Canada Gave Citizens the Right to Die. Doctors Are Struggling to Meet Demand. - The Atlantic (aka "Canada Is Killing Itself.")
"The euthanasia conference was held at a Sheraton. Some 300 Canadian professionals, most of them clinicians, had arrived for the annual event. There were lunch buffets and complimentary tote bags; attendees could look forward to a Friday-night social outing, with a DJ, at an event space above Par-Tee Putt in downtown Vancouver. “The most important thing,” one doctor told me, “is the networking.”
Which is to say that it might have been any other convention in Canada. Over the past decade, practitioners of euthanasia have become as familiar as orthodontists or plastic surgeons are with the mundane rituals of lanyards and drink tickets and It’s been so long s outside the ballroom of a four-star hotel. The difference is that, 10 years ago, what many of the attendees here do for work would have been considered homicide.
When Canada’s Parliament in 2016 legalized the practice of euthanasia—Medical Assistance in Dying, or MAID, as it’s formally called—it launched an open-ended medical experiment. One day, administering a lethal injection to a patient was against the law; the next, it was as legitimate as a tonsillectomy, but often with less of a wait. 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.
It is too soon to call euthanasia a lifestyle option in Canada, but from the outset it has proved a case study in momentum. MAID began 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. In two years, MAID will be made available to those suffering only from mental illness. Parliament has also recommended granting access to minors.
At the center of the world’s fastest-growing euthanasia regime is the concept of patient autonomy. Honoring a patient’s wishes is of course a core value in medicine. But here it has become paramount, allowing Canada’s MAID advocates to push for expansion in terms that brook no argument, refracted through the language of equality, access, and compassion. As Canada contends with ever-evolving claims on the right to die, the demand for euthanasia has begun to outstrip the capacity of clinicians to provide it.
There have been unintended consequences: Some Canadians who cannot afford to manage their illness have sought doctors to end their life. In certain situations, clinicians have faced impossible ethical dilemmas. At the same time, medical professionals who decided early on to reorient their career toward assisted death no longer feel compelled to tiptoe around the full, energetic extent of their devotion to MAID...
Stefanie Green, a physician on Vancouver Island and one of the organization’s founders, told me how her decades as a maternity doctor had helped equip her for this new chapter in her career. In both fields, she explained, she was guiding a patient through an “essentially natural event”—the emotional and medical choreography “of the most important days in their life.” She continued the analogy: “I thought, Well, one is like delivering life into the world, and the other feels like transitioning and delivering life out.” And so Green does not refer to her MAID deaths only as “provisions”—the term for euthanasia that most clinicians have adopted. She also calls them “deliveries.”...
Has Canada itself gotten what it wanted? Nine years after the legalization of assisted death, Canada’s leaders seem to regard MAID from a strange, almost anthropological remove: as if the future of euthanasia is no more within their control than the laws of physics; as if continued expansion is not a reality the government is choosing so much as conceding. This is the story of an ideology in motion, of what happens when a nation enshrines a right before reckoning with the totality of its logic. If autonomy in death is sacrosanct, is there anyone who shouldn’t be helped to die?...
In Quebec, more than 7 percent of all deaths are by euthanasia—the highest rate of any jurisdiction in the world...
The new [2016] law approved medical assistance in dying for adults who had a “grievous and irremediable medical condition” causing them “intolerable suffering,” and who faced a “reasonably foreseeable” natural death. To qualify, patients needed two clinicians to sign off on their application, and the law required a 10-day “reflection period” before the procedure could take place. Patients could choose to die either by euthanasia—having a clinician administer the drugs directly—or, alternatively, by assisted suicide, in which a patient self-administers a lethal prescription orally. (Virtually all MAID deaths in Canada have been by euthanasia.) When the procedure was set to begin, patients were required to give final consent.
The law, in other words, was premised on the concept of patient autonomy, but within narrow boundaries. Rather than force someone with, say, late-stage cancer to suffer to the very end, MAID would allow patients to depart on their own terms: to experience a “dignified death,” as proponents called it. That the threshold of eligibility for MAID would be high—and stringent—was presented to the public as self-evident, although the criteria themselves were vague when you looked closely. For instance, what constituted “reasonably foreseeable”? Two months? Two years? Canada’s Department of Justice suggested only “a period of time that is not too remote.”
Provincial health authorities were left to fill in the blanks... Particularly vexing was the question of whether it should be clinicians or patients who initiated conversations about assisted death. Some argued that doctors and nurses had a professional obligation to broach the subject of MAID with potentially eligible patients, just as they would any other “treatment option.” Others feared that patients could interpret this as a recommendation—indeed, feared that talking about assisted death as a medical treatment, like Lasik surgery or a hip replacement, was dangerous in itself...
For proponents, Couvrette epitomized the ideal MAID candidate, motivated not by an impulsive death wish but by a considered desire to reclaim control of his fate from a terminal disease. The lobbying group Dying With Dignity Canada celebrated Couvrette’s “empowering choice and journey” as part of a showcase on its website of “good deaths” made possible by the new law. There was also the surgeon in Nova Scotia with Parkinson’s who “died the same way he lived—on his own terms.” And there were the Toronto couple in their 90s who, in a “dream ending to their storybook romance,” underwent MAID together.
Such heartfelt accounts tended to center on the white, educated, financially stable patients who represented the typical MAID recipient. The stories did not precisely capture what many clinicians were discovering also to be true: that if dying by MAID was dying with dignity, some deaths felt considerably more dignified than others. Not everyone has coastal homes or children and grandchildren who can gather in love and solidarity. This was made clear to Sandy Buchman, a palliative-care physician in Toronto, during one of his early MAID cases, when a patient, “all alone,” gave final consent from a mattress on the floor of a rental apartment. Buchman recalls having to kneel next to the mattress in the otherwise empty space to administer the drugs. “It was horrible,” he told me. “You can see how challenging, how awful, things can be.”...
There was a time when Madeline Li would have felt perfectly at home among the other clinicians who convened that weekend at the Sheraton. In the early years of MAID, few physicians exerted more influence over the new regime than Li. The Toronto-based cancer psychiatrist led the development of the MAID program at the University Health Network, the largest teaching-hospital system in Canada, and in 2017 saw her framework published in The New England Journal of Medicine.
It was not long into her practice, however, that Li’s confidence in the direction of her country’s MAID program began to falter. For all of her expertise, not even Li was sure what to do about a patient in his 30s whom she encountered in 2018.
The man had gone to the emergency room complaining of excruciating pain and was eventually diagnosed with cancer. The prognosis was good, a surgeon assured him, with a 65 percent chance of a cure. But the man said he didn’t want treatment; he wanted MAID. Startled, the surgeon referred him to a medical oncologist to discuss chemo; perhaps the man just didn’t want surgery. The patient proceeded to tell the medical oncologist that he didn’t want treatment of any kind; he wanted MAID. He said the same thing to a radiation oncologist, a palliative-care physician, and a psychiatrist, before finally complaining to the patient-relations department that the hospital was barring his access to MAID. Li arranged to meet with him.
Canada’s MAID law defines a “grievous and irremediable medical condition” in part as a “serious and incurable illness, disease, or disability.” As for what constitutes incurability, however, the law says nothing—and of the various textual ambiguities that caused anxiety for clinicians early on, this one ranked near the top. Did “incurable” mean a lack of any available treatment? Did it mean the likelihood of an available treatment not working? Prominent MAID advocates put forth what soon became the predominant interpretation: A medical condition was incurable if it could not be cured by means acceptable to the patient.
This had made sense to Li. If an elderly woman with chronic myelogenous leukemia had no wish to endure a highly toxic course of chemo and radiation, why should she be compelled to? But here was a young man with a likely curable cancer who nevertheless was adamant about dying. “I mean, he was so, so clear,” Li told me. “I talked to him about What if you had a 100 percent chance? Would you want treatment? And he said no.” He didn’t want to suffer through the treatment or the side effects, he explained; just having a colonoscopy had traumatized him. When Li assured the man that they could treat the side effects, he said she wasn’t understanding him: Yes, they could give him medication for the pain, but then he would have to first experience the pain. He didn’t want to experience the pain.
What was Li left with? According to prevailing standards, the man’s refusal to attempt treatment rendered his disease incurable and his natural death was reasonably foreseeable. He met the eligibility criteria as Li understood them. But the whole thing seemed wrong to her. Seeking advice, she described the basics of the case in a private email group for MAID practitioners under the heading “Eligible, but Reasonable?” “And what was very clear to me from the replies I got,” Li told me, “is that many people have no ethical or clinical qualms about this—that it’s all about a patient’s autonomy, and if a patient wants this, it’s not up to us to judge. We should provide.”
And so she did. She regretted her decision almost as soon as the man’s heart stopped beating. “What I’ve learned since is: Eligible doesn’t mean you should provide MAID,” Li told me. “You can be eligible because the law is so full of holes, but that doesn’t mean it clinically makes sense.” Li no longer interprets “incurable” as at the sole discretion of the patient. The problem, she feels, is that the law permits such a wide spectrum of interpretations to begin with. Many decisions about life and death turn on the personal values of practitioners and patients rather than on any objective medical criteria.
By 2020, Li had overseen hundreds of MAID cases, about 95 percent of which were “very straightforward,” she said. They involved people who had terminal conditions and wanted the same control in death as they’d enjoyed in life. It was the 5 percent that worried her—not just the young man, but vulnerable people more generally, whom the safeguards had possibly failed. Patients whose only “terminal condition,” really, was age. Li recalled an especially divisive early case for her team involving an elderly woman who’d fractured her hip. She understood that the rest of her life would mean becoming only weaker and enduring more falls, and she “just wasn’t going to have it.” The woman was approved for MAID on the basis of frailty.
Li had tried to understand the assessor’s reasoning. According to an actuarial table, the woman, given her age and medical circumstances, had a life expectancy of five or six more years. But what if the woman had been slightly younger and the number was closer to eight years—would the clinician have approved her then? “And they said, well, they weren’t sure, and that’s my point,” Li explained. “There’s no standard here; it’s just kind of up to you.” The concept of a “completed life, or being tired of life,” as sufficient for MAID is “controversial in Europe and theoretically not legal in Canada,” Li said. “But the truth is, it is legal in Canada. It always has been, and it’s happening in these frailty cases.”...
In 2014, when the question of medically assisted death had come before Canada’s supreme court, Etienne Montero, a civil-law professor and at the time the president of the European Institute of Bioethics, warned in testimony that the practice of euthanasia, once legal, was impossible to control. Montero had been retained by the attorney general of Canada to discuss the experience of assisted death in Belgium—how a regime that had begun with “extremely strict” criteria had steadily evolved, through loose interpretations and lax enforcement, to accommodate many of the very patients it had once pledged to protect. When a patient’s autonomy is paramount, Montero argued, expansion is inevitable: “Sooner or later, a patient’s repeated wish will take precedence over strict statutory conditions.” In the end, the Canadian justices were unmoved; Belgium’s “permissive” system, they contended, was the “product of a very different medico-legal culture” and therefore offered “little insight into how a Canadian regime might operate.” In a sense, this was correct: It took Belgium more than 20 years to reach an assisted-death rate of 3 percent. Canada needed only five.
In retrospect, the expansion of MAID would seem to have been inevitable; Justin Trudeau, then Canada’s prime minister, said as much back in 2016, when he called his country’s newly passed MAID law “a big first step” in what would be an “evolution.” Five years later, in March 2021, the government enacted a new two-track system of eligibility, relaxing existing safeguards and extending MAID to a broader swath of Canadians. Patients approved for an assisted death under Track 1, as it was now called—meaning the original end-of-life context—were no longer required to wait 10 days before receiving MAID; they could die on the day of approval. Track 2, meanwhile, legalized MAID for adults whose deaths were not reasonably foreseeable—people suffering from chronic pain, for example, or from certain neurological disorders. Although cost savings have never been mentioned as an explicit rationale for expansion, the parliamentary budget office anticipated annual savings in health-care costs of nearly $150 million as a result of the expanded MAID regime...
Track 2 introduced a web of moral complexities and clinical demands. For many practitioners, one major new factor was the sheer amount of time required to understand why the person before them—not terminally ill—was asking, at that particular moment, to die. Clinicians would have to untangle the physical experience of chronic illness and disability from the structural inequities and mental-health struggles that often attend it. In a system where access to social supports and medical services varies so widely, this was no small challenge, and many clinicians ultimately chose not to expand their practice to include Track 2 patients...
In 2023, Track 2 accounted for 622 MAID deaths in Canada—just over 4 percent of cases, up from 3.5 percent in 2022. Whether the proportion continues to rise is anyone’s guess. Some argue that primary-care providers are best positioned to negotiate the complexities of Track 2 cases, given their familiarity with the patient making the request—their family situation, medical history, social circumstances. This is how assisted death is typically approached in other countries, including Belgium and the Netherlands. But in Canada, the system largely developed around the MAID coordination centers assembled in the provinces, complete with 1-800 numbers for self-referrals. The result is that MAID assessors generally have no preexisting relationship with the patients they’re assessing.
How do you navigate, then, the hidden corridors of a stranger’s suffering? Claude Rivard told me about a Track 2 patient who had called to cancel his scheduled euthanasia. As a result of a motorcycle accident, the man could not walk; now blind, he was living in a long-term-care facility and rarely had visitors; he had been persistent in his request for MAID. But when his family learned that he’d applied and been approved, they started visiting him again. “And it changed everything,” Rivard said. He was in contact with his children again. He was in contact with his ex-wife again. “He decided, ‘No, I still have pleasure in life, because the family, the kids are coming; even if I can’t see them, I can touch them, and I can talk to them, so I’m changing my mind.’ ”
I asked Rivard whether this turn of events—the apparent plasticity of the man’s desire to die—had given him pause about approving the patient for MAID in the first place. Not at all, he said. “I had no control on what the family was going to do.”
Some of the opposition to MAID in Canada is religious in character. The Catholic Church condemns euthanasia, though Church influence in Canada, as elsewhere, has waned dramatically, particularly where it was once strongest, in Quebec. But from the outset there were other concerns, chief among them the worry that assisted death, originally authorized for one class of patient, would eventually become legal for a great many others too. National disability-rights groups warned that Canadians with physical and intellectual disabilities—people whose lives were already undervalued in society, and of whom 17 percent live in poverty—would be at particular risk. As assisted death became “sanitized,” one group argued, “more and more will be encouraged to choose this option, further entrenching the ‘better off dead’ message in public consciousness.”
For these critics, the “reasonably foreseeable” death requirement had been the solitary consolation in an otherwise lost constitutional battle. The elimination of that protection with the creation of Track 2 reinforced their conviction that MAID would result in Canada’s most marginalized citizens being subtly coerced into premature death. Canadian officials acknowledged these concerns—“We know that in some places in our country, it’s easier to access MAID than it is to get a wheelchair,” Carla Qualtrough, the disability-inclusion minister, admitted in 2020—but reiterated that socioeconomic suffering was not a legal basis for MAID. Justin Trudeau took pains to assure the public that patients were not being backed into assisted death because of their inability to afford proper housing, say, or get timely access to medical care. It “simply isn’t something that ends up happening,” he said.
Sathya Dhara Kovac, of Winnipeg, knew otherwise. Before dying by MAID in 2022, at the age of 44, Kovac wrote her own obituary. She explained that life with ALS had “not been easy”; it was, as far as illnesses went, a “shitty” one. But the illness itself was not the reason she wanted to die. Kovac told the local press prior to being euthanized that she had fought unsuccessfully to get adequate home-care services; she needed more than the 55 hours a week covered by the province, couldn’t afford the cost of a private agency to take care of the balance, and didn’t want to be relegated to a long-term-care facility. “Ultimately it was not a genetic disease that took me out, it was a system,” Kovac wrote. “I could have had more time if I had more help.”
Earlier this spring, I met in Vancouver with Marcia Doherty; she was approved for Track 2 MAID shortly after it was legalized, four years ago. The 57-year-old has suffered for most of her life from complex chronic illnesses, including myalgic encephalomyelitis, fibromyalgia, and Epstein-Barr virus. Her daily experience of pain is so total that it is best captured in terms of what doesn’t hurt (the tips of her ears; sometimes the tip of her nose) as opposed to all the places that do. Yet at the core of her suffering is not only the pain itself, Doherty told me; it’s that, as the years go by, she can’t afford the cost of managing it. Only a fraction of the treatments she relies on are covered by her province’s health-care plan, and with monthly disability assistance her only consistent income, she is overwhelmed with medical debt. Doherty understands that someday, the pressure may simply become too much. “I didn’t apply for MAID because I want to be dead,” she told me. “I applied for MAID on ruthless practicality.”
It is difficult to understand MAID in such circumstances as a triumphant act of autonomy—as if the state, by facilitating death where it has failed to provide adequate resources to live, has somehow given its most vulnerable citizens the dignity of choice. In January 2024, a quadriplegic man named Normand Meunier entered a Quebec hospital with a respiratory infection; after four days confined to an emergency-room stretcher, unable to secure a proper mattress despite his partner’s pleas, he developed a painful bedsore that led him to apply for MAID. “I don’t want to be a burden,” he told Radio-Canada the day before he was euthanized, that March.
Nearly half of all Canadians who have died by MAID viewed themselves as a burden on family and friends. For some disabled citizens, the availability of assisted death has sowed doubt about how the medical establishment itself sees them—about whether their lives are in fact considered worthy of saving. In the fall of 2022, a 49-year-old Nova Scotia woman who is physically disabled and had recently been diagnosed with breast cancer was readying for a lifesaving mastectomy when a member of her surgical team began working through a list of pre-op questions about her medications and the last time she ate—and was she familiar with medical assistance in dying? The woman told me she felt suddenly and acutely aware of her body, the tissue-thin gown that wouldn’t close. “It left me feeling like maybe I should be second-guessing my decision,” she recalled. “It was the thing I was thinking about as I went under; when I woke up, it was the first thought in my head.” Fifteen months later, when the woman returned for a second mastectomy, she was again asked if she was aware of MAID. Today she still wonders if, were she not disabled, the question would even have been asked. Gus Grant, the registrar and CEO of the College of Physicians and Surgeons of Nova Scotia, has said that the timing of the queries to this woman was “clearly inappropriate and insensitive,” but he also emphasized that “there’s a difference between raising the topic of discussing awareness about MAID, and possible eligibility, from offering MAID.”
And yet there is also a reason why, in some countries, clinicians are either expressly prohibited or generally discouraged from initiating conversations about assisted death. However sensitively the subject is broached, death never presents itself neutrally; to regard the line between an “offer” and a simple recitation of information as somehow self-evident is to ignore this fact, as well as the power imbalance that freights a health professional’s every gesture with profound meaning. Perhaps the now-suspended Veterans Affairs caseworker who, in 2022, was found by the department to have “inappropriately raised” MAID with several service members had meant no harm. But according to testimony, one combat veteran was so shaken by the exchange—he had called seeking support for his ailments and was not suicidal, but was told that MAID was preferable to “blowing your brains out”—that he left the country.
In 2023, Kathrin Mentler, who lives with concurrent mental and physical disabilities, including rheumatoid arthritis and other forms of chronic pain, arrived at Vancouver General Hospital asking for help amid a suicidal crisis. Mentler has stated in a sworn affidavit that the hospital clinician who performed the intake told her that although they could contact the on-call psychiatrist, no beds were available in the unit. The clinician then asked if Mentler had ever considered MAID, describing it as a “peaceful” process compared with her recent suicide attempt via overdose, for which she’d been hospitalized. Mentler said that she left the hospital in a “panic,” and that the encounter had validated many of her worst fears: that she was a “burden” on an overtaxed system and that it would be “reasonable” for her to want to die. (In response to press reports about Mentler’s experience, the regional health authority said that the conversation was part of a “clinical evaluation” to assess suicide risk and that staff are required to “explore all available care options” with patients.)...
The United Nations Committee on the Rights of Persons With Disabilities formally called for the repeal of Track 2 MAID in Canada—arguing that the federal government had “fundamentally changed” the premise of assisted dying on the basis of “negative, ableist perceptions of the quality and value” of disabled lives, without addressing the systemic inequalities that amplify their perceived suffering...
Ellen Wiebe never had reservations about taking on Track 2 cases—indeed, unlike most clinicians, she never had reservations about providing MAID at all. The Vancouver-based family physician had long been comfortable with controversy, having spent the bulk of her four decades in medicine as an abortion provider... Coordinators also call her when they have a patient whose previous MAID requests were rejected. (There is no limit to how many times a person can apply for MAID.) “Because I’m me, you know, they send those down to Ellen Wiebe,” she told me. I asked her what she meant by that. “My reputation,” she replied...
On her formal application, the woman gave “akathisia”—a movement disorder characterized by intense feelings of inner restlessness and an inability to sit still, commonly caused by withdrawal from antipsychotic medication—as her reason for requesting an assisted death. According to court filings, no one the woman knew was willing to witness her sign the application form, as the law requires, so Wiebe had a volunteer at her clinic do so over Zoom. And because the woman still needed another physician or nurse practitioner to declare her eligible, Wiebe arranged for Elizabeth Whynot, a fellow family physician in Vancouver, to provide the second assessment. The patient was approved for MAID after a video call, and the procedure was set for October 27, 2024, in Wiebe’s clinic.
Following the approval, detailed in the court filings, the Alberta woman had another Zoom call with Wiebe; this time, her husband joined the conversation. He had concerns, specifically as to how akathisia qualified as “irremediable.” Specialists had assured the woman that if she committed to the gradual tapering protocol they’d prescribed, she could very likely expect relief within months. The husband also worried that Wiebe hadn’t sufficiently considered his wife’s unresolved mental-health issues, and whether she was capable, in her present state, of giving truly informed consent. The day before his wife was scheduled to die, he petitioned a Vancouver judge to halt the procedure, arguing that Wiebe had negligently approved the woman on the basis of a condition that did not qualify for MAID. In a widely publicized decision, the next morning the judge issued a last-minute injunction blocking Wiebe or any other clinician from carrying out the woman’s death as scheduled. “I can only imagine the pain she has been experiencing, and I recognize that this injunction will likely only make that worse,” the judge wrote. But there was an “arguable case,” he concluded, as to whether the criteria for MAID had been “properly applied in the circumstances.”...
A number of similar lawsuits have been filed in recent years as Canadians come to terms with the hollow oversight of MAID. Because no formal procedure exists for challenging an approval in advance of a provision, many concerned family members see little choice but to take a loved one to court to try to halt a scheduled death. What oversight does exist takes place at the provincial or territorial level, and only after the fact. Protocols differ significantly across jurisdictions. In Ontario, the chief coroner’s office oversees a system in which all Track 2 cases are automatically referred to a multidisciplinary committee for postmortem scrutiny. Since 2018, the coroner’s office has identified more than 480 compliance issues involving federal and provincial MAID policies, including clinicians failing to consult with an expert in their patient’s condition prior to approval—a key Track 2 safeguard—and using the wrong drugs in a provision. The office’s death-review committee periodically publishes summaries of particular cases, for both Track 1 and Track 2, to “generate discussion” for “practical improvement.”
There was, for example, the case of Mr. C, a man in his 70s who, in 2024, requested MAID while receiving in-hospital palliative care for metastatic cancer. It should have been a straightforward Track 1 case. But two days after his request, according to the committee’s report, the man experienced sharp cognitive decline and lost the ability to communicate, his eyes opening only in response to painful stimuli. His palliative-care team deemed him incapable of consenting to health-care decisions, including final permission for MAID. Despite that conclusion, a MAID clinician proceeded with the assessment, “vigorously” rousing the man to ask if he still wanted euthanasia (to which the man mouthed “yes”), and then withholding the man’s pain medication until he appeared “more alert.” After confirming the man’s wishes via “short verbal statements” and “head nods and blinking,” the assessor approved him for MAID; with sign-off from a second clinician, and a final consent from Mr. C mouthing “yes,” he was euthanized.
Had this patient clearly consented to his death? Finding no documentation of a “rigorous evaluation of capacity,” the death-review committee expressed “concerns” about the process. The implication would seem startling—in a regime animated at its core by patient autonomy, a man was not credibly found to have exercised his own. Yet Mr. C’s death was reduced essentially to a matter of academic inquiry, an opportunity for “lessons learned.” Of the hundreds of irregularities flagged over the years by the coroner’s office, almost all have been dealt with through an “Informal Conversation,” an “Educational Email,” or a “Notice Email,” depending on their severity. Specific sanctions are not made public. No case has ever been referred to law enforcement for investigation.
Wiebe acknowledged that several complaints have been filed against her over the years but noted that she has never been found guilty of wrongdoing. “And if a lawyer says, ‘Oh—I disagreed with some of those things,’ I’d say, ‘Well, they didn’t put lawyers in charge of this.’ ” She laughed. “We were the ones trusted with the safeguards.” And the law was clear, Wiebe said: “If the assessor”—meaning herself—“believes that they qualify, then I’m not guilty of a crime.”
Despite all of the questions surrounding Track 2, Canada is proceeding with the expansion of MAID to additional categories of patients while gauging public interest in even more. As early as 2016, the federal government had agreed to launch exploratory investigations into the possible future provision of MAID for people whose sole underlying medical condition is a mental disorder, as well as to “mature minors,” people younger than 18 who are “deemed to have requisite decision-making capacity.” The government also pledged to consider “advance requests”—that is, allowing people to consent now to receive MAID at some specified future point when their illness renders them incapable of making or affirming the decision to die. Meanwhile, the Quebec College of Physicians has raised the possibility of legalizing euthanasia for infants born with “severe malformations,” a rare practice currently legal only in the Netherlands, the first country to adopt it since Nazi Germany did so in 1939.
As part of Track 2 legislation in 2021, lawmakers extended eligibility—to take effect at some point in the future—to Canadians suffering from mental illness alone. This, despite the submissions of many of the nation’s top psychiatric and mental-health organizations that no evidence-based standard exists for determining whether a psychiatric condition is irremediable. A number of experts also shared concerns about whether it was possible to credibly distinguish between suicidal ideation and a desire for MAID...
What all sides do agree on is that, in practice, mental disorders are already a regular feature of Canada’s MAID regime...
The argument was meant to assuage concerns about clinical readiness. For critics, however, it only reinforced a belief that, in some cases, physical conditions are simply being used to bear the legal weight of a different, ineligible basis for MAID, including mental disorders. In one of Canada’s more controversial cases, a 61-year-old man named Alan Nichols, who had a history of depression and other conditions, applied for MAID in 2019 while on suicide watch at a British Columbia hospital. A few weeks later, he was euthanized on the basis of “hearing loss.”
As Canadians await the rollout of psychiatric MAID, 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. At the moment, their attention is largely focused on a different category of expansion. 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 parliamentary hearings, Quebec officials have discussed the potential problem of “pleasant dementia,” acknowledging that it might be difficult for a provider to euthanize someone who “seems happy” and “absolutely doesn’t remember” consenting to an assisted death earlier in their illness. Quebec officials have also discussed the issue of resistance. The Netherlands, the only other jurisdiction where euthanizing an incapable but conscious person as a result of an advance request is legal, offers an example of what MAID in such a circumstance could look like.
In 2016, a geriatrician in the Netherlands euthanized an elderly woman with Alzheimer’s who, four years earlier, shortly after being diagnosed, had advised that she wanted to die when she was “no longer able to live at home.” Eventually, the woman was admitted to a nursing home, and her husband duly asked the facility’s geriatrician to initiate MAID. The geriatrician, along with two other doctors, agreed that the woman was “suffering hopelessly and intolerably.” On the day of the euthanasia, the geriatrician decided to add a sedative surreptitiously to the woman’s coffee; it was given to “prevent a struggle,” the doctor would later explain, and surreptitiously because the woman would have “asked questions” and “refused to take it.” But as the injections began, the woman reacted and tried to sit up. Her family helped hold her down until the procedure was over and she was dead. The case prompted the first criminal investigation under the country’s euthanasia law. The physician was acquitted by a district court in 2019, and that decision was upheld by the Dutch supreme court the following year.
In Quebec, more than 100 advance requests have been filed; according to several sources, at least one has been carried out. The law currently states that any sign of refusal “must be respected”; at the same time, if the clinician determines that expressions of resistance are “behavioural symptoms” of a patient’s illness, and not necessarily an actual objection to receiving MAID, the euthanasia can continue anyway. The Canadian Association of MAiD Assessors and Providers has stated that “pre-sedating the person with medications such as benzodiazepines may be warranted to avoid potential behaviours that may result from misunderstanding.”
Laurent Boisvert, an emergency physician in Montreal who has euthanized some 600 people since 2015, told me that he has thus far helped seven patients, recently diagnosed with Alzheimer’s, to file advance requests, and that they included clear instructions on what he is to do in the event of resistance. He is not concerned about potentially encountering happy dementia. “It doesn’t exist,” he said.
The Canadian government had tried, in the early years of MAID, 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.
And yet it was never clear how Canadians were meant to understand their country’s assisted-death rate: whether, in the government’s view, there is such a thing as too much MAID. In parliamentary hearings, federal officials have indicated that a national rate of 7 percent—the rate already reached in Quebec—might be potentially “concerning” and “wise and prudent to look into,” but did not elaborate further. If Canadian leaders feel viscerally troubled by a certain prevalence of euthanasia, they seem reluctant to explain why.
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. The announcement came shortly after Michel Bureau, who heads Quebec’s MAID-oversight committee, expressed concern that assisted death is no longer viewed as an option of last resort. But had it ever been?
It doesn’t feel quite right to say that Canada slid down a slippery slope, because keeping off the slope never seems to have been the priority. But on one point Etienne Montero, the former head of the European Institute of Bioethics, was correct: When autonomy is entrenched as the guiding principle, exclusions and safeguards eventually begin to seem arbitrary and even cruel. This is the tension inherent in the euthanasia debate, the reason why the practice, once set in motion, becomes exceedingly difficult to restrain. As Canada’s former Liberal Senate leader James Cowan once put it: “How can we turn away and ignore the pleas of suffering Canadians?”
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."
The "myth" of the slippery slope strikes again
Politicians can't do anything when an activist judiciary is pushing things along
Left wingers like to claim that capital punishment is wrong because there's a vague chance that someone might be wrongly executed, but this form of state homicide is good
Euthanasia is a "care option". So at some point if you refuse to perform MAID, you can be accused of refusing to provide "basic healthcare", as with abortion today
