relatively straight-forward approach to an otherwise overwhelming task.” 

There is a philosophical debate about providing MAID to people who have lost the capacity to make health care decisions even if they put in writing what they would want in that situation. While the issue will never be black and white, Tim researched this exact topic for his thesis. 

“There is a rich, decades-long debate regarding advance directives for withdrawing life-sustaining therapies or withholding lifesaving therapies in advanced dementia; this debate focuses on whether or not a person should be able to stipulate something like, “I don’t want antibiotics as a treatment for pneumonia if I have advanced dementia.” There are two broad camps in this debate. One is the autonomy focused “critical interests camp” that assert that if the advance directive is based on your critical interests that define your life and values then when you can no longer conceive of your own critical interests, the advance directive takes precedence on your current momentary interests and therefore holds sway in health care decisions. This addresses both what’s in your best interest in terms of reducing suffering and your autonomy. 

The other side of the debate is what I call the “Presentists” who ask, “Does the advance directive fit who the person has become now?” The basis of this argument is that personhood is not concrete, and it can vary over time. 

Where I landed with my thesis is that, yes, you can be a different person, but it doesn’t mean there isn’t an ethical value placed on the connection of who you are through time. So even though you may not be the same definitive person, the psychological connections through time are enough to give some moral weight to the advance directive – if not the same total weight that the critical interests camp may assert. The moral weight may not be sufficient for the 20-year-old person to write an advance request for MAID that applies when they are 90 but would be enough moral weight such that we do not outright dismiss an advance request in the setting of advanced dementia as may occur in the presentist camp. The key will be to maximize the psychological connection the person drafting the advance directive to the person who will be receiving the care. Luckily, these can be simple actions like checking in regularly with your advance directive to ensure it still reflect what you want, if you have any major life changes such as a diagnosis, you want to revisit the document but also consider how you feel about the diagnosis and your prognosis. An expert in the condition can help you understand the potential outcomes so you can make some real world, sensible decisions. 

Given that our ethical obligations in society are to each other, when we come to a medical assistance in dying assessment, we need to ask, “Is this a change we could have foreseen because of the individual or a change that has occurred because of the disease?” We don’t want the disease to speak for the person.” 

In the countries that allow advance requests for MAID, there have been few of the controversial cases we are concerned about, for example, the happy dementia patient. The protocol that experts develop will have to prepare for them, but based on what we can learn from places where this is legal, it is possible. 

“One thing that the conversation about advance requests for MAID has shone a light on, is the lack of appropriate Advance Care Planning in Canada; very few people have their health care wishes properly documented and shared with a Substitute Decision-Maker. Advance Care Planning is more than drafting a set of advance directives and instead focuses on understanding the values and wishes of an individual which will then inform care decisions in the future. Once our advance request for MAID protocol is complete and made legal, my hope is that more people will take the time to consider all their health care wishes should they not be able to speak for themselves.” 

Download DWDC’s Advance Care Planning Kit (ACP) here. The ACP Kit invites you to think about and express your wishes for health care and treatment at the end of life. It is intended to provoke thinking, conversation, and planning, and to encourage communication among you, your loved ones, and your health care providers. 

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