The Cost-Cutting Expedient of Medical Assistance in Dying for the Elderly Ill

"MAID [Medial Assistance in Dying] has already become in Canada a form of elder care."

"The people who are dying from [Canada's] MAID are disproportionately vulnerable. They're disproportionately disabled. They're disproportionately elderly."

"It is very difficult to not see assisted suicide or euthanasia as some sort of escape hatch. Or maybe overflow valve is a better way of putting it."

"When you have long wait times and sick populations, it's very difficult when you have a legalized pathway of suicide that does not become a tempting program." 

Alexander Raikin, fellow in bioethics and American democracy, Ethics and Public Policy Center, Washington

 

"It's not even hypothetical. It's Canada today,"

"[There are] news stories of people who don't even have a lethal condition."

"They go in for a potentially disabling condition, and they're referred for MAID, because their condition's expensive."

Lyman Stone, demographer, Pronatalism Initiative, Institute for Family Studies 

New research suggest medically assisted dying could result in substantial savings. But the study's author says costs should not be considered when individual patients consider the option. (Chris Kreussling)

 

Public health systems in both Canada and the United States have for far too long been facing unsustainable delays in delivering critical health care to their ailing and elderly citizens. It can take months for a referral to a specialist to become a reality. Patients are left dangling, awaiting treatment and surgery. Wait times mean that people suffer longer, their condition deteriorates, sometimes to the point of no return. And while needed surgeries burden an ever-slower delivery time for anxious people requiring attention to prolong their lives, one service is able to swiftly accommodate those who wish to access it and are given help in doing just that, by the medical community.

 

This is the finality of treatment offered by Canada's Medical Assistance in Dying. Its adherents are passionate about its purpose as they see it, reducing pain and suffering for those whose deaths are imminent due to an incurable or unmanageable stage of a disease. End-of-life issues such as the voluntary choice for closure is of massive importance to those in society who believe it is the human, charitable thing to do; offer people the medical means to leave life. And they want that offer to be extended; to those whose mental anguish as well as physical stem from psychiatric conditions.

 

In Canada, people have been known to make that final choice as a result of the misery their life has become; dispirited beyond reckoning by endemic poverty,  homelessness, illness. Ethicists place themselves in either side of the issue, many of them uncertain whether this is the moral path that should be proffered to those eager to take advantage of it. Or choosing that path because they cannot foresee any other choice that could alleviate their pain and suffering. 

 

The MacDonald Laurier Institute

 

Now another issue comes to the fore in the argument, the fear that as health care costs continue to rise, and the medical community remains hard pressed to serve the needs of a growing population, might MAID be viewed as a health-service cost-cutting device? MAID is an option for adults whose deaths are reasonably foreseeable, for those suffering from an irremediable condition. Those with mental illnesses are set to be included in another year. In 2024, 16,499 individuals chose MAID to end their lives; that was 5.1 percent of Canadian deaths; the numbers rise year-over-year. One in 20 Canadian deaths are now attributable to MAID.

 

 Medical aid in dying laws, allowing for prescribed drugs for patients with a death prognosis within six months is available in the United States in 14 states. Data indicate that 1,242 people took advantage of that prescribed aid-in-dying medication in 2024. Now, demographers and health experts feel that MAID may become an increasingly advantageously grotesque way to curb the growing cost of elder care, as the number of elderly citizens reaching their final years continue to mount.

 

Canadians over 85 years of age represent the swiftest growing segment in the country and that number is forecasted to double and more, over the following  several decades. There were 58 million U.S. citizens over age 65 in 2022, a number that will explode to about 82 million by 2050. In both the United States and Canada, seniors are expected in short order to represent close to a quarter of the entire population. 

 

An ambulance is shown at the emergency department entrance at the Windsor Regional Hospital Met campus. Photo by Dan Janisse /Windsor Star

 

On Offer In Canada -- Death In A Hurry

"Canada is now noted as the fastest growing assisted dying program in the world."

"Although many participants [in MAID deaths] experienced respectful, caring and compassionate interactions with health-care professionals involved in the [Medical Assistance in Dying] process, others did not, adding to already stressful and intense emotional pain."

University of Alberta researchers

 

"It was just like a series of losses, right."

"You lose the ability to work. You lose the ability to play. You lose the ability to eat, to sleep, to do everything."

"So, the loss was already there."

"The final, the MAID, was just like the grand finale of the loss journey."

Relative of a MAID participant 

 

"My mom needed psychiatric help. My mom was a victim of a broken health-care system."

"My mom had been trying to see specialists for months and months and months [for a brain injury]. It got to the point she lost all hope."

"And so my mom ended her life because of desperation, not anything to do with dignity."

Transcribed research interview 

(Thomas Northcut/Getty Images)

 

A new study out of the University of Alberta and published in the  journal BMO Palliative Care, once again sheds light on the  experiences of families dealing with doctor-assisted death.  Some of the study's interviewees were satisfied with the care their loved one was given to the end of their life under Canada's Medical Assistance in Dying protocol, and many others complained that the process was too rushed, too impersonal and traumatic, not the least bit helped in facing cheerfully smiling assisted-suicide providers under the program.

 

The purpose of the law that came into effect in June of 2016, with strict parameters that had to be considered before consent would be given for MAID, was to  focus on the rights and autonomy of individuals to make the decision when their lives should be ended in a program envisioned as 'dying with dignity'. Death would have to be foreseeable in the near future, the result of all medical measures having been taken to deal with disease, injury and illness. 

 

In the years that followed, the law was amended to permit entry to the program of a greater number of people, those whose pain and misery failed to respond to medical intervention, whose quality of life was utterly abysmal and in their personal opinion, unlivable. Applications for MAID consideration would have to be made when an individual was of sound mind to be able to do so; relaxed rules allowed for applications to be honoured prior to an applicant's health descent to the point of no longer being in possession of their full mental awareness.

 

Two independent medical assessments must be made for those deemed eligible for MAID. An individual whose suffering cannot be medically ameliorated and who voluntarily makes application must also give a final assent on the day of the procedure, unless the use of an advance consent has been accepted. During the University of Alberta's researchers' outreach study, many families felt that family members should be involved in a profound decision of such a nature as voluntary life-cessation. 

"I got a phone call on June 1st from her family doctor that I had never met. She said, 'I'm sorry to inform you that your mother has passed away'."

"And I literally told the doctor, I said, 'No, no, no, you've got the wrong person, like you've called the wrong person."

Interviewee 

In another instance, despite having been denied assisted death through previous requests in Ontario, 26-year-old Kiano Vafaeian died by MAID in a Vancouver funeral home after experiencing vision loss from diabetes; his constant state of deep depression led him to seek an assisted death. When informed that her son was no longer living, his mother immediately thought this was someone's idea of a bad joke.

 

Between legalizing MAID in the Criminal Code in 2016 and December of 2024, there had been 76,475 MAID deaths reported in the country. That number is expected to rise to 100,000 by the summer of 2025.  

Euthanasia has now become the fifth leading cause of death in Canada. Another amendment to the MAID law is being deliberated on by a special joint parliamentary committee, to extend 'dignity with dying' to people whose only condition is that of a mental illness; to come into effect in March of 2027.

 

The study funded by Health Canada, saw researchers inviting families from British Columbia, Alberta, Saskatchewan, Ontario and Quebec to discuss their experiences -- in support of 35 Canadian family members who received Medical Assistance in Dying -- through one-on-one virtual interviews. The decision to apply for MAID in some instances could be triggered by "unmanageable or unbearable symptoms"; severe shortness of breath, or unmitigated pain.

 

Some were driven to seek out MAID fearing loss of personal agency, having to rely on others for bathing or toileting; even the possibility of having little option but to move into a nursing home. For some, lack of adequate home care led to the final decision. Hasty assessments, lack of deep discussions of alternative options and advice on how families  could help relieve distress "led to their loved ones choosing MAID sooner than they may have", concluded the researchers.

 

The observation was also made that on occasion a second assessor appeared to 'rubber stamp' the first assessor's eligibility agreement. Health issues rated concerns of not having been fully addressed. "Booking our MAID date was like booking a dinner reservation, So, it's just all very, very, very impersonal." The cheerfulness of one assessor was profoundly off-putting for another family. Although either a doctor or a nurse could perform the final MAID injection some families found it a struggle to find a willing provider.

 

"It was an absolutely brutal contradiction of trying to fight for somebody to be able to die when you don't want them to die", explained one family member. 

 

Dr. Cheryl Rowe a Toronto psychiatrist, says she believes patients have a right to die a dignified death. ”Who am I to say you’re suffering, it’s too bad, you just have to find a way to live like this?” Nick Lachance

"MAID policy is often framed as purely about autonomy. But health care has never treated autonomy as absolute."

"Most families are not asking for veto power. They are asking to share information, to be involved and to know that all safeguards and care options were meaningfully considered."

Dr. Ramona Coelho, family physician, member Office of the Chief Coroner MAID death review committee, Ontario  

MAID: Decision of Last Resort in Canada

"I think most people in Canada would at least acknowledge that we've gone way beyond an exceptional practice that is a last-resort measure."

"It is troubling that documented problematic applications of MAID have not yet resulted in either criminal or professional regulatory intervention."

"Some of the frequent providers will say there's a high provision because there's a high demand. 'It's the law of the market'." 

"But I think it's still appropriate to say that it's quite extraordinary, it's simply a fact, that MAID has been prioritized and is so easily accessible." 

Trudo Lemmens, health law and policy professor, University of Toronto 

 

"The current legal regime for delivering MAID is enormously popular among Canadians. That is a lot of potential demand."

"If we  regard an increasing number of joint replacements or abortions as a success, with supply having risen to meet demand, why should we think that an increasing number of MAID provisions is a failure, or somehow a problem."

"If more awareness, more providers and more support are good things for these other services, why are they a bad thing for MAID?"

"Of course, I think MAID is very different from a lot of other medical procedures, just by virtue of its very nature." 

"[MAID], both causes death and is intended to do so. That makes it special enough to require a statutory exemption from the  general legal prohibition of consensual homicide and assisting a suicide."

Professor emeritus Wayne Sumner, University of Toronto

The Office of the Chief Coroner for Ontario. (AP Photo/Angie Wang)

 

In Canada almost ten years ago, the Criminal Code saw medical assistance in dying (MAID) become law, permitting medical staff under certain conditions to end the life of a consenting person living with constant pain and foreseeably approaching imminent death. Since its original guidelines there have been some changes that relax the strictness of those guidelines. The result has been over the years to the present that one in 20 deaths in Canada is now attributable to MAID. In 2024, a total of 16,499 individuals died by physician-administered lethal injection.

 

In Ontario, 88 percent of 4,356 MAID deaths that took place in 2024 met all legislative requirements to legally proceed with the procedure. Still, concerns noted by the death review committee which Dr. Lemmens is a member of, include legislated safeguards being given lax interpretation, along with minimal or careless assessment of an individual's legal capacity to opt for assisted death. As well, minimal discussions respecting alternatives for the relief of suffering, risks of coercion from burnt-out family members, along with doctors taking nods and hand squeezes as assent before lethal injection, were also flagged. 

 

The law itself has been significantly altered over the years, leading to setting aside the rigid requirement of death being foreseeable, nor must all available options to relieve suffering be exhausted before MAID can be considered. Moreover, it is possible to access MAID more readily than vital medical care that might prevent it, pointed out Dr. Lemmens, given Canada's overburdened and tardily-accessible health care system. Further inclusive expansion of  MAID is of particular concern to Dr. Lemmens and his think-alike colleagues. 

 

People in the lowest ‘material resource’ category represent 20 per cent of the general population, but they make up 28.4 per cent of Track 2 MAiD recipients, compared to 21.5 per cent of Track 1 recipients. (Shutterstock)

 

Although MAID sees wide public acceptance, the potential of permitting people with degenerative diseases like Alzheimer's to plan for a written request while they still can, prompted Dr. Lemmens to respond "Who will decide when the time has come? On what basis will these judgments be made? How can we  expect physicians or nurse practitioners to end the life of a person who has no clue as to why they are being sedated or getting a needle inserted into their arm?"

 

Since MAID was legalized in 2016, 75,475 MAID 'provisions' were carried out. The number of  Canadians whose suffering was "enduring and intolerable", but their natural deaths not reasonably foreseeable, who were euthanized as 'Track 2' cases reached 732 in total. "These are 732 people who would be alive (today). We have to ask, in all these 732 cases of people who suffered intolerably, were there no other options? I have my doubts", charged Dr. Lemmens.

 

Canada's record of 5.1 percent of MAID deaths within the total of death from all causes, eclipsed that of Belgium, with 3.6 percent of all deaths in recent years and where since 2002 euthanasia has been legal. Netherlands has a 4.8 percent of total deaths by euthanasia occurrence. However, within Canada, the province of Quebec's average MAID deaths reached 7.9 percent of all deaths; the most globally prolific. 

 

People who chose medically assisted death when they were not terminally ill were more likely to be marginalized than those who chose MAiD when death was already imminent. (Shutterstock)

 

Euthanasia in Canada (oops) MAID

"While the data suggests that the number of annual MAID [medical assistance in dying] provisions is beginning to stabilize, it will take several more years before long-term trends can be conclusively identified."

"[People who receive MAID don't disproportionately come from lower-income or disadvantaged communities; they're] more likely to be represented in higher income neighbourhoods."

"Loss of ability to engage in meaningful activities was the most commonly reported source of suffering]." 

Health Canada's 6th annual report on MAID

According to the latest update, 95.6 per cent of Canadians who died by MAID last year had a "reasonably foreseeable" death. Photo by Getty Images

 

Health Canada was in receipt of 22,535 MAID requests last year of which 16,499 were approved to proceed. Of those not having been approved, 4,017 of those requesting medical assistance in dying, did so before MAID could be provided, while 1,437 people were found to be ineligible and another 692 changed their minds, withdrawing their request for MAID. In that same year of 2024, 2,255 doctors and nurse practitioners were actively involved in providing MAID. Of that total it was a small group of medical volunteers who were responsible for providing 38 percent of all requests (6,185).

 

In 2025, the United Nations Committee on the Rights of Persons with Disabilities called for a repeal of the 2021 law in Canada expanding MAID eligibility to those whose deaths are not reasonably foreseeable, concerned that people with disabilities seek MAID as a result of "unmet needs, a systematic failure of the State party". Groups representing the rights of those with disabilities lobbied government not to include those with disabilities in the expanded eligibility list for MAID, fearing the expansion would take the place of workable medical interventions.

 

Altogether MAID deaths in Canada account for 5.1 percent of all deaths in the past year, representing a small increase from 2023 of some 0.4 percent. Since the introduction of MAID in 2015, 76,475 MAID deaths have been registered, according to Health Canada. In 2024 alone, a total of 16,499 people died by MAID. The vast majority (85.6 percent) of hose who died by MAID (averaging 76 years of age and older) last year qualified for 'Track 1' deaths, representing the category of a 'reasonably foreseeable' death qualifying them for MAID approval.

 

Questions are being raised around how MAID is being approved in Canada for people with dementia. Photo by Getty Images

 

Doctor-assisted deaths where natural deaths  were not reasonably foreseeable, saw a majority of women (56.7 percent), slightly younger qualifying, with autoimmune conditions and chronic pain, along with neurological conditions were most often cited among people asking for MAID, who were not on the verge of dying. There was some controversy linked to MAID requests by individuals suffering the effects of mental conditions making their lives impossible, where medical intervention might make a difference.

 

Concerns that some MAID deaths are driven by loneliness, hopelessness and isolation and that some physicians are stretching the qualification provisions of the law have also emerged. The principal criterion of MAID qualification is that a person must be experiencing intolerable and "enduring physical or psychological suffering". Those applying for MAID approval often report multiple sources of suffering impacting their lives.

 

The most common in 2024 was loss of capacity to engage in meaningful activities, as well a loss of ability to perform daily routines such as eating, drinking, dressing and moving about. Track 1 applicants were likelier to report inadequately controlled symptoms, "while Track 2 MAID recipients were more likely to report isolation or loneliness and loss of dignity". Other findings indicate that MAID applicants are less likely to live in remote areas, thus lack of access to health services is not an issue. 

 

The most frequently reported condition in most all age groups of those who died by MAID in 2024 was cancer, in particular lung, colorectal, pancreatic and blood cancer. With the exception of those 85 and older "for whom 'other conditions' were the most frequently cited". 

 

A screen displays a patient's vital signs during open heart surgery at the University of Maryland Medical Center in Baltimore on Nov. 28, 2016. THE CANADIAN PRESS/AP, Patrick Semansky (Patrick Semansky)

 

MAID, Here Today, Gone Tomorrow

"[His back pain] was neither grievous nor irremediable and therefore did not meet the statutory eligibility criteria for MAID [Medical Assistance in Dying]."

"[His request for MAID was also influenced] by external pressure including concerns about personal finances."

"Despite this, J.M.M. was wrongfully approved for MAID by the defendants. In facilitating J.M.M.'s access to MAID, the defendants acted negligently or recklessly, causing J.M.M.'s death"

"After being allegedly approved for MAID, J.M.M. indicated that he did not wish to proceed with the procedure and wished to pursue other means to relieve any suffering he had, including rehabilitation."

Vancouver family's wrongful death claim

Dr. Ellen Wiebe is pictured at her office in Vancouver. Photo by Ethan Cairns for National Post/File

A 52-year-old Vancouver man identified only as J.M.M., had a long history of mental illness. In 2013, according to a statement of claim filed in the Supreme Court of British Columbia, by the man's former spouse, his father and his three children, J.M.M. was diagnosed with bipolar disorder. As well, he suffered from 'remediable' (treatable), chronic back pain.  The lawsuit launched by the man's family     claims the assisted-death law in Canada is unconstitutional, exposing people with coexisting physical and mental illness to "heightened risks of premature death, facilitated by the state".

J.M.M. was euthanized without his family's prior knowledge, at a Vancouver clinic. At the time the man  was out on a day pass from a hospital psychiatric ward. The lawfulness of an assisted death provision in Canada is being sued once again.  Dr. Ellen Wiebe is among those named in the suit. She has the distinction of being the most prolific provider of medically assisted death in Canada, administering life-ending drugs to over 400 people. De. Wiebe has been described as a cheerful individual, satisfied with her role as an executioner for people living insufferable lives due to chronic medical conditions.

Assisted-death law as it stands currently in Canada, temporarily excludes people from accessing MAID until some point in 2027, with a sole underlying medical condition that is a mental illness. However, people with concurrent mental and physical illness are not excluded by the law from accessing an assisted death. According to the family's claim, J.M.M. had no capacity to make decisions about his  health, much less to consent to MAID, as a result of his mental illness, rendering him ineligible for MAID.

JMM's family claims he was committed to the psychiatric ward at St. Paul's Hospital but was released on a day pass. (Ben Nelms/CBC)

When the family raised concerns over the legitimacy of the approval for MAID, no response was received. A court order was obtained by the family in late 2022, committing J.M.M. to the psychiatric ward of St. Paul's Hospital. There, his treating physicians "opined that J.M.M. should not receive MAID due to his mental illness, which  served to impair his capacity to consent", asserts the claim. "Nonetheless, the defendants negligently or recklessly" allowed J.M.M. to leave the hospital on a day pass.

Whereupon the man took himself to Wiebe's clinic that afternoon, then died "through the improper administration of MAID", according to the claim. Further, the family stated they learned of his death only afterward. The death resulted from the "wrongful action of the physicians and institutions that facilitated MAID, as well as the unconstitutional regulation of MAID by the federal and provincial governments."

 

The federal MAID framework and corresponding provincial policies, they argue, infringe on the Charter rights to life, liberty ad security of the person. Included in the lawsuit is the Attorney General of Canada, B.C.'s minister of health, Wiebe's Willow Reproductive Health Centre, Provincial Health Services Authority, Vancouver Coastal Health Authority and Providence Health Care Society. 

 

This is the second case in two months where Dr. Wiebe has been involved. Months earlier a British Columbia judge granted an urgent injunction that stopped a woman's death by MAID the very day prior to its scheduling. In this case, the woman's common-law partner prevented Wiebe or any other medical professional from helping to end the 53-year-old Alberta woman's life within 30 days

The issues concerning the intersection of physical and mental illness in JMM's claim echo concerns raised in the October injunction application filed the day before a 53-year-old Alberta woman known as NB was scheduled to end her life in a Vancouver clinic. (Shutterstock)

"[The latest case] confirms that there are already serious concerns that non-specialists feel comfortable to end the life of persons with mental illness who need care and protection, rather than death as therapy."

Trudo Lemmens, professor of health law and policy, University of Toronto

MAID (Medical Assistance in Dying) Canada

"Amongst his multiple specialists, no unifying diagnosis was confirmed. [However, his MAID assessors [felt that the most reasonable diagnosis for Mr. A's clinical presentation [severe functional decline] was a post-vaccine syndrome, in keeping with chronic fatigue syndrome."

"[In the case of] Non-reasonably foreseeable death [patients  were more likely to live in the most maginalized areas in the province, more likely to require disability supports, more likely to be female and more likely to live alone at all ages]."

MAID death review medical report

"I think we have gone so far over the line with Track 2 that people cannot even see the line that we've crossed."

"It's pretty clear that some providers are going up to that line and maybe beyond it. This is actually suicide facilitation in some cases."

"[In the case of Mr. A.] even separate and apart from whether post-vaccine syndrome is a valid entry, it's very clear that even [the MAID assessors] weren't sure of it"

"There was repeated discussion about 'no determinant diagnostic results', no unifying diagnosis. It was really just the MAID assessors who ended up saying the most reasonable diagnosis is post-vaccine syndrome completely ignoring the fact that the symptoms of depression, trauma and addictions can cause a whole slew of symptoms, including physical ones."

Dr. Sonu Gaind, psychiatrist, professor of medicine, University of Toronto 

Some members of the MAID death review panel questioned whether “post-vaccine syndrome” — a condition "previously unrecognized in medicine" — could be considered incurable. Photo by Getty Images

 

Euthanasia was extended to a man in his late 40s who had a background of mental illness. His assisted death assessors had decided the most reasonable explanation for his severe physical decline had to be a post-COVID-19 'vaccination syndrome'. 'Post-vaccine syndrome' is not included within Canada's current vaccine report system for adverse effects. Many specialists who had been consulted prior to his assisted death were not able to agree on a diagnosis, which left unanswered the question whether the man's medical condition even met the criteria for "irremediable", the cornerstone of MAID accessibility.

'This particular case is but one of several addressed in a number of reports by a MAID death review committee struck at the behest of the chief coroner's office of Ontario. 'Mr. A' had suffered functional decline in the wake of three SARS-CoV-2 vaccinations. Depression, PTSD, anxiety and personality disorders were also issues that the man suffered from. He was twice admitted to hospital with suicidal ideation "while navigating his physical symptoms".

 

Nonetheless no "pathological findings" were identified at a post-mortem that could pinpoint the presence of any underlying physiological diagnoses.  The report brings to light difficulties in granting euthanasia for those whose medical conditions are not recognized as terminal, those whose natural deaths are not reasonably foreseeable, placed into a "Track 2" category. People suffering from a multitude of medical conditions who are actively seeking approval for MAID, fall into that category.

 

There are troubling instances when a medical care provider will broach the topic of medical assistance in dying, ostensibly as a gentle reminder that the protocol exists whereby an seriously untenable life can be ended with medical intervention under certain qualifying conditions. Those qualifying conditions have departed from the original regulations safeguarding the system from abuse. Simply by casually mentioning MAID, and handing out pamphlets explaining it as an optional solution is a  tendency to guide patients toward requesting that solution to their intractable medical condition.

 

Mental illness in and of itself is not an ultimate qualifying condition for MAID. An individual with mental illness alone "wouldn't suffice" in qualifying for MAID, since it cannot be viewed as the sole underlying condition in seeking out MAID.  According to statistics, over 13 billion COVID vaccine doses have been given globally, saving millions of lives. A study involving over 99 million vaccinated people from eight countries discovered that known side-effects are rare.

 

Yet, according to Immunologist Dawn Bowdish with McMaster University, following vaccination rare conditions can occur that have the potential for 'life-altering consequences'. The immune system attacks the nerves of the spinal cord with transverse myelitis leading to a condition resembling multiple sclerosis; Guillain-Barre system can occur when someone's immune system attacks their nerves causing muscle weakness and occasionally weakness that turns in rare cases to paralysis. 

Still, a chronic post-vaccine syndrome is a controversial issue. A workers' compensation company WorkSafeBC, found no published data supporting the development of chronic fatigue syndrome, following a mRNA COVID vaccination. In responses to an online survey, 241 adults reported continuing symptoms following a COVID vaccination, symptoms including excessive fatigue, brain fog and pain, numbness and tingling.

"So, now we have to say, 'Well, here's what we think is a likely medical diagnosis. And then, on top of it, with the clear diagnostic uncertainty they're able to say, 'Oh, plus this is now irremediable'."

"Because if  they don't say that, obviously you don't qualify for MAID."

Dr. Sonu Gaind

MAID -- At Your Service

"[Only 25 percent of Californians said they were aware that MAID was legally available as an option if they had a terminal illness such as advanced cancer, compared to 67 percent of Canadians who were aware] that MAID [Medical Assistance in Dying] as an option -- were such a calamity to befall them."

"[Other] standout [factors included the number of MAID practitioners in Canada and higher] institutional support."

"In Canada, every provincial and regional public health authority in Canada makes accessing MAID straightforward."

"[Researchers tested ten hypotheses to understand the 15-fold variation in MAID deaths between Canada and California; to determine what factors might be driving Canada's higher MAID uptake], or, conversely, preventing Californians from taking advantage of a legal route toward relieving unnecessary suffering."

Dr. Peter Reiner, professor emeritus, neuroscience and neuroethics, University of British Columbia

Public awareness of MAiD in Canada and California.

 

"MAID is being promoted as a form of therapy], even for only remotely disease-related suffering."

"Canadian patients are much more frequently confronted with offers of MAID and with a physician providing it as a form of care."

Dr. Trudo Lemmens, professor of law and ethics, University of Toronto

Canada's 'dignity in dying' legislation ('death on demand') has gradually altered the safeguard requisites it had originally put in place -- to reflect the gravity of a situation where people in unassuageable pain or living with the prospect of imminent death, prefer ending their lives over continued suffering -- to expand the death-service by softening pre-qualifications to apply for MAID. The requirement of facing a "reasonably foreseeable death" such as terminal cancer has been lifted to offer Canadians MAID when a "grievous and irremediable" condition occurs, absent of the imminence of natural death.

In 2016, both the State of California and Canada, with similar population numbers, granted their citizens access to medical assistance in dying. Between the two no real differences occur in leading the causes of death, or in overall death rates. So it is a bit of a puzzle why so many people in Canada choose MAID in contrast to relatively few in California. A newly published study has attempted to analyze the two populations for an explanation respecting the vast differences in public uptake of the death service.

In 2022, Californians numbering 843 individuals chose to die by MAID. In comparison, 13,241 Canadians chose to die by MAID which in 2022 accounted for 4.1 percent of all deaths in Canada in comparison to 0.27 percent of all deaths in California. The Canadian provinces of British Columbia's and Quebec's rate of uptake are respectively 5.5 and 6.6 percent, numbers that outpace the assisted-suicide pioneers of Belgium and the Netherlands.

 

Moral acceptability of MAiD by modality in Canada and California.

The study suggests that 25 percent of Canadians would select to die by MAID as a solution when facing a long and painful death from any disease. The team of Professor Peter Reiner and co-author Adrian Byram, (a member of advocacy group End of Life Choices California), conducted online surveys of 228 adults from age 60 and up, reflecting the age group accounting for most requests for MAID, in both California and Canada. While 67 percent of Canadians said they were aware "that MAID was an option", only 25 percent of Californians said they knew that MAID was legally available if they had a terminal illness. 

In Canada, explanatory information is available on government websites as well as those for advocates of MAID where well informed staff is made available to provide assistance in navigating the process of applying for, accessing and succeeding in the relief that MAID offers to those wishing to take advantage of it. In comparison, assistance of this kind is not available in California. 

 

No differences in moral acceptance was found by the researchers. Two-thirds of both Canadians and Californians felt MAID to be morally acceptable. In California criteria for accepting a request for MAID requires death to be anticipated within six months, while "both jurisdictions recognize that any such prognosis is fraught with uncertainty", the authors qualified. More explicit punishment for failure to comply with safeguards or reporting standards, exist in Canada as compared to California. 

Assisted deaths as % of total deaths in Canada and California from 2016 to 2022.

 

 

Quebec, Assisted Suicide Capital of the World

"We're now no longer dealing with an exceptional treatment, but a treatment that is very frequent." "[Quebec is on track to complete the year with 7% of all deaths recorded as doctor-assisted] That's more than anywhere else in the world: 4.5 times more than Switzerland, three times more than Belgium, more than the Netherlands. It's two times more than Ontario."

"We see, more and more, that the cases receiving medical aid in dying are approaching the limits of the law. It's no longer just terminal cancer, there are all kinds of illnesses -- and that's very good, but it requires a lot of rigour from doctors to ensure they stay within the limits of the law."

"Medical aid in dying is not there to replace natural death."

"It's very easy to go from palliative care to medical aid in dying."

Dr. Michael Bureau, head, Commission sur les soins de fin de vie

Quebec is at the global forefront of medical aid in dying, with a higher proportion of people choosing the procedure in the province than anywhere else on earth. (Radio-Canada)

The enactment of a federal law permitting end-of-life medical assistance in committing suicide was an issue receiving mixed results in Canada. Some felt it was timely and needed, that when people deeply felt it was time for them to leave life due to extenuating medical conditions causing unendurable pain the humane thing for any caring society to do was to help these souls expedite themselves to freedom from pain, at their choice. 

 

Others raised concerns that once this setting aside of the prohibition against assisted suicide became law, there would be an inevitable loosening of guidelines, opening this new social service to an even greater number of people not facing end-of-life issues. Indeed, there have been 'updates' to the original legislation, loosening some of the strictures against assisted suicide being used indiscriminately by the medical profession and society in general.

 

Medical Assistance in Dying (MAID) as it is practised in Canada now, has resulted in Canada overtaking all other developed countries that permit assistance in accomplishing suicide, surpassing them in numbers and in the looseness of those whose medical conditions and even social status fails the original categories of permissible suicide assistance. Scheduled for the future is the acceptance of requests from people suffering mental illness. And later still, adolescents considered mature enough to make that decision for themselves.

Now, the head of the independent body monitoring assisted suicide in Quebec has publicly stated his concerns that doctor-assisted deaths -- that the original legislation made clear were to be viewed as a last resort -- when all else fails, has fallen by the wayside. MAID, it appears, is no longer viewed as an exceptional procedure to be undertaken on behalf of people suffering unbearably, and approaching the end of their lives.

 

A patient looks out a window at the palliative care unit at St Mary's Hospital Centre in Montreal   Photo by Phil Carpenter /Montreal Gazette

 

The commission that Dr. Bureau heads, earlier in the month forwarded a reminder memorandum to the province's medical practitioners, that it is only those patients with a serious, incurable disease, suffering and who have experienced an irreversible decline in their condition, who are deemed to be eligible to receive MAID. The procedure must be approved independently by two doctors; there should be no 'shopping' for a favourable second opinion.

He has noted, he stated, an increase in the occurrence of cases violating Quebec's end-of-life legislation. In the previous annual report, covering a period between spring of 2021 and spring 2022, 15 of 3,663 doctor-assisted deaths in Quebec failed to respect the letter of the law. Problematic cases included the administering of MAID to an individual with an expired provincial health insurance card; rather than continue to rely on provincial health coverage that had expired, the patient chose death.

Patients in another six cases were found not admissible for the procedure, while in another three cases, patients were in a condition of health that led to their inability to give consent. These are cases reported to the provincial college of physicians, College des medecins du Quebec. An emailed response had the college confirming that none of the 15 cases were referred to its internal disciplinary tribunal; additional negligence. Not was data available whether disciplinary measures may have been taken toward doctors violating MAID rules.

A concern was expressed by Dr. Bureau that doctors find themselves in awkward situations with elderly patients, ready to die, but whose health problems are not sufficiently serious to qualify them for MAID. Doctor-assisted deaths, according to Health Canada's most recent annual report on the subject, accounted for 3.3 percent in 2021 of deaths in Canada. Quebec had the highest rate of MAID deaths country-wide, their number was 4.7 percent that year, and numbers have steadily continued to rise.

Concerns about over-using MAID in Quebec

 

Canada's Assisted Suicide Regimen: "A Slippery-Slope Warning Sign"

"The [Canadian] law itself says this [assisted suicide] doesn't have to be [the] last resort ... and I think that's a very disturbing societal norm."

"[Canada is an example of the world's] most radically medicalized system of providing assisted dying."

"[The] most sobering [reality of Canadian euthanasia is that it pairs] very open eligibility [with a] very aggressive medical delivery system."

Dr. Scott Kim, senior bioethics investigator, U.S. National Institutes of Health 

"[It is a] misconception [that MAID was being employed as a] first resort [option for medical care]. I would simply state that what we know of the individuals who are receiving MAID, that 96 per cent received or had good access to disability support and 98 per cent received or had access to palliative care support."

James Downar, palliative care specialist, University of Ottawa

 

"[The system might create an] obligation to introduce [suicide] as a part of' mental health treatment." 

"Imagine that being applied in the context of mental health. You have a person suffering severe depression, seeks help from a therapist and is offered the solution of dying."

"[Vulnerable patients who aren't in the right state of mind could be convinced suicide is a reasonable option. The entire system is a] perverted concept of autonomy."

"I would say that Canada is a warning sign for countries that legalize medical assistance in dying."

Professor Trudo Lemmens, bioethicist, University of Toronto

The U.K. Health and Social Care Committee hears testimony on Tuesday about the Canadian assisted suicide regime. Photo by Parliament Live screenshot

The United Kingdom is pursuing data from other countries who have passed legislation to allow assisted suicide, under public pressure to legalize some form of doctor-assisted death in Great Britain itself. Currently, suicide and euthanasia, medically assisted, are illegal in Great Britain. Penalties of up to 14 years in prison for health practitioners who are found to be involved in aiding suicides make certain that no doctor at the present time would respond to such requests from their patients.

A panel of Members of Parliament has been struck, leading an official enquiry for information gathering "real-world evidence", pointing to how assisted suicide regimes have functioned in other countries that approve the the controversial regime. "The government has stated it is for parliament to decide on the issue so our purpose is to inform parliament in any debate", explained the committee chair. 

Medical experts from Canada and the United States have been advising the committee on Canada's experience to date on the issue. A 2015 Supreme Court of Canada decision, Carter v. Canada, broadly declared that assisted suicide is a constitutionally protected right. 18 years previously there was an entirely different Supreme Court decision, Rodrigues v British Columbia, where the opposite had been ruled, when justices were asked to consider the constitutionality of assisted suicide. Their reply: "The matter is essentially a policy decision that should be left to Parliament to resolve".

 

An initial, carefully prescribed suicide bill which passed with substantial support from Conservative MPs in the Canadian House of Commons leaned on safeguards to protect MAID (Medical Assistance in Dying) from ever being approved for children, the mentally ill and marginalized communities. A Quebec court in 2019 struck down Bill C-14, and the Trudeau government updated a bill in 2021 broadly lowering eligibility barriers for assisted death.

 

 

Professor Lemmens, bioethicist at University of Toronto, initially supported assisted suicide until it was adopted as a form of "harm reduction", the Canadian medical system accepting the idea of offering MAID "when people don't have adequate access to social support and care". Initial MAID advocates denied such cases were occurring, then championed them as "a solution to a worse-off situation". First legalized in Canada specifically to relieve terminally ill patient suffering where death was "reasonably foreseeable", successive changes to the law now mean it can be approved for any patient claiming a "grievous and irremediable condition".

 

MAID practitioners themselves have recently confirmed the qualifications could be as comparatively negligible as an inability to obtain care for a chronic illness, or even simply living in poverty. "The suffering and the irremediable disease don't have to be the same", observed Konia Trouton, a founder of the Canadian Association of MAID Assessors and Providers, aware that some people opted for assisted suicide as a result of socio-economic factors, and were still eligible.

"Canadian law, in all its majesty, has allowed both the rich as well as the poor to kill themselves if they are too poor to continue living with dignity."

"In fact, the ever-generous Canadian state will even pay for their deaths. What it will not do is spend money to allow them to live instead of killing themselves."

Yuan Yi Zhu, International Relations, University of Oxford

MAID-Accessing Depression - and Potential Alternatives

"To our knowledge, this is the first report of ketamine or any other intervention yielding remission in a patient who would have otherwise likely been eligible for MAID [Medical Assistance in Dying/Euthanasia] for depression."

"Accordingly, it is essential for clinics to have up-to-date and reliable evidence about all potential treatments."

"A lot has improved. There's ups and downs. She [patient] had a lot of challenging life events. [She is not cured, not necessarily] thriving [but her MAID request remains withdrawn]."

"In our hands, we're never really sure how much is biological and how much is psychological about the experience. We think there's a lot of both."

"At the least, before taking an irreversible step like MAID, a trial of ketamine warrants consideration."

Dr. Kyle Greenway, psychiatrist, McGill University / Jewish General Hospital, Montreal

"We don't know how psychedelics, and especially very transformative, deep spiritual experiences even, can shift people's attitudes toward death and toward MAID itself."

"How might we respond to someone who says, 'I do feel a deeper interconnection with the world, a deeper sense of well-being."

"I'm at peace where I'm at, and I would actually like to pursue MAID now."

"That's entirely possible as well."

"[It's] wonderful and important [that people are able to have their suffering alleviated]."

"[Caution is required] so that we're not fuelling additional hype around some of these psychedelic medicines as an easy way, or a magic bullet to reverse MAID decisions."

Daniel Buchman, bioethicist, independent scientist, Centre for Addiction and Mental Health, Toronto

 

In a single case of a suicidal woman who had tried psychiatric drugs, electrical pulses to the brain, shock therapy, none of which provided her any relief from her severe depression, which led her to apply for medically assisted death, her life suddenly turned around when her doctors gave her ketamine. Her depression in the space of under two weeks "rapidly and robustly remitted".

 

This single success has led researchers to be concerned that ketamine may be "easily overlooked" by people considering MAID for major depression, along with their doctors, when medical assistance in dying becomes an available option for people suffering acutely from depression. This case study illustrates the potential for "grave and irreversible consequences" of prematurely declaring an individual's depression to be irremediable; incurable.

There are responses of the study on the careful side cautioning that psychedelic-assisted psychotherapy may not be an automatic lifeline for those seeking assisted death, since requests could conceivably be in either direction, with some people becoming more at peace with such a decision. At the present time, Canadians whose underlying illness is a mental disorder are not eligible for assisted death. 

However, the federal government introduced a bill delaying MAID eligibility for people with mental illness until March 17, 2024, an extension from the original timeline to allow psychiatrists additional time to prepare for the change, in response to outcries of consternation that assisted death be available to people suffering ill mental health. Even as it would be critical in granting euthanasia that "incurability" be established.

Ketamine, available since the 1960s, is one of the most commonly used anesthetics in medical use worldwide, for surgery and for rapid pain relief in emergency procedures such as replacing a dislocated shoulder. It is also a risky and illegal club drug "for those looking to feel a little lighter and a little loopier on the dance floor". Across the United States, ketamine clinics are opening -- with more than a dozen operating privately in Canada.

The charge is about $1,000 per treatment. Dr. Greenway's team is able to treat only a few patients weekly. In 2000, scientists for the first time began testing ketamine as an antidepressant. One very small trial with seven subjects suffering major depression found a significant improvement in symptoms reported by people, within 72 hours of a ketamine infusion. Following that, a review of evidence from 83 publications found depression symptoms can be reduced within one to four hours after a single treatment, lasting up to two weeks.

A Canadian and American research team raised serious safety concerns recently on the effects of repeatedly inducing an altered mental state.  Dr. Greenway, operating out of a ketamine clinic at the Jewish General Hospital, is cautious. The findings are that altered consciousness has a range from a fleeting, pleasant euphoria to "significant psychosis". When used as an anesthetic "people feel a little bit strange, and they might see the room a little bit distorted". 

People experience vivid and "pretty pronounced" hallucinations within ten to 20 minutes when injected in lower doses, part of ketamine-assisted psychotherapy, noted Dr. Greenway. People report variously feeling like they're dissolving, or melting into the universe, as a mystical experience. "Sometimes very emotional stuff comes up. It's very psychedelic that way", explained Dr. Greenway. After about 90 minutes there is a return to normal.

It is unknown how ketamine eases depression and suicidal thinking. There are studies that suggest ketamine promotes the growth of neurons and connections between neurons. People are encouraged by Dr. Greenway to use the "momentum" from immediate effects of ketamine to make life changes and take to psychotherapy -- "stuff that will help keep people well without necessarily needing repeated or weekly doses for the rest of their lives."

Ketamine is inexpensive, about three dollars each dose, requiring an infusion pump, a quiet room, a nurse and a therapist. And not everyone responds; about ten percent of those receiving ketamine for depression remit robustly, though some evidence exists suggesting the greater the treatment-resistance, the greater the odds of ketamine helping to avoid MAID  requests.

All drugs have side effects. When someone is suicidal or severely depressed, possible benefits may outweigh possible risks.

Ketamine given by infusion may cause:

• high blood pressure
• nausea and vomiting
• perceptual disturbances (time appearing to speed up or slow down; colors, textures, and noises that seem especially stimulating; blurry vision)
• dissociation (sometimes called out-of-body experiences); rarely, a person may feel as if they are looking down on their body, for example.

Generally, any changes in perception or dissociation are most noticeable during the first infusion and end very quickly afterward.

Harvard Health