Patients diagnosed with progressive dementia may know exactly how much deterioration they are willing to endure. They can articulate their wishes, discuss alternatives, and put their instructions in writing. Should losing the ability to repeat those instructions invalidate them?

Canada is preparing to address that question. On October 23, its Justice Department announced planned rules that would allow adults diagnosed with an incurable illness expected to destroy their decision-making capacity to consent in advance to assisted suicide (or, as Canada calls it, medical assistance in dying (MAID)). Ministers will discuss the proposal on October 27, but it must pass both houses of Parliament and receive formal approval from Canada's governor general before becoming law. Parliamentary committees can hear testimony and consider amendments along the way. The announcement promises safeguards but offers few details. Those details will determine how well the proposal respects patients' choices.

A free society recognizes individuals as sovereign over their own bodies provided they respect the rights of others. That freedom includes deciding how much suffering they are willing to endure. A competent adult's decision deserves respect even when physicians, relatives, or public officials would choose differently.

Competent adults should be free to choose clinician-assisted suicide or clinician-administered euthanasia, provided they give fully informed, voluntary consent and those assisting them do so willingly. That freedom should include planning for the loss of decision-making capacity. A patient's loss of decision-making capacity should not automatically grant the government authority to override instructions given while the patient was competent.

Physician-assisted deaths are now authorized in 13 states and Washington, D.C. Twelve states and the district enacted laws; Montana permits it under a state Supreme Court ruling. American statutes generally follow the Oregon model: Patients must have decision-making capacity, have a terminal illness expected to cause death within six months, and self-administer the medication.

These restrictions exclude people who suffer greatly but cannot meet the government's timetable or physically perform the final act. Progressive dementia creates another barrier. By the time patients reach the condition they hoped to avoid, they may no longer qualify.

In 1999, Michigan convicted Jack Kevorkian of second-degree murder after he administered lethal drugs to Thomas Youk, a patient with amyotrophic lateral sclerosis ("Lou Gehrig's disease") who had consented to the procedure. As I wrote in Reason, patients' bodily autonomy includes the freedom to request a willing physician's assistance in ending their lives. Requiring patients to administer the medication themselves denies that choice to people whose illnesses have stripped them of the physical ability to act. Dementia raises a further question: whether an informed decision can survive the loss of the capacity to express it.

Other countries give patients more latitude. At least a dozen countries permit some form of assisted dying, though their rules vary considerably. Canada does not require a terminal prognosis. In the Netherlands, euthanasia is permitted for unbearable suffering with no prospect of improvement, subject to statutory safeguards.

Some countries also recognize advance requests, though under different conditions. In the Netherlands, a written advance request can replace an oral request once a patient loses the ability to express a choice, including in advanced dementia. The remaining legal requirements, including unbearable suffering without prospect of improvement, still apply.

Belgium permits advance requests more narrowly, only when a patient becomes irreversibly unconscious. Patients who lose decision-making capacity due to dementia while remaining conscious cannot obtain euthanasia under an earlier directive.

Respecting a patient's earlier wishes raises difficult questions. How clearly must patients describe the circumstances in which they want assistance? Who determines whether those circumstances have arrived? What happens if a patient who can no longer understand the directive resists the procedure or appears content with life?

Legal scholars, working with clinicians and patients, must help lawmakers answer these questions. Finding the right answers is difficult, but the obstacles are not insurmountable. Lawmakers must develop careful safeguards that respect patients' choices rather than impose a blanket refusal to honor decisions made while patients were competent.

Patients already use advance directives to refuse life-sustaining treatment after losing decision-making capacity. Authorizing someone to administer life-ending medication requires additional legal consideration. But the principle of planning ahead deserves the same respect: People should have a meaningful say over what happens to their bodies when illness prevents them from speaking for themselves.

The law has a legitimate role in protecting patients from coercion, fraud, and life-ending procedures they never consented to. Before another person intentionally helps end a patient's life, the law must require reliable evidence that the patient gave informed, voluntary consent and that the applicable conditions were met. Neither a relative's preferences nor a clinician's assessment of whether a life remains worth living can substitute for the patient's decision.

Participation must also remain voluntary. Clinicians and private institutions should be free to decline participation on moral, ethical, or professional grounds. Respect for autonomy extends to all involved.

Oversight should focus on compliance with the law. An independent body could audit cases retrospectively, publish anonymized findings, and refer credible violations to investigators. It should not require patients to obtain bureaucratic approval for individual decisions, nor should it have the authority to rewrite eligibility standards.

Eligibility should hinge on a serious, incurable condition causing enduring, intolerable suffering and on reliable evidence of informed, voluntary consent. A six-month prognosis gives the government too much power over how long patients must endure suffering they consider intolerable.

Canada's proposal deserves careful examination once its details are available. A law that honors clear advance instructions while protecting patients against violations of those instructions would expand their control over the course of an incurable illness. A law that allows others to substitute their preferences would undermine the autonomy it purports to protect.

Dementia can rob people of their memories, judgment, and ability to communicate. The government should not use those losses to erase choices they freely made while competent. Patients who leave clear, informed instructions deserve laws that let willing clinicians honor them. Their bodies belong to them, even when they can no longer say so.

The post Canada Wants To Let Dementia Patients Consent to Euthanasia in Advance appeared first on Reason Magazine.

The federal drug police want to turn consumers of certain concentrated kratom-derived products into criminals while leaving traditional kratom leaf products outside the ban. Before exposing adults to arrest and prosecution, the feds owe them a scientific explanation for that distinction.

On October 14, the Drug Enforcement Administration (DEA) announced its intent to temporarily place 7-hydroxymitragynine (commonly called 7-OH) and mitragynine pseudoindoxyl—above specified thresholds—in Schedule I. Schedule I is the category for drugs that the agency thinks have "no currently accepted medical use" and "a high potential for abuse." A scheduling order could be issued on or after November 13.

The DEA already classifies mitragynine pseudoindoxyl as a Schedule I substance regardless of concentration. The proposal would ease that restriction by introducing thresholds—while imposing new Schedule I restrictions on 7-OH under the same criteria.

The Food and Drug Administration (FDA) and the Department of Health and Human Services (HHS) have supported the DEA's move, and HHS supplied the proposed thresholds. Under the temporary scheduling provision of the Controlled Substances Act, the DEA must consider HHS's comments but need not follow its recommendations. Congress gave a law-enforcement agency the authority to decide which drugs individuals may consume.

The ordinary scheduling process gives health officials more authority: HHS's scientific and medical findings bind the DEA, and its recommendation against control prevents the agency from proceeding. But temporary scheduling lets the DEA bypass those requirements when it determines a substance poses an imminent hazard to public safety.

Congress should never have given federal drug police that power. Having done so, it should at least demand compelling evidence before they exercise it.

Kratom comes from a Southeast Asian plant whose principal alkaloid is mitragynine. Its leaves contain trace amounts of 7-OH. Manufacturers also sell concentrated 7-OH products and products containing the related compound, mitragynine pseudoindoxyl.

Millions of Americans use kratom or kratom-derived products. A 2022 review cited an estimate of 2.1 million U.S. users in 2020. In a survey of 2,798 users, 91 percent reported using it for pain and 41 percent said they use it to reduce or stop opioid use. In a letter to HHS, nine military veterans described using 7-OH to manage pain and symptoms of post-traumatic stress disorder and to move away from other opioids and from alcohol. They warned that banning it could drive them back to more dangerous drugs.

These reports describe benefits that warrant further study and needs that will persist after a ban.

Concentrated 7-OH products deliver a potent alkaloid without requiring consumers to ingest large amounts of kratom leaf. 7-OH is significantly more potent than mitragynine in activating the opioid receptors involved in pain relief. Researchers still need to determine how its benefits and risks compare across different human doses.

The DEA's proposed criminal controls hinge on concentration and composition. The concentration threshold is 1 milligram per gram of solid material or 1 milligram per milliliter of liquid, calculated for the two covered substances combined. Products would also trigger controls if the mitragynine-to-covered-substances ratio fell below 100 to 1.

Consider a tablet containing 15 milligrams of 7-OH, a strength advertised by some sellers. If the tablet weighs one gram, its concentration exceeds the limit fifteenfold. Diluting the same 15 milligrams into a product weighing 15 grams brings it to the concentration limit. Consuming the entire product still delivers the same dose. It would also need at least 1,500 milligrams of mitragynine to avoid the separate ratio restriction.

Adding bulk changes the concentration but does not change the amount of 7-OH consumed. These calculations tell us nothing about whether that dose is effective or safe.

The DEA acknowledges that controlled trials have not established safe consumption limits or standardized dosing for concentrated 7-OH products. Neither DEA nor HHS has determined that below-threshold products are safe.

In a public comment submitted to HHS in July, I urged officials to obtain the human evidence needed to justify a threshold before setting one. Animal studies can reveal hazards, including dependence and respiratory depression, but they cannot, by themselves, identify a scientifically defensible cutoff for human consumption.

Officials may intend these thresholds to distinguish traditional kratom from concentrated products. What evidence shows that crossing that boundary justifies criminal penalties? 

The DEA also owes consumers an accounting of what prohibition could do to them. People seeking relief from pain or withdrawal will still need it after a ban. Some may abandon these products, while others may turn to illicit sellers or switch to other opioids. Criminalizing those choices could make them more dangerous.

Misleading labels, contamination, dependence, and drug interactions warrant attention. Accurate labeling, independent testing, age restrictions, and enforcement against fraud can address several of these concerns. Before resorting to criminal penalties, the DEA should explain why those measures would be inadequate.

We already know how difficult it is to verify a drug's identity, strength, and purity in an illicit market. Creating another prohibited product will give that market another opportunity.

Autonomous adults should be free to decide which substances they consume and which risks they accept. The DEA proposes taking that choice away even as it acknowledges major gaps in the medical evidence. Before the drug police turn more consumers into criminals, they should at least demonstrate how doing so will make those consumers safer.

The post The DEA Wants To Turn 7-OH Consumers Into Criminals appeared first on Reason Magazine.