Canada’s Success with Assisted Dying
Elaina Plott Calabro wrote an extensive expose in The Atlantic on the history and status of Medical Assistance in Dying, or MAiD as it is formally called, in Canada. It is a must read for anyone who desires to understand how medically assisted dying works in a country that has adopted and administered dying with dignity laws. The article describes the successes, the hurdles, and the work that still needs to be done to ease opposition and discomfort in the ever-evolving procedure that allows people to choose to die in peace with grace and dignity. Though Calabro’s article includes substantial objective data, I believe she could have presented a more balanced perspective on a highly emotional issue. She reported on several anecdotal personal accounts of the difficulties associated with MAiD, without highlighting an equal number of positive and peaceful end of life stories.
MAiD now accounts for about one in 20 deaths in Canada—more than Alzheimer’s and diabetes combined—surpassing countries where assisted dying has been legal for far longer. As of 2023, the last year for which data is available, some 60,300 Canadians had been legally helped to their death by clinicians. In Quebec, more than 7 percent of all deaths are by euthanasia—the highest rate of any jurisdiction in the world.
MAiD began in 2016 as a practice limited to gravely ill patients who were already at the end of life. The law was then expanded to include people who were suffering from serious medical conditions but not facing imminent death.
The expansion of MAiD to include individuals whose sole underlying condition is a mental illness was first proposed in 2022. Implementation of the law was delayed one year until 2023, then another year until 2024, and then has been delayed further until March 17, 2027. The delays are due to concerns about the readiness of the healthcare system to safely and adequately assess and provide MAiD in cases where mental illness is the sole underlying condition. The legislation also includes a provision for a parliamentary review of the system's readiness in 2026.
As Canada contends with unfolding claims on the right to die, the demand for euthanasia has begun to outstrip the capacity of clinicians to provide it. As occurs in other countries that have adopted assisted dying laws, many patients have difficulty finding qualified clinicians to conduct the evaluations and procedures. I recently posted a Substack article on a Colombian woman’s distressing journey to reach a dignified end to her life.
Calabro writes about some Canadian practitioners who believe the MAiD laws are too discretionary. She quotes one physician as stating that she supports MAiD when appropriate but is concerned that the federal government’s deferring of responsibility in managing it—allowing too much discretion to the clinicians to establish principles and standards and enforcing boundaries. As a retired attorney, I understand that when adopting innovative legislation, lawmakers are reluctant to draft overly comprehensive or restrictive policies, allowing instead for industry or society in general to adjust to the radical changes and provide feedback that may result in modified legislation. Lawmakers, after all, are far from experts in medicine, medical ethicists, or end of life issues.
This progression is exactly what is happening in Canada with MAiD. First, the law was expanded in 2021 to remove the requirement that a patient’s death “must be reasonably foreseeable,” establishing a Track 1 and Track 2 system of eligibility.
Next, in 2022, a change to include mental illness as an underlying condition was proposed as described above.
Canada’s Parliament’s Special Joint Committee on Medical Assistance in Dying has formally recommended expanding MAiD access to mature minors. In the committee’s 2023 report, following a series of hearings, lawmakers acknowledged the various factors that could affect young people’s capacity to evaluate their circumstances—for one, the adolescent brain’s far from fully developed faculties for “risk assessment and decision-making.” But they noted that, according to several parliamentary witnesses, children with serious medical conditions “tend to possess an uncommon level of maturity.” The committee advised that MAiD be limited (“at this stage”) to minors with reasonably foreseeable natural deaths, and endorsed a requirement for “parental consultation,” but not parental consent. As a lawyer with the College of Physicians and Surgeons of Saskatchewan told the committee, “Parents may be reluctant to consent to the death of their child.” Whether Canadian officials will eventually add mature minors to the eligibility list remains unclear.
Last year, the province of Quebec took the next step in what some regard as the “natural evolution” of MAID: the honoring of advance requests to be euthanized. Under the Quebec law, patients in the province with cognitive conditions such as Alzheimer’s can define a threshold they don’t wish to cross. Some people might request to die when they no longer recognize their children, for example; others might indicate incontinence as a benchmark. When the threshold seems to have been reached, perhaps after an alert from a “trusted third party,” a MAID practitioner determines whether the patient is indeed suffering intolerably according to the terms of the advance request. Since 2016, public demand for this expansion has been steady, fueled by the testimonies of those who have watched loved ones endure the full course of dementia and do not want to suffer the same fate.
In the early years of MAiD, the Canadian government had tried to forecast the country’s demand for assisted death. The first projection, in 2018, was that Canada’s MAiD rate would achieve a “steady state” of 2 percent of total deaths; then, in 2022, federal officials estimated that the rate would stabilize at 4 percent by 2033. After Canada blew past both numbers—the latter, 11 years ahead of schedule—officials simply stopped publishing predictions.
The original assumption was that euthanasia in Canada would follow roughly the same trajectory that euthanasia had followed in Belgium and the Netherlands. But even under those permissive regimes, the law requires that patients exhaust all available treatment options before seeking euthanasia. In Canada, where ensuring access has always been paramount, such a requirement was thought to be too much of an infringement on patient autonomy. Although Track 2 requires that patients be informed of possible alternative means of alleviating their suffering, it does not require that those options actually be made available. Last year, the Quebec government announced plans to spend nearly $1 million on a study of why so many people in the province are choosing to die by euthanasia.
As Calabro writes: “In the end, the most meaningful guardrails on MAiD may well turn out to be the providers themselves. Legislative will has generally been fixed in the direction of more; public opinion flickers in response to specific issues, but so far remains largely settled. If MAiD reaches a limit in Canada, it will happen only when practitioners decide what they can tolerate—morally or, in a system with a shrinking supply of providers, logistically. ‘You cannot ask us to provide at the rate we’re providing right now,’ Claude Rivard, who has decided not to accept advance requests, told me. ‘The limit will always be the evaluation and the provider. It will rest with them. They will have to do the evaluation, and they will have to say, ‘No, it’s not acceptable.’”
After all, at the end of a person’s life, it is a clinician—not a lawmaker or lawyer or pundit—who must administer the injection that stops a heart.
Assisted dying in Canada, and across the world, interweaves societal, familial, ethical, legal, and religious debates that are gaining urgency as nations around the world grapple with evolving assisted dying laws and more and more people are selecting to die voluntarily with peace and dignity. As much success as MAiD has achieved in Canada over the past decade, more progress needs to occur. Fortunately, the trajectory is moving in the right direction.