Volume 24, Number 4, April 2023 Supplement - Section II: Opinions

North America

A cautionary tale from Canada: MAiD, intended as an exceptional event to relieve intolerable suffering, is now commonplace. How about medical aid in living?

Romayne Gallagher
Palliative care physician (retired); Clinical Professor, Division of Palliative Care, Department of Family Medicine, University of British Columbia, British Columbia, Canada; member, Virtual Hospice Clinical Team

The survey questions, responses, and comments illustrate how end-of-life issues are so difficult to explore adequately in a survey. In Canada, we had very similar answers to similar questions, but what happened once our society crossed the red line is beyond what I would have imagined. I will focus my commentary on Canada’s experience as a cautionary tale for others.

Canada adopted euthanasia and physician-assisted suicide, called Medical Aid in Dying (MAiD) in 2016. The legislation was expanded in 2021 to include those without a foreseeable death, and some of the “safeguards”—such as a minimum 10-day period of reflection—have been dropped or abbreviated. This year the government was to grant access to MAiD for those with mental illness as their sole cause of suffering, but the federal government has paused the expansion. Within six years of allowing MAiD, it was attributed to 3.3% of all Canadian deaths, with some provinces approaching 5%: figures that do not yet fully reflect the death rate of the expanded criteria.

Access to MAiD has not improved access to or quality of palliative care. Government reporting on MAiD (short yes/no questionnaire filled out by MAiD providers) shows that 21% of persons receiving MAiD for a terminal illness received palliative care only in the last two weeks before life termination. For most people, that means they received palliative care after applying for MAiD. Academic studies have shown a lack of access to palliative care and high symptom burden among those granted MAiD. Government action on implementing palliative standards and indicators—essential for comparing data and raising quality—is lacking. Significant investments in building palliative capacity, particularly in rural and remote regions and lower-socioeconomic populations, is deficient.

Most palliative care providers view MAiD as separate from palliative care, yet advocates are framing MAiD as just another end-of-life decision. This view is not in keeping with the original legislation’s vision of an exceptional event to relieve intolerable suffering. Some health care regions have used this attempted conflation to fund assessments for MAiD from inadequate palliative care budgets, and have suggested that MAiD assessment/provision may be a condition of employment in palliative care programs. MAiD is regularly emphasized as a “right,” yet there is no equivalent right to quality palliative care or disability supports sufficient to live above the poverty line.

Though advocates for MAiD provide verbal support for the need for palliative care or disability support, many don’t see it as their responsibility to facilitate access, seeing patient autonomy as the ultimate and only card they are obliged to play. Some advocates insist that patients should be made aware of MAiD as part of informed consent, discounting the power and knowledge differential between patient and health care provider. Emphasizing the peaceful and romanticized death they can provide, it becomes a coercive answer to those suffering from the complexities of uncontrolled symptoms, losses, and daily challenges of chronic illness and disability.

In the last year, there have been increasing examples of those who have applied for, and received, MAiD because of inadequate quality of housing, health care at home, and access to therapies for their chronic conditions. So far, police, regulatory colleges, and governments have tossed this hot potato around with no resulting conclusions or charges. Post-pandemic health system inadequacies have met a permissive MAiD regime.

In Canada, the call to protect vulnerable people has been “weaponized” by MAiD advocates who promote themselves as champions of the rights of those with chronic illness or disability. Some have even suggested that palliative care providers “just want people to suffer.” Palliative care must promote itself as giving hope, courage, symptom relief, and the practical help to make life valuable and worth living to its natural completion: Medical Aid in Living. I urge you all to learn from Canada’s experience.

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