Medical assistance in dying in Canada: too much, too fast?

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Canada will expand eligibility for medical assistance in dying (MAID) in 2023 to include people with a mental disorder as the sole underlying condition. The change is fueling the MAID debate, which has been simmering among practitioners and the public since the law came into effect in 2016.

The data suggests that approximately 80% of Canadians support to make their own end-of-life decisions; however, this support is nuanced, according to Canadian think tank Cardus. While 33% are “enthusiastic supporters” of MAID, 48% are “cautious supporters” who “express serious concerns about how MAID could harm aging and vulnerable Canadians and the health care system.” Canadian health”.


Dr. Donna Wilson

Donna M. Wilson, RN, PhD, a professor in the Faculty of Nursing at the University of Alberta in Edmonton, said Medscape Medical News, “If you’re not terminally ill, if you’ve never been to the bedside of someone who’s dying or who’s had someone with cancer, you might say, ‘Oh , my God, they can just get palliative care. What is the problem ?’

“But MAID is about respecting people who are going through a unique time in life, and it’s hard to understand if you’ve never had that experience,” said Wilson, co-author with Herbert Northcott, PhD, of Dying and dying in Canada.

“Yeah, there’s a lot of controversy about making sure people with mental illness have the right,” she said. “But it’s going to be discussed so it can be done safely. And we know there are mentally ill people who say, “I’m in real pain and I know I’m never going to be okay.” “

Eligibility criteria

MAID became available in Canada in June 2016 for people whose natural death is “reasonably foreseeable”. The law effectively decriminalized euthanasia and exempted physicians and nurse practitioners who provide MAID from criminal prosecution.

On September 11, 2019, the Superior Court of Quebec determined that the law was unconstitutional because it limited access to MAID to people at the end of life (Truchon c. Attorney General of Canada). The law was amended across Canada on March 17, 2021 and is still in effect.

According to Canada justice department, the law was amended following feedback from more than 300,000 experts, practitioners and other stakeholders. The current version makes the following key changes to the original law:

  • It removes the requirement that a person’s natural death must be reasonably foreseeable.

  • It introduces a two-pronged approach to procedural safeguards that relies on the fact that a person’s natural death is reasonably foreseeable.

  • It excludes people with only mental illness from eligibility for 24 months (until March 2023, when the law will be modified Again).

  • It allows eligible people whose natural death is reasonably foreseeable and who have a set date to receive MAID to waive final consent if they risk losing capacity in the meantime.

  • It allows for expanded data collection and analysis through the federal oversight regime to provide a more complete and inclusive picture of MAID in Canada.

“Fortunately,” Wilson said, “we’ve begun to recognize that death happens, and some people will choose not to have all the bells and whistles to extend their lives for a few days or weeks or months or whatever.”

Are the guarantees sufficient?

The website of the justice department summarizes MAID eligibility and safeguards for people whose natural death is foreseeable and those for whom it is not.

For Wilson, that is enough. “The person has to apply. There has to be an assessment by two qualified medical professionals, and there has to be some sort of grace period. It’s not like you apply today and it’s done tomorrow.”



Dr. Harvey Schipper

But Harvey Schipper, MD, professor of medicine and adjunct professor of law at the University of Toronto, takes a different view. “These requirements are mostly procedural and don’t go far enough,” he told Medscape. “They’re not clear or applied uniformly. There’s nothing in any university curriculum about it. It’s really a Wild West moment here, and therefore PAD rates based on of the population vary across Canada, from very, very low in the Maritimes to 4.8% of deaths on Vancouver Island.

“Before, you had to have a serious illness,” said Schipper, who is a member of the Council of Canadian Academies. MAID Advance Request Expert Group and the MAID Expert Advisory Group. “Now it’s not an option of last resort. Instead, if you have a disease or disorder and you’re just sick of living with it, if you don’t want medical, surgical or psychiatric treatment, you can have MAID.”

Schipper reported instances where the law may have been violated, including a case involving an individual with amyotrophic lateral sclerosis who apparently received “poor quality care” at the hospital, did not want to stay there and instead underwent MAID at home. The Vancouver Sun reported that, according to his family, the patient’s life ended “sooner than he wished”.

More recently, the Associated press reported on a man with a history of hearing loss and the Depression whose brother claims he was unlawfully ‘put to death’ in 2019 after submitting a MAID application stating that hearing loss was the reason for his request.

“I argued in 2014 that we shouldn’t legalize MAID, and now we’re stuck with it,” Schipper said. “We’ve opened up a Pandora’s box of much greater complexity than expected. There’s a range of terms to describe the end of someone’s life. You can call it murder. You can call it murder by pity. You can call it euthanasia, you can call it MAID, you can call it whatever you want. It always ends someone’s life and this Pandora’s box has ramifications in the healthcare system and in the society.

“Now that we’ve decided to do this,” he said, “I think we’re compelled to do this with great care, great diligence and meticulous attention to detail of how it evolves – from the same way we did with everything from airline security to drug security. That didn’t happen with MAID.”

MAID on the rise

The number of MAID deaths in Canada continues to rise. The last report indicates that there were 10,064 deaths involving MAID in 2021, representing 3.3% of all deaths in Canada and bringing the total number of MAID cases since 2016 to 31,664. The number of people receiving marketing authorization increased by 32.4% in 2021 compared to 2020.

The number of practitioners providing MAID increased to 1,577 in 2021, up 17.2% from 1,345 in 2020. Most (94.4%) were physicians and the rest nurse practitioners.

Only 4% of MA applications have been rejected, far less than in other countries, such as the Netherlands, which reject 12% to 16% of applications, according to Trudo Lemmens, DCL, professor of law at the University of Toronto who, like Schipper, is a member of the Council of Canadian Academies’ expert panel on MAID pre-applications. In an e-mail comment to CTV NewsLemmens said, “This … may be an indication that the restrictions (in my view, the safeguards) are weaker here than in more liberal euthanasia regimes.”

Guidance and support

Jean Marmoreo, MD, a family physician and MAID provider in Toronto, said Medscape Medical News“As I turn 80, I think people at the end of life, even if they are physically fit and capable and have no disabilities, can predict what lies ahead. If you had a good life and you’ve lived it well, you should also have the ability to know when it’s time to leave this life on your own terms.”



Doctor Jean Marmoreo

Marmoreo is aware of the challenges that many practitioners face regarding MAID. “Practitioners need to come to terms with their own level of comfort in having difficult conversations, knowing what their limit is, and what their tolerance for moral and ethical dilemmas is,” she said. “They need to know when they are on a path that they are no longer comfortable with and that they can back off and refer.

“Canada is a very large country with a very small, widely dispersed and very diverse population, and each province has its own enforcement of this law, who you have to answer to and oversight bodies,” she noted.

In response to this fragmentation, Canadian Association of MAID Assessors and Providers (CAMAP) emerged. CAMAP has been curriculum development which will be available across Canada in the fall to help practitioners meet legislative requirements and develop the interviewing and other skills needed to manage patient issues and dilemmas, according to Marmoreo. The aim is to provide standards and guidelines for the provision of MAID.

Marmoreo notes that CAMAP provides a secure forum where practitioners can get help and information. “Next year, mental illness as the sole underlying cause will come into effect,” she said. “There’s a jolt every 2 years with this law, which means the whole process of determining quality of life and what living means becomes more nuanced, broader. It all takes a lot more input and of understanding. As a solo practitioner, I don’t want this burden alone. I want help on this journey.

Follow Marilynn Larkin on Twitter: @MarilynnL.

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