The Canadian government is pushing for Canada to become a global leader in providing Medical Aid in Dying (MAiD), also known as physician-assisted suicide, medically assisted death, or euthanasia in other countries.

Carter vs. Canada physician

Prior to the 2015 Supreme Court case of Carter vs. Canada, Canadians generally viewed MAiD as a humane option to end unbearable suffering caused by incurable diseases. However, the current discourse surrounding MAiD for minors, infants, and individuals with mental health conditions suggests a departure from this perspective.

Rather than being viewed as a last resort for terminally ill patients, MAiD is now being promoted as a treatment option to alleviate concerns about potential suffering, address feelings of loneliness and isolation, and even as a solution for unmet social needs.

Simons Canada

In the autumn of last year, Simons Canada, a fashion company, gained global attention for a video advertisement that portrayed a romanticized version of Medical Aid in Dying (MAiD) (Harrington 2022).

According to British media, the patient featured in the ad, Jennyfer Hatch, had previously expressed to CTV in June that she felt neglected and unsupported, falling through the cracks (Pennock 2022).

During the same period, the world was closely following several instances of Canadian patients applying for Medical Aid in Dying (MAiD) due to financial difficulties. Reports emerged of young adults undergoing screenings and receiving approval for MAiD without informing their families (Subramanya 2022). physician

In December, CTV News reported that several veterans were offered MAiD as a treatment option (Yun 2022). One veteran, who was also a former Paralympian, had been attempting to have a wheelchair ramp installed in her home for five years, but her case worker suggested MAiD as an alternative solution.

Presently, the discussions regarding Medical Aid in Dying (MAiD) in Canada appear to be as commonplace as discussions about any other medical procedure. A study conducted by Brassolotto, Manduca-Barone, and Zurbrigg (2022) analyzed Canadian news media coverage of MAiD in December and reported that “the public discourse in Canada has largely shifted away from these philosophical debates (e.g., ‘should we permit assisted death?’)

Canadians have moved away from debating the philosophical aspects of MAiD, as the Supreme Court of Canada has already addressed and settled these debates. In the Carter v. Canada (2015) case, the Court ruled that ending a patient’s life is lawful and justified in specific circumstances with proper safeguards. With the Court’s approval for MAiD, the focus can now be on implementation, which is what Canada has been doing.physician

Patient volumes and cost savings

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the federal government’s annual report, since Canada legalized MAiD in 2016, 31,664 Canadians have undergone the procedure.

More than 80 percent of MAiD requests are approved, and 17 percent of patients cited “isolation or loneliness” as a primary motivation for death. Canada leads the world in organ donation from MAiD patients, with 6 percent of transplanted organs in 2021 obtained after MAiD.

The cost of MAiD is often discussed in relation to Canadian healthcare.. According to the Parliamentary Budget Officer (PBO) report, Bill C-7 and the expansion of MAiD to patients whose death is not expected soon could result in significant cost savings. Current legislation, Bill C-14, would reduce healthcare costs by $86.9 million, but Bill C-7 could offer an additional $62 million in net incremental savings. Patients who choose MAiD do so sooner, making it a more efficient and cost-effective option. With Bill C-7, the total net reduction in healthcare costs would be $149 million.physician

Readmore When suicide attempts turn into assisted suicides

The Financial Healthcare

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The financial impact of Bill C-7 is larger due to the high healthcare costs in the last year of life. Patients in their last year of life represent only 1 percent of the population but account for 10-20 percent of total healthcare costs. However, the Parliamentary Budget Officer’s report does not suggest that MAiD should be used to reduce healthcare costs.

Bill C-7 became law in March 2021, with provisions for patients suffering from mental illness included in the bill, but with a delay in exclusion until March 2023. In response to public outcry in late 2022 and early 2023, the government extended the temporary exclusion until March 2024 through Bill C-39.

Canada’s single-payer healthcare system presents a conflict of interest for the government regarding MAiD, and MAiD presents a financial conflict for physicians. Although a small group of physicians has made MAiD a core element of their practice, only a small percentage of physicians are involved. In 2021, 1,577 of the 93,998 physicians in Canada provided MAiD, with approximately one-third performing only one procedure. However, the number of doctors who offer two to nine and ten or more procedures has been increasing.physician

Physicians present patients with two MAiD options: self-administered medication or physician/nurse-administered medication. Patients who choose self-administration typically take a combination of medications on their own, while patients who choose the physician-administered option receive a combination of intravenous medications.

The medications used in both cases include sedatives and paralytic agents to induce unconsciousness and stop breathing. In Canada, only seven patients chose the self-administered option in 2020. The physician/nurse-administered option is more popular because it offers immediate backup in the rare event that the initial medications fail to cause death.

In California, where assisted death is also legal, only 486 people chose this option in 2021, or 20 times fewer than in Canada. California law only allows self-administered medication, which may contribute to this significant difference in outcomes (Kay 2023). A review of 3,557 Canadian MAiD patients published in the Canadian Medical Association Journal reported that the medications most commonly used were propofol (98.5% of cases), midazolam (91.4%), and rocuronium (90.8%) (Stukalin et al. 2022).

New language for old ideas

Canada has refrained from using traditional terms such as “physician-assisted suicide,” “medically assisted death,” or “euthanasia” when referring to medical aid in dying. Instead, Canadian legislators coined a new term, “medical assistance in dying,” which is now known as medical aid in dying.

Some argue that the new language used for medical aid in dying was repurposed from palliative care, which has long been focused on normalizing death as a natural part of life. The positive connotations associated with palliative care were leveraged in the language of MAiD legislation to create a positive perception of the process of hastening death. Essentially, it was a way to use equivocation by legislation.

The use of this new language is intentional and avoids specific details, which suggests that there is public discomfort with the concept itself. Throughout history, other cultures have embraced death, including suicide, infanticide, and capital punishment. In recent years, Canadian advocacy groups worked to normalize the idea of a “good” death as part of a good life.

Dying With Dignity Canada is now seeking to normalize MAiD and urges people to avoid using old terms. American groups, such as the Portland association Compassion and Choices, also argue that “suicide and euthanasia” are not compassionate terms and that MAiD is a more suitable term.

Definitions

MAiD is a term that encompasses various forms of assisted dying and euthanasia. Its use allows for regulatory changes to be made without drawing attention to changes in terminology. While MAiD presently includes physician-assisted suicide and voluntary active euthanasia, debates are now considering non-voluntary active euthanasia, with only involuntary active euthanasia remaining completely outside public consideration in Canada.

Despite advocates insisting that these terms are no longer relevant, they still refer to distinct clinical scenarios that attract different levels of public support. To understand these scenarios, it is necessary to review their definitions.

Physician-assisted suicide involves a physician or nurse practitioner providing a patient with the means (medications) to end their own life. Nurse practitioners in Canada are now authorized to perform this act, which is referred to as “provider-assisted suicide.”

Euthanasia, from the Greek words for “well” and “death,” refers to someone other than the patient ending their life. Nurse practitioners in Canada are also authorized to offer this service to patients. Euthanasia can be active or passive and can be voluntary, nonvoluntary, or involuntary.

Active euthanasia involves a physician or nurse intentionally causing a patient’s death. Passive euthanasia involves the withdrawal of nutrition with the intent to cause death, which is different from stopping futile therapy. There is a clear distinction between stopping futile treatment and intentionally causing death, and equivocation between the two should be avoided.

Euthanasia also differs in terms of consent. In Canada, voluntary-active euthanasia is permitted, meaning that patients must provide full and informed consent before the procedure. Non-voluntary active euthanasia involves causing death for patients who are unable to provide consent, such as infants or adults with dementia, or for those who did not have the opportunity to provide consent. Involuntary active euthanasia involves causing death against a patient’s wishes, which is universally condemned.

Incorporating MAiD Medicine

Prior to the pandemic, Canadian hospitals had integrated MAiD into their established medical treatment lists. Hospital medical advisory committees had formed subcommittees to update hospital rules and regulations to incorporate medically assisted death even before the MAiD legislation in 2016. Hospitals now only require minor adjustments to their eligibility criteria and procedural manuals to implement MAiD’s ever-expanding criteria.

The Canadian Association of MAID Providers advocates for all physicians to mention MAiD as a viable treatment option. While some medical institutions remain silent on the matter, others push for further expansion of MAiD. For example, last fall, the Quebec College of Physicians proposed to include euthanasia for infants born with conditions that make life impossible. However, euthanizing infants may have been a push too far, as even the progressive-leaning Toronto Star columnist Andrew Phillips expressed shock at the notion.

The overwhelming support for MAiD in Canada advertised by advocacy groups may not be as clear-cut as it seems. While surveys suggest 80% of Canadians support MAiD, both ends of the spectrum – for and against – have strong and committed opinions, with the majority of Canadians expressing “cautious support.”

Unresolved tensions

The incorporation of MAiD into medical bureaucracy has not been without its challenges for healthcare professionals. The legislation has introduced ethical, ontological, and procedural tensions, which have yet to be resolved.

Ethical tension arises from a conflict between the reordering of values brought about by MAiD. Medicine has traditionally been focused on the restoration or preservation of health, with patient autonomy and respect for human life coexisting due to the inherent limits to autonomy.

Informed consent was balanced against a duty-based ethic that included the principle of non-maleficence, expressed in the Hippocratic Oath. Prior to MAiD, clinicians could follow both principles without ethical tension.

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