A man diagnosed with metastatic cancer initially expressed interest in Medical Assistance in Dying (MAiD). Though the treating team determined he lacked capacity and was being sedated for pain management, a MAiD practitioner “vigorously rouse[d]” him to ask if he wanted MAiD. Withholding sedation, the practitioner accepted mouthing “yes,” nodding and blinking in response to questions as capable consent. The MAiD practitioner then facilitated a virtual second assessment, conducted in the same way, and MAiD was administered immediately after.
This active displacement of clinical care, as documented in government reports, is illustrative of a broader trend – MAiD is shifting the focus of medicine from the treatment of suffering to the elimination of the suffering patient. This shift does not reflect the intentions of every clinician, but it reflects structural pressures that are increasingly shaping practice. Canada is approaching 100,000 MAiD deaths since legalization 10 years ago. That number marks a quiet but profound transformation in how medicine understands suffering, autonomy and its own purpose. What was introduced as an exceptional measure is now a normalized part of clinical care.
Assisted dying is often framed as compassion for the suffering and preservation of a patient’s autonomy. But what happens when assisted dying becomes embedded in clinical decision-making and clinicians shift from focusing on healing to evaluating whether suffering justifies death? If practitioners are rushing to MAiD, even when other physicians have determined a lack of capacity to consent, does that sound like preserving autonomy?
In Canada, MAiD is legally exempt from homicide and assisted suicide laws under the Criminal Code. Health Canada maintains MAiD should not count as a cause of death, yet it is now Canada’s fourth leading cause of death. Many MAiD requests cite fear of being a burden, loneliness, or social isolation as drivers of suffering. These are not medical diseases but signals of social vulnerability.
MAiD should not count as a cause of death, yet it is now Canada’s fourth leading cause of death.
As a family physician caring for marginalized patients and as a member of Ontario’s MAiD Death Review Committee, I see how structural pressures appear in practice. Government reviews document similar patterns.
In one reported case, a man with cerebral palsy living in long-term care voluntarily stopped eating and drinking, leading to renal failure and dehydration. He was deemed eligible for MAiD under what is called Track 1 because his death was considered “reasonably foreseeable.” No psychiatric expertise was consulted despite evidence of psychosocial distress.
To provide MAiD, clinicians must assess whether the condition is grievous and irremediable, whether death is reasonably foreseeable for Track 1, and whether capacity and voluntariness are present. These are legal judgments layered onto clinical practice, leading to wide variation in clinician interpretation.
Interpretations of “reasonably foreseeable death” vary. Canadian law does not require terminal illness to meet that criterion. Some clinicians consider death foreseeable with a five-year prognosis. Others accept decisions to stop eating, drinking or taking medications as evidence of decline, making death foreseeable.
Social conditions also shape MAiD requests. Patients may seek assisted death after losing caregivers, entering long-term care or when they cannot access palliative or community supports. These situations should trigger aggressive efforts to improve care rather than being reframed as intolerable suffering requiring MAiD.
When people lack supports to live, assisted dying can become a structurally constrained choice rather than a voluntary one. A choice made in the absence of realistic alternatives is different from one made in the presence of robust supports.
Health Canada encourages proactive MAiD discussions and referrals for MAiD by objecting physicians. This creates clinical pathways that subtly direct patients toward assisted death rather than toward expanded care.
Over time, this changes professional identity. Medicine traditionally demands persistence with patients through uncertainty, slow recovery and complex suffering. MAiD introduces a different model, asking clinicians to decide when suffering should no longer be treated and when life may be ended instead. The deeper danger is cultural and professional. With MAiD’s integration into our system, medicine may shift from asking, “How do we treat suffering?” to “When is suffering severe enough to justify death?”
If Canada continues expanding assisted dying, it must answer hard questions. Are we expanding access to death faster than access to care? Are we ending lives prematurely when people could have flourished with adequate suicide prevention and support?
A health system that offers assisted death without ensuring access to housing, mental health care, disability supports, palliative care and community supports risks changing medicine in ways we may not recognize until it is too late.
Great and timely article. MAID is changing our values and priorities. Parents struggling with depressed children are finding them talking about “checking” out. Normalized suicide is a moral and ethical disaster in too many ways to list. Ramona has done us a huge service by pointing the pitfalls.
This article is a bit histrionic.
I have had two people in my life choose MAID due to very painful diagnosis with no hope.
They were housed, supported and loved but chose to end life without pro-longed pain.
I would hate for any restrictions to be put on this very dignified choice.
Thanks for covering this very important topic. In less than a decade since MAiD was legalized in Canada, many of the warnings that were dismissed as alarmist have sadly been validated. MAiD has changed in a fundamental way the relationship between patients and the healthcare system. The categorizing of MAiD as essentially a government service to which one is entitled has also profoundly changed the relationship between the citizen and the state by establishing the legal precedent that the government has the authority to actively terminate a human life.
Yes, a very important topic indeed and the author has made excellent points without a doubt. That being said, it is my belief that as citizens within a democracy, suffering patients that have an extreme illness do indeed have entitlement to have a dignified death in a timely fashion on their own terms in a primarily state funded health care system that of course also should provide and promote the expanded treatment of suffering at the same time. The two are not mutually exclusive. And really is the government actively terminating a human life when physicians, nurses and most allied health care workers in this country are not civil servants?
Disabled Canadians and allies call attention to the monstrousness of facilitating death while refusing to support purposeful life. Now Dr. Coelho’s perceptive account from the system’s core shows how patients, caregivers and clinicians may be nudged along widening euthanasia pathways, greased by simulacra of consent, with no sincere search for supportive care.
But failure to support begins much earlier for people with chronic illness and age-related disability. Rehabilitation is the poor cousin in public institutional medicine. Its clinics and labs are under-resourced. Fewer and smaller grants are awarded for rehab investigation than for “discovery.”
As a result, proof of efficacy for physical and cognitive therapeutic interventions is often slender. Wait times for green lights are lengthy. Small wonder that even trained, diligent care prospectors have trouble finding resources that might ease suffering toward the end of life.
Is another pathway possible? Imagine not only controlling pain but offering novel forms of participation, connection, experience, even learning. Take the same sapience we consider essential for consent, and mobilize it so that instead of “how can we end the suffering/smooth the passage” the question becomes “what does the patient need to flourish in their own way, to the limit of their capacity?”
Dr. Coelho introduces flourishing as a value at the end of her essay. But philosophers construct elaborate ethical frameworks with human flourishing as the goal. Perhaps it should be the starting point for all considerations of capacity, suffering and rehabilitative — even palliative — care.