“Primum non nocere [First, do no harm].”
Hippocrates
Medical Assistance in Dying (MAID) marks a significant change in Canada’s end-of-life care, sitting at the crossroads of legal, ethical, and social discourse. In 2016, MAID was legalized following the Supreme Court’s *Carter v. Canada* decision. It was formally established through Bill C-14, which permitted those 18 and older with intolerable suffering and a foreseeable death to seek assistance in ending their lives. Then in 2021, Bill C-7 removed the foreseeable death requirement, allowing individuals with chronic conditions to access MAID and creating a two-track system for cases with and without foreseeable death. Starting in 2027, eligibility will extend to individuals with mental illness as the sole underlying condition, intensifying ethical debates around safeguarding vulnerable groups. This legal evolution underscores Canada’s commitment to individual autonomy. Yet it also highlights the need for compassionate frameworks that protect those at risk while balancing individual rights with social and ethical responsibilities.
“It’s my right”
Canada’s legalization of MAID is built on the foundation of respecting patients’ autonomy. MAID enables individuals to exercise control over their end-of-life choices, prioritizing their personal values and preferences. While autonomy is a fundamental right, the decision-making capacity of the individual must be carefully assessed, considering any mental health issues or cognitive impairments. Importantly, patients must give informed consent, which means they must fully understand their diagnosis, prognosis, alternatives, and the nature of the procedure while having the capacity to withdraw their consent at any time.
A qualitative study interviewed 23 patients eligible for MAID and their support persons in Vancouver, Canada in the first year after its legalization. When asked why certain patients would choose MAID over natural death or other medical interventions, the most common reason was their desire to exercise full autonomy and control over their life and suffering. Other common reasons for choosing MAID included deteriorating quality of life, decline in independence and function, and inability to participate in meaningful activity – which are all significant losses for patients who were previously independent and self-reliant. Interestingly, this qualitative study found that many patients who opted for MAID felt adequately supported by their family and friends and viewed MAID as an appropriate end-of-life care option.
Choice v. Coercion
It may be challenging to secure informed consent for all MAID participants, particularly from those who are vulnerable and subject to coercion by external factors. Members of such vulnerable population may include elderly or disabled individuals, and people with mental illnesses. Social, familial and financial pressures, along with insufficient healthcare support, may lead patients to choose MAID out of guilt rather than genuine desire. Although safeguards like required written consent with a paid, independent witness are put in place, critics against MAID argue that compensating witnesses could undermine their neutrality and create financial barriers that limit equitable access.
There is also concern from the Supreme Court of Canada that MAID acts as a mere substitute for investing in essential healthcare and social services. In other words, the program might be a cost-saving alternative to addressing systemic issues like long hospital wait times and low public health funding. The Parliamentary Budget Officer’s report in 2020 noted that 62 million CAD is saved annually from Bill C-7, fueling intense debates and speculation that MAID may be chosen reluctantly by patients as a final solution due to inadequate support.
Conscientious objection – a physician’s duty?
For some healthcare providers, the principle of “do no harm” may go against their personal, religious, or ethical values, leading them to reject any involvement in MAID. Balancing the obligate respect for patient autonomy with physicians’ rights to follow their moral beliefs is a sensitive topic. Many Canadian institutions allow for conscientious objection, permitting medical providers to refuse participation but requiring them to refer patients to another practitioner. However, critics argue that a physician’s objection could restrict patients’ access to an essential medical service. As an accessible alternative, the Canadian government has allowed patients to bypass non-participating providers and acquire MAID referrals without the need for clinicians’ approval. However, this alternative approach still creates burden on the patient to seek out a participating provider, potentially delaying access to MAID, prolonging patient suffering, and undermining the right to equitable, timely care. A more fundamental criticism to conscientious objection is that it allows publicly funded physicians to choose which lawful procedures they will provide. The practice of conscientious objection places the physician at the center of decision-making rather than the patient, instigating ethical debates about properly balancing the rights of all parties involved in MAID.
A slippery slope: what about mental health?
Expanding Canada’s MAID law to include individuals with mental disorders would raise profound ethical questions. Advocates argue that individuals with irremediable mental health disorders should have the same right to die with dignity as those with physical illnesses, emphasizing autonomy and equality. However, this expansion could expose individuals to higher risks of suffering due to social factors like poverty, isolation, or inadequate mental health care. Without robust support systems, individuals may choose MAID due to remediable conditions such as homelessness or unemployment. Ultimately, these dilemmas present policymakers with the challenge of protecting vulnerable individuals from transient distress while respecting their rights.
Another ethical issue in broadening MAID eligibility is its potential impact on mental health stigma and quality of care. Allowing MAID for those with mental health disorders could unintentionally reinforce the perception that certain conditions are untreatable, potentially eroding trust in mental health care. It could also discourage the development and delivery of improved treatments or support mechanisms. Healthcare professionals who support MAID could undermine therapeutic relationships by inadvertently conveying hopelessness to susceptible patients. The need to protect individuals from systemic failings while respecting their autonomy highlights the importance of cautious policymaking that centers on the well-being of vulnerable individuals.
Final comments
Medical Assistance in Dying (MAID) in Canada presents a complex ethical challenge of respecting patient autonomy while protecting vulnerable populations and acknowledging professional responsibilities and societal values. This evolving practice requires ongoing dialogue and legal refinement to uphold ethical standards within a framework that respects individual rights and public safety. The ongoing shifts in MAID policies reflect Canada’s efforts to carefully integrate end-of-life autonomy with essential safeguards. In the coming years, we anticipate further discourse and adjustments as Canada navigates this intricate issue.
Resources
https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
MAID patient interview: https://pmc.ncbi.nlm.nih.gov/articles/PMC6135118/
Ethical considerations: https://www.erudit.org/en/journals/bioethics/2021-v4-n2-bioethics06607/1084456ar.pdf
Concientious objection: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-020-00486-2
The Spectator: https://www.spectator.co.uk/article/most-read-2022-why-is-canada-euthanising-the-poor/
MAID and mental health: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-023-00971-4#Sec3
https://pmc.ncbi.nlm.nih.gov/articles/PMC5788138/