Does Canada's medical assistance in dying (MAiD) program harm the most vulnerable?
Content warning:Explicit and extensive discussion of suicide
On October 4, 2022, the CBC released a shocking story. A 44-year-old woman from Winnipeg named Sathya Dhara Kovac chose to undergo medical assistance in dying (MAiD) after living her whole life with amyotrophic lateral sclerosis (ALS).1 Hoye, 2022. “Winnipeg woman who chose to die with medical assistance said struggle for home care help led to decision”. CBC. Oct 4, 2022. ALS is a highly debilitating degenerative condition and it has also afflicted her mother, grandmother, and uncle. She died that week surrounded by her friends, a photo of her dog, candles, and crystals. Her friend, Janine LeGal, stated that Sathya had actually believed “she could have been around for several more years” but had purposely withheld this from the medical panel because she was afraid they would have denied her request.
Sathya had received 55 hours of home care support every week but as her ALS progressed, her needs increased and she could not afford any private care beyond the public health system. When she spoke with the ALS Society, officials recommended that she move out of her home into a long-term care facility called the Riverview Health Centre, despite her express wishes to remain at home and in her community. Sathya had felt humiliated and hurt.
Her true reason for choosing MAiD was a lack of proper home care and support. Sathya had written an obituary which made it clear that it could’ve been different: “Ultimately it was not a genetic disease that took me out, it was a system.”
MAiD has made Canadian headlines as the federal government is expanding MAiD law starting March 2023 to include eligibility for both nonterminal conditions and mental illnesses. This has been a controversial move, alarming mental health professionals and ethicists.2Various forms of medically assisted death began to be made available in countries with more developed welfare states at the start of this century, including the Netherlands, Belgium, Luxembourg, Colombia, and others. Generally these take the form of euthanasia programs, which place strong limits on the procedure, such as saying that only those with terminal diseases that would have killed them anyway can receive the assistance to help them die less painfully and with more dignity. Other places allow for what gets called “assisted suicide” or “assistance in dying,” that is, when the patients themselves cause their death by their choice rather than any preexisting disease and the doctors merely facilitate this. Generally these, too, have restrictions focusing on patient autonomy. Canada’s expanded MAiD is now arguably the loosest and most expansive assisted suicide program in the world. Socialists seem to find themselves on either side of this issue, as you can see in the pages of Jacobin: many Canadian socialists have called out the problems with MAiD (Jeremy Appel, “The Problems With Canada’s Medical Assistance in Dying Policy,” 8 January 2023), while Spanish socialists have actually pushed for the creation of a euthanasia program in their country, albeit a more typically restrictive one (Jordan G. Teicher, “We All Deserve a Death With Dignity,” 5 April 2021). -Eds.
But what does the administration of MAiD truly mean? Why would a society want to provide this?
Many proponents of MAiD argue that it is a procedure that can provide a sick or dying person with autonomy to make healthcare decisions, even if their decision is ultimately to end their life. When a patient gives informed consent, they are able to control the circumstances of their death. This comes from the idea that a person has the “right to die with dignity”, which for some may be to simply remove support systems or be given a lethal pill.3 Rodriquez. “The Arguments for Euthanasia and Physician-Assisted Suicide: Ethical Reflections.” The Linacre Quarterly 68, no. 3 (2001): 7. Another important factor is that MAiD is a medical procedure which occurs in a safe environment, while a self-inflicted suicidal action is not.4 Dugdale et al. “Focus: Death: Pros and Cons of Physician Aid in Dying.” The Yale journal of biology and medicine 92, no. 4 (2019): 747.
Canada’s MAiD legislation has developed and expanded since it was first legalized in 2016.5 Ontario Ministry of Health. “Medical Assistance in Dying”. In February 2021, the federal government received Royal Assent to expand MAiD for people with disabilities in Bill C-7, removing the requirement of “imminent” death to provide the option of MAiD for patients with non-terminal physical conditions with chronic pain.
The most updated statistics from the federal government show that 10,029 MAiD deaths occurred in Canada in 2021, up about 34.7% from 2020.6 Statistics Canada. “Medical Assistance in Dying, 2021”. In March 2023, Canada was due to allow people with solely a mental illness to apply for MAiD.
To be approved for MAiD, a person must have: “serious and incurable disease, illness or disability” and “an advanced state of irreversible decline in capability”, according to the federal government.7 Government of Canada. “Final Report of the Expert Panel on MAiD and Mental Illness”. May 6, 2022. The applicants have to be approved by two assessors and must have the competence to make the decision following a 90-day assessment. The assessment of competence includes analysis of whether the person fully comprehends the condition that they have, including the prognosis, their choices, and the ability to give consent to receive an assisted death. People who have treatment-resistant mental illness would likely qualify.
The news has been met with controversy. Many healthcare professionals have pointed out that the current guidelines for determining eligibility for MAiD are not clear and concise enough.8 Jones. “Most don’t support latest planned MAID expansion: survey”. CTV News. February 13, 2023. Others point out that treatment for an illness is not solely medical. According to the provincial New Democratic Party (NDP) leader Wab Kinew, stories like Sathya’s highlight the importance of investing into home care services and increasing support for people living with illness and disability. A professor and director of the interdisciplinary master’s program in disability studies at the University of Manitoba, Nancy Hansen, states that MAiD appears to be a “sort of simplistic solution to something that requires more creative thinking.”
Some, like John Scully, are happy to have a chance to have the option.9 Favaro. “The Death Debate: why some welcome Canada’s move to assisted dying for mental illness and others fear it”. CTV News. CTV National News Medical Correspondent. October 15, 2022. As an 81-year-old journalist who has struggled with anxiety, depression, PTSD, and suicidal ideation for 35 years, he has already begun his paperwork and even received the approval of his two children and wife. He has attempted suicide twice, been hospitalized seven times, received counselling, and received 19 electroconvulsive therapy (ECT) treatments; now, he takes 30 pills per day. He is not alone – CTV reports that many Canadians with debilitating mental illnesses could potentially welcome the option of assisted death.
Others, however, are highly critical of what they call “state-sanctioned suicide.” John Maher, a psychiatrist at the Canadian Mental Health Association, has pointed out the danger of providing MAiD at a time when health services are constantly strained. The wait times for various treatment programs in Ontario are up to five years – longer than most medical specialists.10 Maher. “Why legalizing medically assisted dying for people with mental illness is misguided”. CBC. February 11, 2020. The underlying message, Maher shows, slowly reveals itself to be: “MAID is cheaper than caring.”11 Maher. “MAID is cheaper than caring”. The Hamilton Spectator. January 4, 2022.
Could providing MAiD empower a suicidal person to complete their suicide rather than provide support? The MAiD administrator essentially becomes “the sanitized gun with a white coat,” Maher told the Canadian Medical Health Association.12 Maher. “From pallbearer to psychiatrist: How childhood loss propels one of Canada’s leading medical ethicists”. Canadian Medical Health Association. May 3, 2021. He has also pointed out that the parameters for determining if a person has irremediable illness can be blurry. Many mental illnesses work in cycles, with ups and downs which lead many to suffer in bursts. A person could experience a rough period, which could drive them to apply for MAID and qualify.
Discussion of assisted death could backfire in other ways. For example, can discussion of suicide increase the likelihood of a suicide attempt? In short, the answer is that it depends on how it is discussed. Historically, psychiatrists and physicians have generally avoided discussing suicide under the assumption that discussing it can encourage thoughts of suicide. But this has largely been a misconception. According to peer-reviewed studies involving thousands of participants, discussing suicidality in an educational program can actually decrease the likelihood of a person attempting it.13 Dazzi et al. “Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?.” Psychological medicine 44, no. 16 (2014): 3361-3363. A 2012 study found that interventions and outreach programs specifically decrease the levels of suicidality.14 Mathias et al. “What’s the harm in asking about suicidal ideation?.” Suicide and Life‐Threatening Behavior 42, no. 3 (2012): 341-351. Even simply speaking about life experiences in an interview setting with a professional could significantly reduce feelings of suicidality in participants according to a 2013 peer-reviewed study.15 Biddle et al. “Qualitative interviewing with vulnerable populations: Individuals’ experiences of participating in suicide and self-harm based research.” Journal of affective disorders 145, no. 3 (2013): 356-362.
This has additional dimensions. Suicidal “contagion” is a phenomenon where reporting of suicide is sometimes followed with an increase in suicide rates among the general public.16 Gould & Lake. “The Contagion of Suicidal Behavior” Contagion of Violence: Workshop Summary. February 6, 2013. This effect is often seen when the news media report about the suicide of celebrities or beloved figures; consequently, repetitive reporting and positive portrayals of these events can push a person with a history of attempts or major depression into another attempt. However, when news media portrayed suicide as an anomalous behavior or focused on negative consequences of suicide, there were fewer rates of attempts.
As mentioned earlier, many consider MAiD a tool for preventing unsafe, non-assisted suicides – but does the evidence actually support this? According to a 2022 study, European countries showed an increase in non-assisted suicide, with female patients having a greater risk of “avoidable premature death.”17 Jones. “Euthanasia, assisted suicide, and suicide rates in Europe.” Journal of Ethics in Mental Health 11 (2022): 1-35. Furthermore, other systemic factors can significantly push a struggling person towards choosing suicidality. One 2020 peer-reviewed study looked at 34,653 US adults and found that suicide attempts were strongly associated with financial debts or crises, past homelessness, unemployment, and lower income.18 Elbogen et al. “Financial strain and suicide attempts in a nationally representative sample of US adults.” American Journal of Epidemiology 189, no. 11 (2020): 1266-1274. People who experienced all 4 of these variables were 20 times more likely to attempt suicide than those who experienced none. Thus, a person may be compelled to consider premature death not only because of their mental illness but also a lack of social support, which can be integral; social support is incredibly beneficial in preventing major adverse events for patients with depression.19 Cleary et al. “Polygenic Risk and Social Support in Predicting Depression Under Stress.” American Journal of Psychiatry (2023): appi-ajp.
Opponents of MAiD also point out that MAiD acted as an easy solution to social problems evenbefore it was expanded for mental illness. This even includes some MAiD providers. Madeline Li, a medical doctor at the University Health Network and head of the MAiD program, has maintained her belief that the removal of reasonably foreseeable death from the previous MAiD bills was highly unethical As she has stated, “If your suffering is because you can’t afford your medication, or other structural vulnerabilities only indirectly related to a medical condition, is that a good reason for MAID?”20 Agrba. “I am a MAID provider. It’s the most meaningful—and maddening—work I do. Here’s why” Macleans. February 13, 2023.21Even amongst terminally ill patients, research has observed that the desire to live often fluctuates significantly in as little as a few weeks. See: Rosenfeld et al. “Does desire for hastened death change in terminally ill cancer patients?.” Social Science & Medicine 111 (2014): 35-40. https://doi.org/10.1016/j.socscimed.2014.03.027
Gerard Quinn, a UN watchdog, responded in 2021 to the Canadian government once the Bill C-7 was expanded for people whose death is not imminent.22 CBC Radio. “As Bill C-7 reaches Senate, UN watchdog raises concerns about MAiD for persons with disabilities” February 2, 2021. He pointed out that in a living situation lacking basic services for managing a health condition, the “architecture of choice” is rigged towards choosing assisted death. People will not be freely able to choose assisted dying but rather will be made to choose because of a lack of resources. As he points out, Bill C-7 rests on a “very pernicious assumption” that a disabled person’s life is “somehow worth less than somebody else’s life.”
The UN subsequently sent a note to the Canadian government, stating that “It is not beyond possibility that, if offered an expanded right as per Bill C-7, persons with disabilities may decide to end their lives because of broader social factors such as loneliness, social isolation and lack of access to quality social services.”23 Mulligan & Bond. “Ethics of medically-assisted death questioned as some turn to it as an alternative to poverty” CityNews, October 15, 2022.
There have already been some potential examples of this trend. In October 2022, a 54-year-old man named Amir Farsoud from St. Catharines, Ontario spoke out about having to apply for MAiD.24 Mulligan & Bond. “Ontario man applying for medically-assisted death as alternative to being homeless”. CityNews, October 14, 2022. After suffering a debilitating back injury, he reported that he often is “crying like a 5-year-old and not sleeping for days in a row.” He also suffers from depression and anxiety and reports his life is “awful, non-existent, and terrible.” But his medical quality of life is decidedly not the reason for applying to MAiD. Despite living on social assistance in a home shared with two other people, he cannot afford his housing and is in danger of becoming homeless. As he has stated, “I don’t want to die, but I don’t want to be homeless more than I don’t want to die.” If he had had stable housing, he wouldn’t “even be close” to considering MAiD. Patients like Amir cannot ethically be said to have given free consent for MAiD. Consent must be freely given – not coerced or held up as the only option.
Health outcomes are commonly impacted by social determinants including policies and systems in place for basic needs such as food and housing.25 World Health Organization. “Social Determinants of Health”. Canada provides some financial support to patients, but it is often fixed without any adjustment for inflation rates and therefore remains astonishingly low – in some provinces, lower than the minimum wage.26 Madeline. “Canadians with disabilities, like me, are choosing to die because we can’t afford to live”. QuoiMedia, November 19, 2021. 27Northcott. “High inflation is hitting people on fixed disability benefits hard”. CBC News, April 23, 2022. In parts of Canada where healthcare services are declining, patients with a previously enriching and happy life now feel that they are neglected – and are more likely to resort to MAiD.28 Roy. “’I can’t live that way’: Montreal man seeking medically assisted death due to home care conditions”. CTV News, October 3, 2022.
There are also alarming cases of MAiD being pushed on disabled Canadians. Retired corporal and paralympian Christine Gauthier had been speaking with a Veteran Affairs Canada (VAC) case worker about getting a wheelchair ramp installed in her house – which she had been trying to get for five years – who subsequently suggested MAiD to her, “even offering to supply the MAID equipment for her.”29 Yun. “Paralympian trying to get wheelchair ramp says Veterans Affairs employee offered her assisted dying”. CTV News, December 2, 2022. VAC then admitted to offering MAiD to “at least four other veterans.” Not only was MAiD not a VAC service, but only physicians and nurse practitioners should be performing the procedure after a lengthy assessment and discussion. As Gauthier expressed to CTV News, “you’re going to be helping me to die but you won’t help me to live?” The situation was so outrageous that Prime Minister Trudeau had responded, calling it “absolutely unacceptable.”
In contrast, countries who have amped up their support for mentally ill or chronically disabled citizens have seen a positive effect. For example, following an economic crisis in the 1990s, Japan’s suicide rates skyrocketed, with a peak of 40.1 deaths per 100,000 males in 2003.30 Kato & Okada. “Can financial support reduce suicide mortality rates?.” International journal of environmental research and public health 16, no. 23 (2019): 4797. In 2006, the country introduced the several countermeasure programs including the General Policies for Comprehensive Measures Against Suicide in 2007 and the Second Comprehensive Suicide Prevention Policy in 2012, the latter of which had a budget of over $216 million per year. After providing intensive research for suicide prevention, medical service and support for suicidal individuals and a detection system for high-risk individuals, the suicide rates in Japan decreased from approximately 26 per 100,000 in 2000-2009 to about 16.5 per 100,000 in 2018.
As of now, due to much backlash, the federal government has delayed the expansion of Bill C-7 until March 2024 to develop more coherent practice standards for assessing MAiD applications.31 Fraser. “Liberals table bill delaying assisted dying expansion to March 2024”. CTV News, February 2, 2023. It increasingly appears that MAiD in Canada has become a procedure that is not freely chosen but simply offered as an easy, dismissive fix for significant systemic failures to provide social support. Before expanding a tool such as MAiD, the federal government has a duty to address systemic inequalities that can skew a person’s decision-making with regards to MAiD. Dying with dignity is important to ensure that we have control over the circumstances of our deaths. But it is equally important for us to control the circumstances of our lives. ~
Zhala is a Clinical Research Coordinator based in Toronto. She enjoys helping others find their voice and is on the board of directors of Ripple Foundation, an educational non-profit that brings creative writing workshops to kids. In her own writing, she explores scientific research, while contextualizing the impacts of storytelling and institutional outcomes on people's wellbeing and opportunities. She enjoys hiking, writing, traveling, and playing the piano.