MAID IN CANADA

“Having the choice at the end of my life has become incredibly important. It has given me a sense of peace during a time that otherwise would be dominated by fear, uncertainty, and pain.” –Brittany Maynard

The debate is over.  MAID or Medical Assistance In Dying has been the law in Canada since Bill C-14 was passed in June 2016. Since its inception, there have been many amendments to the law, most recent changes in eligibility in March of this year.  More on this later.

EARLY TRAILBLAZERS

Nearly 30 years ago, Sue Rodriguez, a Victoria, BC woman with amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease), asked legislators to change the law banning assisted suicide. The Supreme Court of Canada ultimately ruled against Rodriguez. She committed suicide in 1994 with the help of an anonymous doctor.

Gloria Taylor, a right-to-die activist who had ALS, won support from the BC civil liberties union, which eventually led to lifting the federal ban on assisted suicide by the BC Supreme Court. Taylor got an exemption from the law but died in Oct. 2012 before she could avail of an assisted suicide.

Dr. Donald Low, a Toronto microbiologist the public health officer in the 2003 SARS crisis, made a posthumous plea for Canada to change the law to allow assisted suicide. He died in 2013 of a brain tumour at 68, well before MAID legislation became law.

In 2015, a landmark Supreme Court of Canada decision re: Carter v. Canada ruled that prohibition of assisted suicide was contrary to the Canadian Charter of Rights and Freedoms. A woman suffering from degenerative Spinal Stenosis, Kay Carter, won a MAID decision when the SC overturned an earlier SC 1993 ruling in the Sue Rodriguez case, which denied her a MAID. Unfortunately, this decision came too late as the family of Kay Carter had already taken her to Switzerland to avail of MAID in January 2010.

In the US, Dr. Jack Kevorkian, a Michigan pathologist, made headlines about his “suicide machine,” publicly advancing the concept of physician-assisted suicide. In 1999, he was jailed for second-degree murder after helping a terminally ill patient to die. However, he was released in 2007, unapologetic for conducting assisted suicide.

In June 2014, the province of Quebec adopted a right-to-die legislation, a law respecting end-of-life care.  At the time, Quebec was the fourth jurisdiction in North America, after Oregon, Vermont, and Washington, to allow MAID.

ASSISTED SUICIDE IN OTHER COUNTRIES

Switzerland has been at the forefront of assisted suicide since 1937.  It only considers it a crime if the motivation is selfish (i.e., monetary gain ) but condones it for altruistic reasons ( terminal illness, chronic pain ).  Doctors are prohibited from professionally participating in assisted suicide. 

Several organizations have been formed to help individuals seeking assisted suicide. For example, Zurich-based Dignitas, whose slogan ” Live with dignity, die with dignity” was founded in 1998, had 7 764 members from 98 countries in 2016.  In 2015, 201 people traveled to Switzerland to end their lives.

Since then, seven other countries have enacted laws to legalize euthanasia and assisted suicide.  They are, in the order of legalization: Netherlands, April 2002, Belgium, May 2002, Luxembourg, March 2009, Columbia, Dec. 2014, Canada, June 2016, Spain, March 2021, New Zealand, Nov. 2021 ( when it will take effect )

There are now 10 US states that have legalized assisted suicides.  Except for Oregon, Vermont, and Washington, all the other seven jurisdictions have passed ” death with dignity statutes” only in the last six years.  California, Colorado, D.C., Hawaii, Maine, New Jersey, and  New Mexico.

“For my patients who have used this law, I was honored that I could be with them every step of the way, ensuring that they were cared for and that they

had control of the final days of their lives. That’s what death with dignity really means.”

—NICHOLAS GIDEONSE, MD

EUTHANASIA, MAID, DNR, PST:   WHAT DO THEY MEAN?

The old definition of euthanasia ( from the Greek word “euthanos,” which means “easy death” ) as “mercy killing” was thought to represent the intentional ending of a person’s life suffering from a terminal, painful illness. However, most jurisdictions have legal ramifications on how euthanasia is applied, hence several categories. 

Active euthanasia ( where a person deliberately causes the patient’s death )or passive ( when death occurs due to a withdrawal of treatment ). Voluntary ( when carried out at the request of a patient ) and non-voluntary  ( when a patient is not able to indicate a request due to a medical condition, in which case another person can request on behalf of the patient )

MAID  or medical assistance in dying is typically a physician-assisted death in which a doctor knowingly and intentionally participates in the death of a patient or provides the means to self administer a substance leading to his demise. It can also include counseling, prescribing, or supplying the drugs.

DNR or “do not resuscitate” is usually part of a living will, where individuals indicate their preferences for end-of-life care.   It is commonly requested by aging and terminally ill patients.  A doctor signs this order according to a patient’s directive if there is a stoppage of breathing or cardiac arrest.

PST or palliative sedation therapy is sought to relieve suffering to a dying person.  It is not euthanasia, and it is not MAID.  The use of barbiturates, benzodiazepines, morphine, and other medications induces a person into a semi-conscious state to relieve pain, anxiety, and distress. This practice does not hasten death, but it comforts the final hours/days of life as the body gradually shuts down.

MEDICALLY ASSISTED DYING IN CANADA

Before the new law came into effect, the Criminal Code of Canada outlaws suicide assistance with penalties of up to 14 years in prison.  Indeed several people were prosecuted and jailed for helping people kill themselves.  Out of desperation, several Canadians traveled to Switzerland and Netherlands to avail of assisted suicide.

Support for medically assisted dying had been very high, especially after the well-publicized travails of Sue Rodriguez, Carter, and others.  The increasing secularism of the country also played a role, as religious opponents’ voices increasingly fell on deaf ears.  Support ran into the ’80s and as high as 90% in BC and NS.

When Quebec passed its end-of-life care legislation in 2014, it was only a matter of time before a federal law was instituted. Under Bill C-14, which came into effect on June 17, 2016, assisted suicide and voluntary euthanasia are permitted. MAID is an umbrella term that includes: a) the administration by a medical or nurse practitioner of medication that will cause a person’s death at their request and b) prescription by a medical or nurse practitioner that a person can self administer to cause their death.

The law limits eligibility to competent adults whose natural death was reasonably foreseeable ( amended in 2021 )

ELIGIBILITY CRITERIA AND SAFEGUARDS

The law no longer requires a person’s natural death to be reasonably foreseeable as an eligibility criterion for MAID.

As of March 17, 2021, persons who wish to receive MAID must satisfy the following eligibility criteria:

• be 18 years of age or older and have decision-making capacity
• be eligible for publicly funded health care services ( OHIP in ON. )
• make a voluntary request that is not the result of external pressure
• give informed consent to receive MAID, meaning that the person has consented to receive MAID after they have obtained all information needed to make this decision
• have a serious and incurable illness, disease, or disability (excluding a mental illness until March 17, 2023)
• be in an advanced state of irreversible decline in capability
• have enduring and intolerable physical or psychological suffering that cannot be alleviated under conditions the person considers acceptable

Safeguards

“ The approach to safeguards differs from the previous law, under which only persons whose natural death was reasonably foreseeable were eligible for MAID. New safeguards now apply to persons whose natural death is not reasonably foreseeable. These safeguards seek to address the diverse source of suffering and vulnerability that could potentially lead a person who is not nearing death to ask for MAID.”

A detailed procedural safeguard in the revised law creates a two-track approach to ensure sufficient time and expertise to assess MAID requests. This website (https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html) points out the details in the following:

– Safeguards for persons whose natural death is reasonably foreseeable

– Safeguards for persons whose natural death is not reasonably foreseeable

– Final consent for persons whose natural death is reasonably foreseeable

– Final consent for persons who choose to self-administer substance for MAID

SELECT STATISTICS ON MAID, FROM 2016 TO 2019*

Where relevant, figures will reflect the Ontario data, with the highest figure and the national total
Total reported MAID deaths in Canada
Year	Total
2016	1,015
2019	5,631
Total MAID deaths by jurisdiction
Jurisdiction	Total
Quebec (From Dec. 2015)	4,172
Ontario	4,318
Canada	13,946
Percentage of total deaths attributed to MAID by jurisdiction
Jurisdiction	Percent
Ontario	1.6%
BC	3.3%
Profile of persons receiving MAID
Profile	Percent
Cancer	67.2%
Other	10% or less in each of 6 categories
MAID by age categories (in 2019)
Persons	Ages
888 (Highest)	65-70
103 (Lowest)	18-45
Number of persons receiving MAID by gender (2019)
Jurisdiction	Gender	Persons	Percent
Ontario	M	898	51.4%
Ontario	F	849	48.6%
Canada	M	–	50.85%
Canada	F	–	49.16%
NATURE OF SUFFERING OF THOSE WHO RECEIVED MAID IN 2019
(some random reasons below and rank out of 12 levels)
Rank	Reason	Percent
1	Loss of ability to engage in meaningful life activities	82.1%
4	Inadequate control of pain ( or concern about it )	53.9%
6	Perceived burden on family, friends or caregivers	34.0%
8	Isolation or loneliness	13.7%
10	Loss of control, autonomy or independence	4.1%
MAID REQUESTS AND OUTCOMES IN 2019
Request	Total	Percent
MAID Requests	7,336	–
Requests that have been declined	571	7.8%
Requests that have been withdrawn	263	3.6%
Requests where the individual died prior to MAID	1,113	15.2%
Requests that resulted to MAID	5,389	73.5%

*Complete Statistics is found in the First Annual Report on MAID in Canada, https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html#a1.0

MAID  DEATHS BY SETTING

Specialty of MAID Practitioner, 2019

*

DEMENTIA AND “WAIVER OF FINAL CONSENT”

In the old law, there was a danger that people may elect to request MAID in the early stages of dementia because of worry that they may lose their ability to give informed consent if they wait too long.

The newly amended MAID legislation allows people to avail of something called a “waiver of final consent.”  This provision grants a person who is already eligible to make a written arrangement with a medical practitioner for the MAID to be provided on a future date if he loses decision-making capacity.

Dementia ( e.g., Alzheimer’s) is a severe and incurable disease, and their natural death has become reasonably foreseeable. However, over time, the condition may cause enduring, intolerable, and unrelievable suffering. While the patient still has decision-making capacity, he can enter into an arrangement that a clinician will provide MAID on a specified day even if he loses the ability to consent.

“This change to the law will enable some people with dementia to live longer than they would have under the old law (as they won’t have to proceed with MAiD prematurely to avoid losing access to MAiD entirely).”

RELIGIOUS POSITION ON EUTHANASIA AND MAID

As many would expect, the sectarian community is the most vocal group to voice their feelings to the MAID law. For millennia, the long-standing ideology of the churches has been one of opposition to suicide, whether assisted or self-inflicted ( because, according to them, “God owns your life and God alone can take it” ). As I recall, in my parochial school years, suicide was looked at as a “sin” ( the origin of the word “committed” as it pertains to suicide was borne of this fact, as in “committing suicide,” instead of “dead of suicide” ), and a guaranteed spot in hell.  Unless, as my religion teacher used to say, you have declared your “act of contrition” before you hit the pavement.

There are 4,300 religions in the world. Here is a snapshot of 26 of the most practiced faith in the world. A detailed position of each denomination can be accessed at: https://deathwithdignity.org/learn/religion-spirituality/

Religion (in alphabetical order )          Position

Anglican                                                        opposed

Baptist                                                          violation of the sanctity of life

Buddhist                                                      alright for people who are”enlightened.”

Roman Catholic                                           violation of divine law

Christian Reformed                                      condemns it (1971)

Christian Scientist                                        a denial of God’s presence and power

Eastern Orthodox                                        morally and theologically impermissible

Episcopal                                                     morally wrong; approve in rare cases

Evangelical                                              opposed; allows withdrawal of life support

Evangelical Lutheran                                   supports MAID; not euthanasia (1992 )

Hindu                                                            several positions; basically opposed

Jainism                                                          seems neutral; the soul is indestructible

Jehovah’s Witness                                          violates the sanctity of life

Judaism                                                          an offense against the Deity

Lutheran Church ( Missouri Synod )             supports euthanasia and MAID

Mennonite                                                       opposed

Methodist                                                        endorses freedom of conscience

Mormon                                                           condemns it

Muslim                                                             forbids MAID

Presbyterian,                                                     the practice is “murder.”

Russian Orthodox                                             opposed

Sikh                                                                   rejects it

Spiritualist                                                          supports the law

Reformed Church (Great Lakes Synod )          opposed but values individual liberty

Unitarian Universalist                                        supports ( 1988 )

United Church of Christ                                    supportive but needs further study

CONCLUSION AND FUTURE OF MAID

In a poll conducted in January of 2020, over 8 of 10 ( 82% ) Canadians support the idea of availing a medically assisted dying if a grievous and irremediable condition arises, including those with dementia, virtually unchanged since 2016. Moreover, it has broad national support with numbers higher in Quebec and Atlantic Canada.

The three leading political parties show high support,  led by the NDP (88% ), Liberal Party (87%), and the PCs at 82%. In addition, 86%  of Catholics and 79% of Protestant  Christians support the measure, including health care professionals at 82%.

Once again, the vaunted church’s opposition to assisted dying made little impact on the wishes of the great majority of Canadians.  The highly Catholic province of Quebec passed MAID legislation a year ahead of the Federal law. It is consistent with the four original countries ( Switzerland and the BENELUX countries), all Roman Catholics, which started assisted suicide.  Interestingly, the next two countries ( Columbia and Spain ) following the original four were also mostly Catholics.

The increasing secularization of the Christian population is a driving force behind these significant shifts in the spiritual landscape of these once-upon-a-time leaders of the Christian world.  There are nearly as many atheists as practicing Catholics in Spain today! So it is not entirely surprising if you follow trends in the new generation’s shifting priorities and the real-world challenges young people face today.

We have only begun the MAID journey.  It will follow the pattern of contraception in the ’60s and what became of it today.  Virtually all catholic women (90 to 98%) use or support contraception outside of the prescribed Vatican-approved methods. Corollary to this is the total acceptance of all federal parties of pro-choice  (a.k.a. pro-abortion ) in the abortion debate.

Besides the increasing corporeal landscape in the west, I believe there is a certain amount of backlash in religious leaders’ absolutist, non-compassionate stance in the MAID debate.  ( as in “guaranteed spot ” in hell belief after a suicide as I mentioned earlier )  The late Christopher Hitchens has only two words for people who think they have a God-given right to determine some universal standards for us all.  “F..k You”  I happen to share that sentiment!

Sources:

DWDC ( Dying With Dignity Canada ) Website: https://www.dyingwithdignity.ca/get_the_facts_assisted_dying_law_in_canada

First Annual Report on MAID Website: https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html

Policy Options Website: https://policyoptions.irpp.org/magazines/december-2020/canadians-views-on-assisted-dying-are-complex/

CBC Website: https://www.cbc.ca/news/canada/the-fight-for-the-right-to-die-1.1130837

Edwin is a long term advocate of MAID and DWDC

edwingdeleon@gmail.com