Medical assistance in dying (MAID) in Canada
On February 15, 2023, the Special Joint Committee on Medical Assistance in Dying reported on five mandated issues: advance requests, access to MAID for mature minors, access to MAID for those whose sole underlying medical condition is a mental disorder, the state of palliative care, and the protection of people living with disabilities. A considerable amount of misinformation has circulated in the public sphere and media and Dying With Dignity Canada (DWDC) would like to set out some clear facts surrounding MAID, the strict criteria and safeguards that govern its use, and aspects of its proposed expansion.
Fact: Dying With Dignity Canada has never advocated for medical assistance in dying for infants, with or without a disability. We believe mature minors (individuals at least 12 years of age and capable of making decisions with respect to their health) should be allowed the right to choose MAID with special eligibility criteria in place. In many jurisdictions across Canada, mature minors already have the right to make important decisions regarding their care. This includes the right to consent to or refuse lifesaving medical treatment. We recommend that the informed consent of a competent parent or guardian be required for eligible minors 12-15 years of age inclusive, and that MAID assessors be required to consult a competent parent or guardian for eligible minors aged 16-17. The most important criterion in Canada’s assisted dying law is the ability to request MAID and provide informed consent to the procedure. We do not advocate for MAID for infants as they cannot request MAID nor provide consent.
Fact: This is not true. MAID is not currently available to individuals under 18 and will not be unless amendments are applied to the Criminal Code. The eligibility of mature minors (under the age of 18 but capable of making decisions related to their health) is a separate issue and has no connection to the legalization of MAID for mental disorders. There is currently no legislation proposed that addresses the eligibility of mature minors for medical assistance in dying. In its Final Report, the Special Joint Committee recommended that mature minors be eligible to access MAID with appropriate protections and safeguards – including that the Government of Canada restrict MAID for mature minors to those whose natural death is reasonably foreseeable.
Fact: Under Bill C-7, the eligibility of individuals whose sole underlying medical condition is a mental disorder applies only to adults 18 years of age or older and have decision-making capacity. Access to MAID by mature minors (under the age of 18 but capable of making decisions related to their health) is a separate issue and has no connection to the legalization of MAID for mental disorders. There is currently no legislation proposed that addresses the eligibility of mature minors for medical assistance in dying. Regardless of age, individuals experiencing suicidality or in a state of crisis will not be eligible for MAID.
Fact: The most important criterion in Canada’s assisted dying law is the ability to request MAID and provide informed, voluntary consent to the procedure. In many jurisdictions across Canada, mature minors already have the right to make important decisions regarding their care. This includes the right to consent to or refuse lifesaving medical treatment.
When considering a mature minor’s capacity to consent to or refuse treatment, the courts look to age, maturity, intellect, life experience, and the psychiatric, psychological, and emotional state of the minor. Many of the expert witnesses before the Special Joint Committee testified that neither suffering nor capacity is related to age. Nevertheless, Dying With Dignity Canada believes that MAID assessors be required to consult a competent parent or guardian for eligible minors aged 16-17, and that the informed consent of a competent parent or guardian be required for eligible minors 12-15 years of age inclusive.
In the Netherlands, assisted dying for mature minors has been legal since 2002. Between 2002 and 2015, seven minors accessed an assisted death, and “the majority concerned children with terminal cancer.”1 In Belgium, assisted dying for mature minors has been legal since 2014, and data from 2016 to 2017 showed that a total of three minors received medical assistance in dying.
In its Final Report, the Special Joint Committee recommended several protections and safeguards, and that MAID for mature minors only be available in instances where the individual’s death is reasonably foreseeable. One such recommendation was that the Government of Canada establish a requirement that, where appropriate, the parents or guardians of a mature minor be consulted in the course of the assessment process for MAID, but that the will of a minor who is found to have the requisite decision-making capacity ultimately take priority. It was also recommended that the Government of Canada appoint an independent expert panel to evaluate the Criminal Code provisions relating to MAID for mature minors within five years of the day on which those provisions receive Royal Assent, and that the panel report their findings to Parliament.
1 Brouwer, M. (2021). At the boundaries of life: Suffering and decision-making in children with life-threatening conditions (1-12 years). [Thesis fully internal (DIV), University of Groningen]. University of Groningen. https://doi.org/10.33612/diss.159020586
Fact: This is not true. All MAID assessments are done on a case-by-case basis, and individuals must meet the rigorous criteria to be eligible for an assisted death; the same rigour would be applied to those whose sole condition is a mental disorder.
Under Bill C-7, Track 2 patients (those who do not have a reasonably foreseeable death) must meet strict criteria, including that one of the two assessors have expertise in the condition causing suffering; the person must be informed and seriously consider available and appropriate means to relieve their suffering, including counselling services, mental health and disability support services, community services, and palliative care, and must be offered consultations with professionals who provide those services; the eligibility assessments must take a minimum of 90 days; and final consent must be given by the patient immediately before the procedure.
We anticipate that a very small number of individuals will be eligible for MAID with a mental disorder as the sole underlying condition – individuals who have endured many years of persistent, unbearable suffering that has not been improved by many attempts at different interventions. In the Netherlands, where assisted dying for mental illness has been available for 20 years, only 1% of assisted deaths have been approved for those suffering from mental disorder. Individuals who are in an acute mental health crisis will not be eligible for MAID.
Fact: Medical assistance in dying (MAID) is a medical procedure provided by qualified nurse practitioners and physicians. These clinicians are regulated through independent regulatory bodies in each province and territory whose mandate is public protection. Like any other medical procedure, MAID assessors and providers must adhere to legislation, regulation, practice standards, policies, and procedures. Failure to comply with these regulations could have serious consequences for a clinician, such as losing their license to practice, and/or possible prosecution under the Criminal Code. There is no provision in the law that prohibits health care professionals from initiating a discussion or responding to questions about MAID. All health care providers have a professional obligation to respond to questions about MAID, but only nurse practitioners and physicians involved in care planning and consent processes have a professional obligation to initiate a discussion about MAID if a patient might be eligible – together with the option of palliative care.
Fact: This is not true. Bill C-14, Canada’s original assisted dying law, did not exclude people living with a disability from accessing MAID. The law stated that, in order to be approved for MAID, one must have a serious and incurable illness, disease or disability; be in an advanced state of irreversible decline in capability; that illness, disease, disability, or state of decline causes them enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions they find acceptable; AND their natural death has become reasonably foreseeable (without a prognosis as to the specific length of time they have remaining). Bill C-7 removed the last requirement, that natural death has become reasonably foreseeable, after a Canadian Charter of Rights challenge (launched by two Canadians living with disabilities), determined that it was discriminatory and a violation of the constitutional right to the security of person.
Fact: Suffering from a lack of social supports does not qualify a person for MAID. No one can receive MAID on the basis of inadequate housing, disability supports, or home care.
To be eligible for an assisted death, a patient must have a serious illness, disease or disability, be in an advanced state of decline that cannot be reversed, and experience unbearable physical or mental suffering from that illness, disease, disability or state of decline that cannot be relieved under conditions that person considers acceptable. A person must be approved by two independent assessors, each of whom work within the parameters of the law; they are careful and thoughtful in their work.
Fact: This is not true. The most important criteria in Bill C-7 is that an individual must have made a voluntary request for MAID that was not a result of external pressure and must give informed consent to receive MAID after having received all information needed to make this decision, including a medical diagnosis, available forms of treatment, and options to relieve suffering (including palliative care). MAID assessors carefully assess a person’s reasons for applying for MAID to ensure there are no signs of coercion.
Fact: Palliative care and MAID both provide quality options for care at the end of life. According to Health Canada, 80% of Canadians that seek an assisted death have also accessed palliative care. In the situations where palliative care was not accessed prior to MAID, it was available to the patient 88.5% of the time.
Fact: MAID is not about cost savings; it is about compassion and choice to end suffering that is intolerable to the individual. A 2020 report by the Parliamentary Budget Office (PBO), created as part of its mandated independent economic and financial analysis to Parliament, has stated that the “net reduction in health care costs for the provincial governments represent[s] a negligible portion (0.08%) of the health care budgets of provinces.”
Fact: The criteria for eligibility for MAID are clear: a person must have a serious and incurable illness, disease, or disability, be in an advanced state of irreversible decline in capability, and they must be experiencing intolerable suffering caused by the illness, disease or disability or state of decline. Poverty, short intervals of depression, or feelings of being a burden do not qualify a person for MAID.
No one can be forced into accessing MAID. It is a decision made by free and informed individuals after having been offered alternative means to relieve their suffering. Suffering caused by social or financial factors may contribute to someone applying for medical assistance in dying, but that application would not be approved based on those factors. MAID assessors carefully assess a person’s reasons for applying for MAID to ensure there are no signs of coercion.
As concluded by Madam Justice Christine Baudouin in Truchon v. Quebec, “Neither the national data in Canada or Quebec nor the foreign data indicate any abuse, slippery slope or even heightened risks for vulnerable people when imminent end of life is not an eligibility criterion for medical assistance in dying.”
Fact: The root of the term euthanasia comes from the Greek – eu, meaning good, and thanatos, meaning death. A simple definition of euthanasia is “the practice of intentionally ending life to relieve pain and suffering.” The term itself is not inherently wrong or bad; in fact, some jurisdictions around the world still use the term euthanasia in their assisted dying legislation. The reason Dying With Dignity Canada avoids this term is because it has been commandeered by the anti-choice movement in Canada.
Fact: The provision of medical assistance in dying (MAID) in most of Canada is by intravenous administration of a series of medications – most typically midazolam, propofol, and rocuronium. The first medication is used as a sedative, the second puts the individual into a deep coma, and the third ultimately stops the person’s heart. The injecting of medications, and death, typically occur within five to eight minutes.
These medications have been used in emergency departments and operating rooms long before they were used for medical assistance in dying. If you have ever been sedated before an operation or procedure, you were likely given midazolam, followed by propofol, and will know that there is no memory, pain, or suffering during the procedure. The dosages provided during a MAID provision are much higher. The medical assistance in dying procedure is a peaceful one.
Empower. Inform. Protect your rights.