Legal Framework & Definitions, Vulnerable Populations

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.  

DWDC, “Myths and Facts: Medical assistance in dying (MAID) in Canada”

Medical assistance in dying (MAID) is a process that allows someone who is found eligible to be able to receive assistance from a medical practitioner in ending their life. The federal Criminal Code of Canada permits this to take place only under very specific circumstances and rules. Anyone requesting this service must meet specific eligibility criteria to receive medical assistance in dying. Any medical practitioner who administers an assisted death to someone must satisfy certain safeguards first.

Only medical practitioners are permitted to conduct assessments and to provide medical assistance in dying. This can be a physician or a nurse practitioner, where provinces and territories allow.

Government of Canada, “Medical assistance in dying: Overview”

The next thing I want to speak about is whether the vulnerable need protection. Again, this has been tried in court with both the Carter case and Truchon case. There is no evidence that vulnerable people are at risk for MAID. [Ed. Minor evidence suggests otherwise, now, but small and select, see AP News.] In fact, if you look at the actual people who are receiving MAID, they are typically white, well educated and well off. You could easily argue that the marginalized communities are disadvantaged because they’re not accessing MAID. In the Truchon case, Justice Baudouin equally found that the disadvantaged are not being taken advantage of and you must do each case at a time.

Dr. Derryck Smith, “Special Joint Committee on Medical Assistance in Dying”

Death is a sensitive topic. It is a different question from the origin of life, the evolution of organisms, the speciation of species, and the point when life begins for human beings. We’re dealing with a live person who can make, ideally, informed decisions about a profound moment in life: its end. For those who know those who have tried to take their life, the sensitivity is multiplied over social relations. Rational foundations for care in finality are important, though. A lot of smart humanists have thought deeply about this topic.

Humanists can be stereotyped–as a whole without exception–supporting medical assistance in dying (MAID) at the expense of palliative care. MAID as a way to reduce healthcare burden (of the old, the sick, the disabled), and dangerous as a “social contagion.” Atheist humanists get the worst of it, because of the major prejudices felt and only recently researched in an academic context.

The lattermost, as a piece of falsehood, emerges with relative frequency. These will be case examples for this article. These cases critiquing the imperfection of MAID have a sensibility akin to creationist critiques of evolution with God of the Gaps arguments. God of the Gaps arguments point to absences or uncertainties in scientific knowledge and then assert divine intervention. It is a form of magical thinking. Critique evolution superficially without proposing a workable alternative; what is the evidence-based alternative with greater efficacy than MAID, where MAID is merely one option? This challenges the trade-off myth. There will be failures in any system. Is this more efficacious than the system not existing? Stuff like that. 

Debunking Common Myths

Canada has an organization devoted to these issues, DWDC. I found and took a statement about the spread of misinformation about MAID by DWDC seriously. DWDC noted myths about:

• “advocating to kill infants with disabilities” 
• “mature minors will be eligible for medical assistance in dying (MAID) in March 2027” 
• “opening the door for suicidal children and teenagers to access an assisted death” 
• “eligibility of mature minors is being considered without adequate protections in place and without consultation or consent from parents or guardians”
• “clinicians inappropriately recommending MAID to patients who are not eligible or as an alternative to treatment” 
• “vulnerable populations being eligible for MAID because they are suffering from inadequate social supports, including housing” 
• “Canada is systematically targeting and ‘killing’ the poor, disabled, and marginalized instead of giving them the proper supports they need to live.”

Social Contagion Concerns

DWDC identified a few more. However, this sets a foundation for knowledge about misinformation’s ubiquity dispensed flippantly by both left and right alike. This has political debate content. The fundamental issue is humane treatment. That shouldn’t be political. Upon doing a first search on social contagion, the source of some misinformation was made by right-wing conservative groups. The idea being, thus: “Physician-assisted suicide is social contagion.” 

Social contagion research on suicide seems to rely on fear of copycats: a good fear. The substantive enquiry: Is the evidence proportional to support this assertion, or is the general assertion of social contagion of suicide equivalent to medical contexts, including MAID? Health Canada’s 2022 MAID monitoring report analyzed suicide rates. The 2022 study found no significant increase in suicide rates following MAID legalization in 2016. This differs compared to patterns after high-profile celebrity suicides. The American Psychological Association’s 2014 review (Psychological Bulletin, Vol. 140) links media sensationalism to copycat suicides. In other words, MAID’s regulated approach mitigates the standard effects seen in social contagion risks. Health Canada did the study. The American Psychological Association 2014 found the same for copycat behaviours and media exposure, not due to structured medical processes.

Palliative Care vs. MAID

According to DWDC and the Government of Canada, MAID has multiple safeguards in place, as stipulated at the outset. General suicides exclusive to MAID do not have safeguards in place. Of those two, to the original question, what is the evidence-based alternative with greater efficacy than MAID, where MAID is merely one option? Which is to say, in either case, conditions for palliative care exist equivalently, while MAID is in place versus not. 

Exceptional (Super‑Minority) Cases

What about the exclusionary cases? That one does not wish to happen at all. A super-minority of unfortunate cases as exceptions to the principles of MAID. “Canadians with nonterminal conditions sought assisted dying for social reasons” described social conditions under which some MAID cases continued with “unmet social need.” Health Canada’s Fifth Annual Report (2023) report showed less than 2% of the 13,241 assisted deaths by individuals involving psychosocial factors as primary motivators.

We should all strive to help those with unmet social needs, who may fall under this category. These commentaries point to inefficiencies in safeguards, particularly in super-minority specific cases, not the principle. This is the relevance of God of the Gaps arguments with creationism against evolution. 

To identify gaps is to identify gaps in MAID-specific cases and, thus, in the general population too, the bodies found in general populations, probably, result in less dignified and compassionate deaths. We should emphasize palliative care and other care more to balance the ratio of provisions for Canadian citizens. The Special Joint Committee’s 2023 report found that 3 in 10 Canadians can access high-quality palliative care. Rural areas and Indigenous communities are underserved. Ontario integration of palliative consultations with MAID assessments reduced requests by 15%. This synergy shows promise; it’s not either-or. This is to say, again, that the principle stands while exclusive super-minority cases require more work. Critics do a service here, up to and including robust, systemic, integrated alternatives. 

Social contagion merely applies to the unregulated and unsafe cases of suicide, as in a double-barrel shotgun after a woman in a depressive fit after a breakup. It is different than a considered, regulated, informed choice about suicide with the assistance of a qualified professional in most of the other cases. MAID supports something more akin to the latter than the former. We should have expanded social programs for those who need them, more robust MAID mechanisms, and condemnation of stereotypes about MAID that harm people who need them. Expanding social programs may incorporate guaranteed housing subsidies. 

Conscience, Faith, and Coercion

MAID is the main option available for those who need it. If an individual believes in a divine being, and does not want to become enmeshed in humanist or other ideology around their decision or their end of life, they should be permitted to make that choice, according to their conscience and faith. Similarly, those who do not share that notion, in which human beings do not ultimately own their life, a god does, should be permitted their conscience-based free choice too. If someone is being coerced, this would fail the principle and the spirit of the MAID options permitted in Canada.

Scott Douglas Jacobsen is the publisher of In-Sight Publishing (ISBN: 978-1-0692343) and Editor-in-Chief of In-Sight: Interviews (ISSN: 2369-6885). He writes forThe Good Men Project, International Policy Digest (ISSN: 2332–9416), The Humanist (Print: ISSN 0018-7399; Online: ISSN 2163-3576), Basic Income Earth Network (UK Registered Charity 1177066), A Further Inquiry, and other media. He is a member in good standing of numerous media organizations.

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