# introduction

There are different strategies used to justify legalization of euthanasia and/or assisted suicide (EAS) in jurisdictions around the world. Canada’s EAS regime, labelled “medical assistance in dying” (MAID), is unique, and uniquely problematic. It claims — in law, in statements of public officials, and in public documents — to be a kind of EAS regime based on medical criteria, but it is at bottom another kind, one that is based on “autonomy-only” criteria. By this I mean that on the surface, Canadian MAID law looks like a form of a “medical suffering” based EAS law found in places like the Netherlands. But this appearance is misleading. Although Canadian MAID is incorporated into and implemented as standard medicine/health care, the actual model underlying the law is tantamount to EAS justified only by an “autonomous request.” As I will argue, the result is an autonomy-only model of EAS that is misleadingly marketed and practiced as an inherently medical procedure, a result that is unique to Canada.

I begin by first comparing the Canadian system with the laws from other jurisdictions where EAS is legal. This will show how the Canadian system has the appearance of one type of regime (EAS justified on medical grounds), but actually is another kind of regime (EAS justified only by the autonomous request of the requestor). I then explain the divergence between how it is marketed versus its reality, between the manifest justification and the actual regime in practice, by reviewing public documents from official sources on how the law is to be interpreted. I then discuss some of the implications and tensions created by this masquerade, i.e., a medical mask that obscures the true nature of the policy, especially how it enables bypassing certain types of public debate that one would expect in this context. After briefly explaining how public officials perpetuate and reinforce the masquerade, I examine some recent survey data which show that the public seems unaware of these implications of their MAID law. I end with some concluding reflections as to why all of this represents suboptimal policymaking.

For the purposes of this paper, I use the terms medical assistance in dying (MAID) to refer to the specific law and practice in Canada, and euthanasia and/or assisted suicide (EAS) to refer to the general concept, of which Canadian MAID is just one manifestation. This is necessary because the very name of Canadian EAS system (‘medical’ assistance in dying) is itself part of the issue I wish to address. Finally, I focus on EAS laws only insofar as they apply to competent requests, i.e., I put aside for now issues of nonvoluntary or involuntary EAS.
# The Canadian MAID regime and its unique place among EAS
        regimes

To understand the uniqueness of Canadian MAID law, one needs to understand where it stands in the range of actual EAS laws.

In the United States, what is permitted is physician assisted suicide (PAS) for those with a terminal illness (6 months of expected life or less). There is no requirement of suffering, functional decline, or poor quality of life: it is an autonomy model within the context of a terminal illness. A doctor *may* participate, but no doctor is required to perform or make a referral. A clinic or hospital, without any need to invoke a conscience objection, may *prohibit* its doctors from participation, on pain of sanctions, even if it is legal for such doctors to participate in eligible cases (cf. the Oregon law (2)).

In Australian states and New Zealand, although there are some variations, generally the eligibility requirements are terminal medical illness, with 6 to 12 month life expectancy, “causing suffering to the person that cannot be relieved in a manner that the person considers tolerable” (example of law in Victoria, Australia) (3). The phrase “the patient considers tolerable” is a double-edged sword that needs comment, as it foreshadows some aspects of the Canadian MAID system that will be discussed below. If the phrase is applied with the understanding that “terminal illness” means only a condition that is medically irreversible *even* *with* current best standard of care — i.e., if we assume it applies only to palliative care interventions — then it may seem reasonable to include such a phrase since whether palliative measures are acceptable or not would be largely up to the patient’s own experience of such interventions. Such an interpretation would be a natural one, and perhaps that accounts for its presence in the law. However, if the phrase is stretched to apply even to a situation where a patient refuses current best standards of care that would reverse the condition’s progression to death (e.g., insulin dependent diabetes), then the effect would be to create a new and more expansive meaning of terminal illness — one that is largely determined by the “autonomous choice” of the requestor.

The Netherlands has a medical suffering-based EAS regime. Specifically, the legal basis is necessity: doctors with two perceived conflicting duties (preserve life vs relieve suffering) are not held liable for homicide (4). There is thus no terminal illness requirement, since suffering need not occur only at end of life. The criteria are that a doctor must be satisfied that the patient has a medical condition that causes intolerable and hopeless suffering, with no reasonable medical alternative — as determined by the doctor, with the patient. Of course, the patient can refuse even the “reasonable alternatives” that may exist (i.e., EAS would not be last medical resort) but by law the doctor would then find the person ineligible for EAS.

Canada also, at least on the surface, seems to have a medical suffering-based regime. The Canadian law requires the requestor to have a medical condition or disability, with no end-of-life requirement, whose intolerable suffering cannot be alleviated under conditions the patient considers acceptable. But as we will see in much greater detail below, the Canadian law is different from the Dutch medical-suffering based EAS law. In Canada, the health care practitioner need only discuss “reasonable and available means,” and the patient can refuse them and still be eligible. Further, even if what would avert the request is a widely accepted standard of care intervention, a poor person without access to it would still be eligible.

Other jurisdictions allow EAS without a suffering justification, indeed, with only an autonomy justification. Let’s call these “autonomy only” EAS regimes. The 2020 German Federal Constitutional Court ruling states that assisted suicide is protected by the principle of autonomy (as part of human dignity, enshrined in their Basic Law), and thus assisted suicide is a right that is: “…not limited to…serious or incurable illnesses, nor…certain stages of life or illness…. Restricting the scope of protection to specific causes or motives…of the person seeking to end their own life…is alien to the notion of freedom.” Despite this unambiguous language about the autonomy-only basis for EAS, 5 years after the ruling there has yet to be any legislation implementing and regulating the practice. For our purposes, there is nothing inherently medical about this kind of assisted dying framework; indeed, as the court notes above, to require a medical illness condition is foreign to the overarching rule of autonomy as the basis for this right.

Switzerland also has an autonomy-only regime, not based on a constitutional principle but instead by legislation: 1937 law, Article 115, regulating assistance in suicide, with condition only on the motive of the assistor (it cannot be a selfish motive) (5). Assisted suicide is largely managed by voluntary organizations and is not seen as an inherent part of medical practice. As the Swiss Academy of Medicine states:

> The true role of physicians in the management of dying and death, however, involves relieving symptoms and supporting the patient. Their responsibilities do not include offering assisted suicide, nor are they obliged to perform it. *Assisted suicide is not a medical action to which patients could claim to be entitled, even if it is a legally permissible activity*.
> — My italics, See 6.2.1 of the SAM document (6)
# The uniquely misleading nature of Canadian MAID
        law

On the surface then, Canadian MAID law looks like a form of a “medical suffering” based EAS law. And in fact, great effort has been made to market and incorporate Canadian MAID as a medical treatment. But a close look at the law and at how it is to be interpreted (e.g., according to guidance documents from official sources) reveals the true nature of Canadian EAS regime as an autonomy-based model like the German or Swiss models. The result is an autonomy model of EAS misleadingly marketed and practiced as an inherently medical procedure.

## Canadian MAID regime: marketed as medical, but the active ingredient is
        autonomy

Consider the following elements of the eligibility criterion that a person must have a “grievous and irremediable medical condition” (i.e., the criterion which makes Canadian EAS a “medical” procedure):

Now consider the following excerpt from German Federal Constitutional Court’s ruling:

> the individual’s decision to end his/her own existence *according to his/her understanding of quality of life and meaning of his/her own existence* ought initially to be respected by the State and society as an act of autonomous self-determination… [italics added]

Although the italicized sections in the two texts clearly share the same idea of primacy of requestor’s autonomous choice, the remaining parts of the Canadian law seem to create several additional restrictions on MAID eligibility, explicitly based on having “a grievous and irremediable medical condition” defined by the text in conditions a-c. These restrictions are, however, largely illusory.

Consider, first, that whether in an autonomy-only or a medical suffering-based regime, the pool of potential requestors of EAS will likely be the same. Happy and healthy people might be eligible for EAS in an autonomy-only regime, but they do not ask for EAS. The potential pool of EAS requestors in either type of regime will almost entirely consist of:

Second, the restriction of eligibility to only those with medical conditions is likely far outweighed by the practical reality of incorporating EAS as a standard medical procedure grafted into the machinery of a modern healthcare system as a delivery vehicle for EAS. That is, as the practice of EAS requires resources, integrating it into an existing public healthcare system is tantamount to a massive public investment promoting the practice<fnref n="1" /> and that could far outweigh any theoretical restriction imposed by “medical suffering,” especially if that medical criterion is interpreted very flexibly (see below).

Still, it is hard to shake off the impression that the specific criteria in the Canadian MAID law seem to make access to MAID more restrictive than would be in an autonomy-only regime, where anyone who makes an informed competent choice qualifies. Surely having a “serious and incurable” condition and “advanced state of irreversible decline” creates a significant restriction to EAS access? Let’s consider the criteria in turn. We can look to a document on an official Canadian government website (Health Canada) called *Model Practice Standard*(15).

The Standard gives guidance on incurability with the following:

> 9.5.1 …the provider and assessor must be of the opinion that the person has a serious and incurable illness, disease, or disability.
> 9.5.2 ‘Incurable’ means there are no reasonable treatments remaining where reasonable is determined by the clinician and person together exploring the recognized, available, and potentially effective treatments in light of the person’s overall state of health, beliefs, values, and goals of care.

The first point is a mere repeat of the criterion itself, with the addition of “the provider and assessor must be of the opinion.” Obviously, as a guide to how a clinician ought to arrive at such an opinion, it adds nothing.

The second point 9.5.2 says that “incurable” means there are no reasonable treatments remaining, which sounds right. But then “reasonable” is defined further. Two features of the definition seem especially pertinent, as they lead to a novel definition of an “incurable condition.” First, reasonableness is something that is arrived at, not by an objective standard of medical science, but through an “exploration” by the clinician and the patient, “in light of” not just their health but also “beliefs, values, and goals of care.” Second, the definition implies that even if a disease is medically curable, if it is not “available” to that individual, then it makes the condition incurable.

Whatever “incurable” means in ordinary medical practice, the definition in the Model Practice Standard is not it. When a patient is told that they have cancer that is incurable, our first thought is not, “the patient should ask whether this is consistent with the patient’s beliefs, values, and goals of care.”<fnref n="2" /> Also, according to the Model Practice Standard, if your neighbour also has the same condition, but is cured by an intervention to which they have access, but you die because you couldn’t afford it, then it turns out that your neighbor had a curable illness whereas you had an incurable one. At minimum, this is a very novel take on the meaning of incurable.

Next, what does “advanced state of irreversible decline in capability” mean? How should it be determined? Below, I quote the Model Practice Standard and comment on each point inside the brackets:

> 9.6.1 …the provider and assessor must be of the opinion that the person is in an advanced state of irreversible decline in capability. [See above]
> 9.6.2 Capability refers to a person’s functioning (physical, social, occupational, or other important areas), not the symptoms of their condition. Function refers to the ability to undertake those activities that are meaningful to the person. [Note that as qualified by the second sentence, capability is entirely defined by the perspective of the person. Again, it transforms the criterion into an individual subjective standard.]
> 9.6.3 ‘Advanced state of decline’ means the reduction in function is severe. [No definition of ‘severe’ given. And since capability itself is subjectively defined, it is ultimately up to the requestor to determine the severity that defines ‘advanced state of decline.’]
> 9.6.4 ‘Irreversible’ means there are no reasonable interventions remaining where reasonable is determined by the clinician and person together exploring the recognized, available, and potentially effective interventions in light of the person’s overall state of health, beliefs, values, and goals of care. [Here, the same ‘reasonableness’ formula from the previous criterion is used, and will have the same implications in terms of ‘availability’ and personal ‘values’ defining the concept.]

Finally, we can deal with the criterion of “intolerable suffering that cannot be relieved under conditions that they consider acceptable” briefly since we’ve already discussed this criterion and the autonomy point is transparent in the legal criterion itself (rather than needing the convoluted reasoning provided by the Model Practice Standard).

Thus, according to official Canadian government documents, once a person requests MAID (recall the same pool of requestors as in autonomy-only regime) there are really no restrictions beyond autonomy — despite the appearance of medical language that suggests otherwise. The appearance of the “medical” is left intact, but under the surface are interpretations that do violence to the meaning of “medical”.

This tendency toward an expansive definition of eligibility criteria by emphasizing or reinterpreting the criterion as a matter of preference or choice of the requestor is a common theme in MAID guidance documents in Canada. For example, for the definition of reasonably foreseeable death, the best-known MAID provider/assessor organization in Canada states that a person’s natural death can be reasonably foreseeable “if they have demonstrated a clear and serious intent to take steps to make their natural death happen soon or to cause their death to be predictable. Examples might include… voluntarily cease eating and drinking.” (17)<fnref n="3" />

Returning then to a comparison with the German (or Swiss) system of autonomy-only EAS regime, we can say the following. Both regimes are in practice autonomy-only systems of assisted death. In Germany, there is a single step of transparent stipulation that EAS is justified by autonomy. In Canada, there are two steps used: first, specifying pseudo-medical criteria that places MAID within medicine/healthcare system as a medically justified intervention, and second, interpreting those criteria to effect an autonomy-only regime that operates within the healthcare system.

<footnote n="1">Including making it part of routine information for persons entering nursing homes, EAS hotlines provided by the government, guidance documents claiming that bringing up the option of EAS unsolicited is in circumstances a professional obligation, etc.</footnote>

<footnote n="2">In another Health Canada document, Advice to the Profession (16), we find this: “At the same time, a capable person cannot refuse all or most interventions and automatically render themselves incurable for the purposes of accessing MAID.” This is another artfully worded constraint that gives an appearance of setting a genuine limit. But the combination of “all or most” with “automatically” renders the constraint practically meaningless. A person could refuse all or most treatments but as long as the pronouncement of incurability is not automatic — say, after an “exploration” of the person’s refusals — that constraint is rendered moot.</footnote>

<footnote n="3">In the Model Practice Standard, the following quotes from a provincial court are provided: It is difficult to see how such artful legal quotes can provide clinical practice guidance. But they clearly do convey the point that there is to be a wide latitude in applying the concept *and* that it should be “person-specific.” Since “person specific” can’t mean the *object* of the prognosis is the person’s disease — since that is obvious, there is no need to add ‘person specific’ in that sense, and thus it must imply another meaning. Is the point that the person determines their own prognosis? The logic here is by now familiar.</footnote>
# Practical implications of an autonomy-based EAS clothed
        as a medical intervention

What is the significance of an autonomy-based EAS system packaged as a medical EAS system? There are several significant points to note.

First, we should ask what is gained by endorsing an autonomy-based EAS regime with the veneer of a medical suffering based system. Why not just adopt a transparent autonomy-only system? The obvious one is that it is much easier to convince the public of a medical-suffering based regime than an autonomy-only regime. Appealing to compassion (an emotion widely shared and idealized) is a more promising strategy than stirring up the inner libertarian in the average person. No one opposes “relieving suffering” but few would endorse “every individual can terminate their life for whatever reason they prefer.” It’s good marketing.

Second, by placing an autonomy-only EAS practice inside an already established, publicly funded healthcare system, it is possible to bypass a policy debate that will inevitably arise when an autonomy-only system is proposed, viz., who will perform EAS (should doctors be involved), with what safeguards and guidelines, and how much resources will be devoted to it from public funds, among other important policy questions. Such debates are hard debates. Note that the German high court ruling is now 5 years old, without clear signs of how to implement the ruling.

In Canada, the effect has been a massive public investment (without debate) in MAID. Indeed, the investment has been such that many find it more accessible (i.e., death is more accessible) than the standard treatments or resources they would rather have in the first place (13). It is difficult to think of a medical service that is so heavily defined by patient preference, that is so accessible, and whose consequences are so momentous and irreversible. All of this has occurred with no prior specific debate over resources because of the ideological nature of the Canadian MAID regime: as the true nature of the system is hidden under the veneer of medicine, important policy debates have been bypassed.

The final implication is that there are inevitable tensions and contradictions arising from a non-transparent implementation of an autonomy-only regime cloaked as a medical regime. Medical science and clinical standards can’t be so plastic as to accommodate the ideologically driven regime. They will inevitably clash with the masquerade. To see this, consider the following cases:

```
P1 says she would rather have MAID than try a likely curative, but moderately
              burdensome, treatment that is available.
          
          
            P2 with cancer is quite depressed, but cognitively intact, and requests MAID; she
              refuses recommended treatment for depression.
          
          
            P3 requests MAID as a second choice as he would rather receive a known treatment
              that will likely work, but cannot afford it or lacks access to it even as more
              privileged persons next door, or in next province, have access, etc.
          
          
            P4 has bipolar disorder that has been difficult to treat in recent years. She
              discontinued her standard antipsychotic medications abruptly, resulting in side
              effects that also cause a severe sense of restlessness and anxiety. Two specialists
              have told her that the side effects will disappear if she goes back on the drugs and
              then gradually tapers off. But she is insistent on seeking MAID for the somatic
              adverse reaction to medication, and finds a willing provider.
```

P3 is by now a familiar kind of case in Canada, with some bioethicists more concerned about defending EAS in such circumstances instead of trying to identify why a system that leads to such situations is problematic (18). P1 occurs too (19). P2 and P4 (20) are familiar in the sense that psychiatrists are well acquainted with patients whose conditions are treatable but which obscure the vision and desire of the patients themselves (hence the emphasis on suicide prevention); the only difference here is that these patients are seeking MAID as the means, and the Canadian law seems to protect providers who provide it.

The point to keep in mind is not what a reasonable health care practitioner *would* do in the above cases, but rather what such a doctor or a nurse practitioner would be legally permitted to do, using the interpretations provided by something like the Model Practice Standard or by organizations like CAMAP. So following the guidance provided by Health Canada we examined above, all of these hypothetical patients could be interpreted as eligible for MAID. But the cases are deeply problematic by ordinary medical standards — doctors do not opt for an amputation over an antibiotic just because that is the patient’s preference. One would need to be in the grip of an ideology to think death is an appropriate *medical* response to an ameliorable medical condition.

But the Canadian law goes even further, at least according to Health Canada. As we saw above, a doctor’s refusal to perform MAID in the above cases is consistent with, and would seem to be required by, ordinary standards of clinical medicine. Such a doctor may in fact perform MAID in other situations, but refuse to do so in these situations because they do not think MAID is *medically* indicated, *even if legal*. But consider this guidance from the Model Practice Standard:

> Conscientious objection may be case specific. Some [physicians/nurse practitioners] are conscientiously opposed to all MAID. Some to only certain kinds of MAID (e.g., Track 2). Some to only specific cases given the specific circumstances. The same rules apply no matter the scope of objection – [physicians/nurse practitioners] cannot be compelled to participate but they must follow the steps laid out in 5.2 if they are unwilling to participate.

But following this guidance would result in compelling a doctor to refer a patient to another practitioner who will do what the doctor believes is *medically* contraindicated (not because of religious or philosophical objection). Nor does the guidance obligate the doctor to say, e.g., “You have effective medical alternatives that I recommend instead, in my medical judgment.” Instead, according to the Model Standard, the Canadian law compels acting against a doctor’s own best medical judgment.
# How this uniquely opaque nature of Canadian MAID law is
        communicated by public officials: the debate over MAID where mental disorder is the sole
        underlying condition (MD-SUMC)

Is the true nature of the Canadian EAS system transparently communicated by Canada’s officials when they have the opportunity to do so? Two examples will suffice, from the debate over the legalization of MAID for persons with mental disorders as the basis<fnref n="4" />.

Canada’s then Attorney General Lametti at one point stated, in arguing in favour of legalizing MAID for mental illness, that it would be granted only “where everything has been tried, where the person is an adult capable of making up their own mind and there is no remedy.” (21) He did not, however, clarify that the true legal meaning (at least in Canada) of “no remedy” (i.e., incurability and irremediability as defined by the requestor) and of “where everything has been tried” (where “everything” does not include medically standard therapies if the person cannot afford it). The public therefore would have been misled about the true nature of the proposed expansion. The same goes for the Minister of Families, Children and Social Development, Ya’ara Saks’s statement that the proposed expansion to mental illness will apply only to those “who have been presented treatment after treatment” and “have tried everything imaginable to address their suffering.” (22)<fnref n="5" />

One might wonder why the ministers would say such inaccurate things in public. Are they statements of intentional misdirection or are the ministers themselves confused? My speculation is they have the correct political sense that if they made truly transparent statements, their cause of expanding MAID even further would face pushback from the public. This is especially so since they did not propose any additional protections or safeguards for this uniquely vulnerable population.

This leads to another observation about the so-called debate over MAID for MD-SUMC (mental disorder as sole underlying medical condition) in Canada. It is a uniquely Canadian way of framing the issue. In anticipation of legalizing MAID for mental illness, the government created an Expert Panel to recommend “‘safeguards, protocols and guidance’ to structure the practice of MAID for persons with mental illnesses.” (23) This made sense given the controversial nature of MAID for psychiatric disorders. Surprisingly, the Expert Panel charged with the task felt that there was no need for a special set of safeguards. The reason given is something that can only be described as Orwellian — there is no need for special safeguards for MAID for MD-SUMC because MAID for mental illness is already legal and occurring in Canada, and MAID for mental illness with physical illness is not that different from MAID for MD-SUMC.

The Panel’s *unstated* premise is that if it is happening under current law, there is no need to worry about adding special safeguards since the *current process is fine as it is*. This amounts to denying the rationale for the Panel itself. But surely the question is whether such a practice is in fact fine as it is. Again, without argument or debate, the Canadian policy guidance process bypasses necessary debate by a sleight of hand reasoning. This is in contrast to jurisdictions, such as the Netherlands and Belgium (which allow psychiatric euthanasia), that acknowledge the need for additional protections in their guidance discussions and standards (24-26). In countries like Belgium and the Netherlands, what matters — what needs scrutiny in order to determine whether special protections are needed — is the idea that EAS is being given for mental illness (regardless of whether the person has another illness).

If one asked the average Canadian whether MAID for mental illness is legal, they would likely say no. Indeed, even bioethicists not specializing in MAID would likely say no. That the Canadian MAID law *makes it appear that somehow MAID for mental illness is not yet legal* is yet another example of the mismatch between how it is marketed and how it is practiced<fnref n="6" />.

<footnote n="4">The term used by the government is MAID where the sole underlying condition is a mental condition, or MAID SUMC. The Canadian conception of psychiatric EAS is unique, and this is often lost in the discourse. Because of the way it is phrased, a person who is seeking MAID for mental disorders but who also has a chronic medical condition could qualify for MAID even now — that is, using the flexible guidance of the Model Practice Standard. See below how this loophole is used as a justification for downplaying the unique concerns associated with psychiatric EAS.</footnote>

<footnote n="5">Of course, some people seeking psychiatric MAID might fall under such a description, but clearly the context of the statement is that anyone seeking it would fit that description. Even by low standards of veracity in political speech, these comments are rather disturbing.</footnote>

<footnote n="6">There is currently no legal barrier to MAID even if a person seeks it primarily because of their major depressive disorder. The person could still meet MAID criteria because the law as written does not require that the medical condition (the basis for MAID) be the cause of, for instance, meeting other criteria, such as being in state of advanced decline, etc. Recall that according to the dominant interpretive framework in Canada, a person whose death is not reasonably foreseeable can become so by the act of not eating or drinking, independent of the justifying medical condition.</footnote>
# Is the Canadian public aware of the implications of
        their MAID law?

In a survey conducted in August of 2023 (27), after informing them of the Canadian legal criteria for MAID, we asked 2140 Canadian adults if they supported MAID if all conditions for eligibility in the current law were met. As in other previous surveys (28), a clear majority (73%) said they supported MAID. Further, when asked about whether certain situations met the necessary “grievous and irremediable” criterion for MAID eligibility, 78% and 71% respectively answered correctly that the patient must have a “serious and incurable illness, disease, or disability” and that “the patient must be in an advanced state of irreversible decline in capability.” Thus, our respondents were typical of Canadians in supporting the MAID law, and, further, they seemed to at least recognize two of the key eligibility criteria. But when we examined their understanding of the actual implications of the current eligibility criteria, only 19% correctly answered that terminal illness is not an eligibility condition and only 21% correctly answered that refusal of effective treatment is compatible with eligibility. The public know and support the fact that MAID is legal, but they do not fully understand for whom it is legal.

This lack of awareness of the full implications of the law was further confirmed when they were given scenarios depicting situations that are compatible with MAID eligibility (they were modelled on media reports of known MAID cases — namely, refusal of effective intervention or lack of access to standard resources that would ameliorate the condition). Only 23-32% (depending on scenario) correctly answered that such situations are compatible with Canadian MAID eligibility criteria. Notably, a similarly low proportion felt the persons portrayed in the scenarios should be able to receive MAID<fnref n="7" />.

How does one explain the fact that Canadians are strongly supportive of their MAID law and are able to recognize at least two key eligibility criteria when presented with the law’s wording, but be so wrong about the implications of that law? Although causation cannot be inferred from observational data, the data are nevertheless consistent with the obfuscating effect of the Canadian MAID law: the Canadian public seems to be in the dark about what their law really implies and how it actually applies in practice, because the law is not what it seems, and that is reinforced by statements of public officials. It is important to again note that most Canadians seem to think that their country’s MAID law prohibits some types of MAID that are in fact legal.

<footnote n="7">Respondents who were older, with higher income and more education, were less religious, and identified as white tended to support MAID law in general, in higher proportions. However, we found that when answering questions about persons seeking MAID under conditions of treatment refusal or lack of access to needed resources, those characteristics were either not correlated or were correlated with lower support for MAID.</footnote>
# Concluding Reflections

The current monitoring and safeguard system presumably assumes that MAID is a medical procedure. But if the Canadian MAID system is actually an autonomy-only EAS regime, it is worth asking whether there are adequate protections and monitoring of such a system. It is, after all, a framework that gives doctors and, uniquely, nurse practitioners, plenty of signals to flexibly interpret the law toward a pure autonomy model.

In this regard, the pattern of uptake in practice by Canadian health practitioners is notable, as it suggests that MAID is heavily driven by a small minority of highly active practitioners, rather than by a widespread adoption by the healthcare community (7). There were 2,200 unique providers of MAID in 2023. Of the 15,343 MAID deaths in 2023, only 361 providers accounted for 10,138 (66%) of those deaths. Remarkably, a subgroup of 89 providers accounted for 5,345 deaths, or 35% of all Canadian MAID deaths in 2023; on average these providers performed MAID more than once a week. It is difficult see these numbers as reflecting a broad willingness to provide MAID among health care providers. Further, all of this is consistent with few doctors publicly stating they have performed hundreds of cases of MAID (29-31) and some even adopting it as their primary or only medical activity (7)<fnref n="8" />. Of course, without individual level data (i.e., of individual MAID cases), it is difficult to evaluate the full significance of a tiny number of clinicians accounting for such high proportions (and absolute numbers) of MAID deaths in Canada. It also means we cannot rule out the possibility that MAID practice reflects the work of a small number of activist clinicians driven by an ideology whose implications are at odds with the values of most Canadians.<fnref n="9" />

The way that Canadian MAID policy has evolved and is publicly guided do not seem like a good way of making and implementing policy in a pluralistic democratic society, especially regarding a policy about life and death decisions. It is concerning that the ideological nature of Canadian law could be keeping the public in the dark. It does not seem respectful to its citizens that the law borrows familiar terms used in medicine, but the public guidance on interpreting it relies on novel meanings, and the country’s public officials (intentionally or ignorantly) perpetuate that obfuscation — especially given that the hidden implications are likely contrary to the values of most citizens. The ideological structure of the law also means that important policy debates have been bypassed. The Canadian MAID law is a product of flawed democratic policymaking.

<footnote n="8">Based solely on the high number of cases performed per provider, Health Canada attributes “focused expertise” to the prolific providers (7, p.53). Given that virtually anyone who asks for MAID in Canada is found eligible and given that the procedure itself is hardly complex, it is unclear what kind of expertise is meant.</footnote>

<footnote n="9">For a comprehensive analysis and discussion of the highly concentrated nature of MAID provision and its relation to MAID activism, see (32).</footnote>

## Références

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2Oregon Health Authority. Oregon Revised Statute: Oregon's Death with Dignity Act. Government of Oregon.

3State Government of Victoria. Voluntary Assisted Dying Act 2017. Act no. 61/2017, ver. 003. Victoria, Australia.

4Griffiths J, Weyers H, Adams M. Euthanasia and Law in Europe. Oxford: Hart Publishers; 2008.

C, Cohen-Almagor R, Kim SYH. Expert views on medical involvement in the Swiss assisted dying practice: “we want to have our cake and eat it too”? AJOB Empirical Bioethics. 2024;15(1):41-59.

6Swiss Academy of Medical Sciences. Management of Dying and Death. Bern: House of Academies; 2018.

7Health Canada. Fifth Annual Report on Medical Assistance in Dying in Canada, 2023. Government of Canada; 11 Dec 2024.

8Commission fédérale de Contrôle et d’Évaluation de l’Euthanasie. EUTHANASIE – Chiffres de l’année 2022. Santé publique, Sécurité de la Chaîne alimentaire et Environnement; Brussels. 17 Feb 2023.

9Regional Euthanasia Review Committees. Annual Report 2022. Government of the Netherlands; 12 Sept 2024.

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