How We Sold Our Soul–Canada’s MAID Program

photorandy2023

1 year ago

I have written several articles on the coronavirus and on masks. A series of links have been provided at the bottom of this article for your convenience. This article will, however address a different aspect of the virus or on healthcare issues in general.

Euthanasia in Canada in its legal voluntary form is called Medical Assistance in Dying (MAiD, also spelled MAID) and it first became legal along with assisted suicide in June 2016 for those whose death was reasonably foreseeable. Before this time, it was illegal as a form of culpable homicide. In March 2021, the law was further amended by Bill C-7 which to include those suffering from a grievous and irremediable condition whose death was not reasonably foreseeable. An expansion to include people with mental illnesses is planned for 2027. This expansion was originally planned for 2023 and the legality of the delay is being challenged in court.

The intensity and breadth of Canada’s MAID program has led to condemnation of its program by UN human rights experts and disability rights groups in Canada. It has also been the subject of substantial international attention and criticism. Human rights advocates have criticized Canada’s euthanasia laws for lacking safeguards, devaluing the lives of disabled people, prompting health workers and doctors to suggest euthanasia to people who would not otherwise consider it, and killing people who were not receiving adequate government support to continue living. According to the Fourth Annual Report on MAID, there were 13,241 MAID deaths reported in Canada in 2022. The underlying medical conditions from MAID applications include cancer (63%), cardiovascular (18.8%), other at 14.9% (can be frailty, diabetes, chronic pain, autoimmune), respiratory (13.2%), and neurological conditions (12.6%). Seventy-seven percent of MAID recipients received palliative care and of the MAID recipients who did not receive palliative care 87.5% had access, a level similar to the three previous years.

Background

Euthanasia was previously prohibited under the Criminal Code as a form of culpable homicide. The prohibition was overturned in a February 2015 decision by the Supreme Court of Canada in Carter v. Canada (Attorney General), which ruled that the Criminal Code provisions that make it a crime to help a person end their life violate the Canadian Charter of Rights and Freedoms and that eligible adults with grievous and irremediable medical conditions are entitled to an assisted death. The Court delayed its suspension of invalidity for a period of 12 months, to allow Parliament the opportunity to amend its laws if it so chose. In January 2016, the Court granted an additional four-month extension to the suspension to allow for further time. As an interim measure, it ruled that provincial courts can now begin approving applications for euthanasia pursuant to the criteria in the Carter decision. On 6 June 2016, the suspension of invalidity expired and the law was struck down. On 17 June 2016, a bill to legalize and regulate euthanasia passed in Canada’s Parliament Ostensibly to prevent suicide tourism, Canada’s current law makes euthanasia available only to residents eligible for Canadian healthcare coverage.

The previous law’s requirement that a natural death must be reasonably foreseeable and that the medical condition be grievous and irremediable medical condition had been controversial for how it limited the original Supreme Court of Canada ruling, mandating that euthanasia be made available to all adults with grievous and irremediable medical conditions. The British Columbia Civil Liberties Association (BCCLA) challenged the constitutionality of the previous law because it excluded people with long-term disabilities and those with “curable” medical conditions whose only treatment options people may find unacceptable. The BCCLA argued these medical conditions should qualify under the court’s definition of grievous and irremediable. The BC Supreme Court and the Quebec Supreme court in Truchon ruled in 2019 that the law could not limit euthanasia only to individuals whose death was reasonably foreseeable.

The current law prohibits mental illnesses as being considered as a grievous and irremediable condition, but this prohibition was initially set to expire on 17 March 2024. On 2 February 2023, the Canadian government introduced legislation to extend the temporary exclusion of eligibility in circumstances where a person’s sole underlying medical condition is a mental illness for a period of one-year, until 17 March 2024. In 2024, this was further delayed until 2027. After this date, persons with a severe refractory mental illness will be eligible for medical assistance in dying, subject to any further amendments to the law or any new regulations.

Canada’s euthanasia law includes some legal safeguards aimed at preventing abuse and ensuring informed consent. Neither the legal witness nor the physicians involved can have any legal or financial interest in the outcomes of the patient. Consent must be repeatedly expressed, not implied, including in the moment right before death. Consent can be revoked at any time, in any manner. There are no consequences for backing out and there are no limits to how often it can be requested. Doctors are permitted to suggest euthanasia to patients, regardless of whether the patient has already said that they do not want it. To receive euthanasia, patients experiencing disease, disability or terminal illness must sign a written request expressing their wish to end their life in front of one independent witness who can confirm it was done willingly free of coercion. Next, two physicians and/or nurse practitioners must independently confirm their written agreement that the patient has an incurable grievous and irremediable medical condition that is in an advanced state of irreversible decline, and that the patient is capable of receiving and willing to receive euthanasia. If their death is not reasonably foreseeable, a medical expert in the underlying medical condition must sign off on the request, their assessment must take at least 90 days, and they must be informed about and decline all other forms of treatment, including palliative care.

Canada’s law is consistent with many other nations that allow euthanasia in requiring at least two physicians to confirm the details of a diagnosis. Canada’s law no longer requires the presence of a terminal illness, unlike many other countries where euthanasia is only legal in those circumstances. Canada’s law is more restrictive than those of Belgium and the Netherlands in that it does not permit minors access to euthanasia. Canada will not allow euthanasia on the grounds of severe refractory mental illness, a practice allowed in the Netherlands, Belgium, and Switzerland, until at least 17 March 2027. Canada’s law is less restrictive in that it does not require a patient to have exhausted all other treatment options, unlike Beligum and the Netherlands. While Belgium allows advanced directives in all circumstances, such advance directives in Canada may only be used if the patient’s death is reasonably foreseeable. Canada is the only country that allows nurses to administer the drugs used for euthanasia.

Carter v. Canada (Attorney General) decision

On 15 June 2012, in a case filed by Gloria Taylor, the Supreme Court of British Columbia ruled that provisions in the Criminal Code prohibiting euthanasia were unconstitutional as they apply to severely disabled patients capable of giving consent. The lower court ruled that the Criminal Code provisions “infringe s. 7 [and s. 15 ] of the Charter, and are of no force and effect to the extent that they prohibit physician-assisted suicide by a medical practitioner in the context of a physician-patient relationship”. Moreover, the court found that the relevant sections were legislatively overbroad, had a disproportionate effect on people with disabilities, and was “grossly disproportionate to the objectives it is meant to accomplish.” The case reached the Supreme Court of Canada in Carter v. Canada (Attorney General). The court ruled that the law banning euthanasia of terminally-ill patients (based on the Rodriguez v British Columbia (Attorney General) decision) was unconstitutional, and violated Section 7 of the Canadian Charter of Rights and Freedoms. The Supreme Court issued a 12-month suspended declaration of invalidity. As a result of the decision, euthanasia was expected to be made legal for “a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition”.^[24] The court decision includes a requirement that there must be stringent limits that are “scrupulously monitored”. This will require the death certificate to be completed by an independent medical examiner, not the treating physician, to ensure the accuracy of reporting the cause of death.

Bill C-14

As required by the 2015 Supreme Court decision, Justice Minister Jody Wilson-Raybould tabled a bill in parliament in April 2016 to amend the Criminal Code to allow euthanasia. Bill C-14 “create[s] exemptions from the offences of culpable homicide, of aiding suicide and of administering a noxious thing, in order to permit medical practitioners and nurse practitioners to provide medical assistance in dying and to permit pharmacists and other persons to assist in the process”. The bill restricted euthanasia only to mentally competent adults with “enduring and intolerable suffering” and in cases where death is reasonably foreseeable. It also mandated a 10-day reflection period.

After the House of Commons passed Bill C-14 that would allow for euthanasia, it was debated in the Senate in mid-June 2016. Initially, that chamber amended the bill, expanding eligibility for euthanasia. However, when it became apparent that the elected House of Commons would not accept the amendment, a final vote was held on 18 June. At that time, a majority agreed with the restrictive wording provided by the House of Commons indicating that “only patients suffering from an incurable illness whose natural death is ‘reasonably foreseeable’ are eligible for a medically assisted death”, as summarized by the Toronto Star. Some opponents to the law indicate that the Carter v. Canada (Attorney General) decision was broader, including desperately ill individuals and not only those who are terminally ill or near death. The House of Commons did accept a few Senate amendments, such as requiring that patients be counseled about alternatives including palliative care and barring beneficiaries from acting in the euthanasia. Senators such as Serge Joyal who disagree with the restrictive wording believe that the provinces should refer the issue to the Supreme Court of Canada for an opinion in order to preclude the need for individuals to proceed with such an Appeal and incur the significant expense of doing so. There was also a debate on the issue of suicide in Indigenous communities with MP Robert-Falcon Ouellette (Liberal) voting against the government on C-14. This was the first instance of a government backbencher voting against their party. Ouellette believes that large-scale changes to social norms like euthanasia should move very slowly because the impacts will be felt differently across Canada and societies.

Truchon v Attorney General of Canada

On 11 September 2019, the Superior Court of Quebec declared that restricting euthanasia to those whose death is reasonably foreseeable violated the Charter’s guarantee to “life, liberty, and security of the person” as well as the Charter’s guarantee of “equal protection” under the law. The ruling declared the reasonably foreseeable clause in the federal euthanasia legislation to be unconstitutional. Neither the Attorney General of Canada or the Attorney General of Quebec appealed the decision.

Bill C-7

The federal government passed Bill C-7 on 17 March 2021. The new legislation relaxed or eliminated some of the safeguards for patients whose deaths were reasonably foreseeable, notably removing the 10-day waiting period, requiring only a single independent witness, and removing the requirement to offer palliative care. The legislation also introduced a new avenue for those whose death was not reasonably foreseeable to access euthanasia, conditional on the approval of medical practitioner who specialized in the underlying condition, a 90-day assessment period, and discussion on all other available treatment methods. The legislation also included a sunset clause that would allow people with severe refractory mental illnesses that have exhausted all treatment options to be eligible for euthanasia two years after the legislation passed. This clause has been particularly controversial due to the perceived difficulty of receiving informed consent from individuals suffering from a mental illness, particularly when the mental illness is already associated with suicide ideation. However, multiple studies show that the majority of people with mental illnesses do not lack the mental competence or the capacity to make treatment-related decisions. This expansion in access to medical assistance in dying was originally planned for March 2023 before being postponed by one year to 17 March 2024. It was further postponed to 2027.

A panel was established by the government to study potential issues and safeguards with implementing medical assistance in dying for people whose sole medical condition was a mental illness.^[39] A report of this process was given to parliament on 6 May 2022. The panel had nineteen recommendations that could be implemented without amending the Criminal Code. Some arguments addressed to the panel suggested that there was no evidence that safeguards and protocols could be adequate and thus the panel’s mandate could not be fulfilled. The panel concluded that despite these uncertainties, people could still voluntarily wish to request medical assistance in dying and thus its mandate could be fulfilled. One member of the panel, Ellen Cohen, resigned for ethical reasons. Cohen believes that the issues faced by those in poverty or seeking housing was not adequately considered by the rest of the panel. A person can simultaneously seek medical assistance in dying while waiting for other treatments.

In 2024, a lawsuit about the legality of delaying expansion of euthanasia to those with a mental disorder was filed due to the belief that denying it on these grounds is discriminatory and violates the Charter of Rights and Freedoms.

Statistics

There have been 44,958 MAID deaths reported in Canada since the introduction of legislation in 2016. In 2022, 13,241 MAID provisions were reported in Canada, accounting for 4.1% of all deaths in Canada. This represents a growth rate of 31.2% over 2021. The average age of individuals at the time MAID was provided in 2022 was 77.0 years. The underlying medical conditions included cancer (63%), cardiovascular (18.8%), other at 14.9% (can be frailty, diabetes, chronic pain, autoimmune), respiratory (13.2%), and neurological conditions (12.6%). Seventy-seven percent of MAID recipients received palliative care and of the MAID recipients who did not receive palliative care 87.5% had access, a level similar to the three previous years.

Reception

Before euthanasia was made legal in Quebec in June 2014, the Quebec College of Physicians had declared that it was prepared to cross the line on the debate over euthanasia and proposed that it be included as part of the appropriate care in certain particular circumstances. The Canadian Medical Association (CMA) describes euthanasia as “one of the most complex and ethically challenging issues facing Canadian physicians”. Before the legalization of euthanasia, the organization stated that it is not up to them to decide on the issue of euthanasia, but the responsibility of society. The organization also reported that not all doctors were willing to help a terminally-ill patient die.

A 2015 survey indicated that 29% of Canadian doctors surveyed would consider providing euthanasia while 63% would refuse. However, the belief in late 2015 was that no physician would be forced to do so. The extent of conscientious objection to providing euthanasia continues to be debated on issues such as whether objecting physicians must refer patients to a doctor who is willing to provide euthanasia and whether institutions have a right to refuse to provide euthanasia services; at present doctors are required to make effective referrals. Catholic hospitals often refuse to provide healthcare that goes against the institution’s tenets, such as abortion or euthanasia.

A 2023 survey by the Angus Reid Institute showed 61% of Canadians supported the current version of the legislation, while 31% supported extending euthanasia to mental disorders. A poll conducted by Leger in the summer of 2022 regarding further liberalization of Canada’s euthanasia laws found that 51% of Canadians supported expanding euthanasia to mature minors, with 23% opposed and 26% being unsure. 65% supported advanced directives in the face of a worsening cognitive condition, with 14% opposed and 22% being unsure. 45% supported expanding eligibility for euthanasia to include individuals with serious mental health illnesses, with 23% opposed and 32% being unsure of their position.

Criticism

In 2021, the United Nations Human Rights Council‘s special rapporteur on the rights of persons with disabilities criticized Bill C-7 and assisted death in general, for undermining both disabled people’s equal right to live and their ability to autonomously access support to continue living. An estimated 25% of disabled Canadian adults live in poverty. Money available through social programs differs across provinces but is often below the poverty threshold: New Brunswick offers the least at $705 per month and Alberta offers the most at $1,685 per month. In an August 2023 paper, Medical Assistance in Dying, Palliative Care, Safety, and Structural Vulnerability, the authors argued that while socioeconomic deprivation drives mortality to a large degree, it does not drive medical assistance in dying to any substantial degree. Another 2023 paper, The Realities of Medical Assistance in Dying in Canada, concluded that “The Canadian MAiD regime is lacking the safeguards, data collection, and oversight necessary to protect Canadians against premature death.”

In certain cases, family members are not informed that their relative has died through MAID, as individuals have a right to medical privacy. While standard reviews of MAID cases may be conducted, Canada’s process has been criticized for lacking regional panels and oversight processes that other countries with legal euthanasia provide.

Impact on the impoverished

After the repeal of the reasonably foreseeable requirement in Bill C-7, there have been claims from writers for The Spectator, Jacobin, and Global News that many might opt into euthanasia because of poverty, with accusations of Canada “euthanizing its poor”. Critics believe that a lack of social spending structurally places these people in poverty, and then introduces MAID as a way out, citing issues like insufficient welfare for disabled people and unconstitutionally long waiting times for healthcare as evidence that those who are disabled and impoverished do not have enough support to survive. An analysis piece from The Spectator, their most popular article in 2022, stated that the Canadian government sees MAID as a more economical alternative to investments in social programs and welfare. The Canadian Parliamentary Budget Officer released a report claiming the old MAID policies will save Canada $86.9 million per year and that Bill C-7 will save an additional $62 million per year. There have also been intersectional issues raised with MAID relating to higher rates of poverty in marginalized communities, lack of social support, and ableism and racism in the medical community.

Ableism and equality concerns

Bill C-7 has been criticized as discriminatory towards disabled people. A letter from the United Nations Human Rights Council’s Special Rapporteur on the rights of persons with disabilities, the Independent Expert on the enjoyment of all human rights by older persons, and the Special Rapporteur on extreme poverty on human rights raised concerns that the bill would not adhere to “international human rights standards”. They believe that the bill potentially violates the right to life of disabled people, that provisions of the bill are not consistent with Canada’s obligation to equality and non-discrimination, and that the bill perpetuates negative stereotypes about disabilities. In a paper from August 2023 authored by a member of the law faculty at the University of British Columbia, Legislated Ableism: Bill C-7 and the Rapid Expansion of MAiD in Canada, the author argues that the expansion of MAID through Bill C-7 conflicts with the Canadian constitution, violating s.7 and s.15, which pertain to equal protection under law and anti-discrimination.

Handling of specific cases

In addition to broader criticism of MAID, the handling of certain cases have been subject to media coverage. These include:

In 2017, a mother of a young woman with cerebral palsy was told by a doctor that not applying for MAID was “selfish”. Her daughter was in the room when the conversation took place and described the experience as traumatic.
In 2018, Roger Foley was being treated for cerebellar ataxia at an Ontario hospital. Foley alleged that his only options were to be forcibly discharged from the hospital and then treated by an organization that had previously failed to provide him adequate care or apply for MAID. Foley hired a lawyer for a charter challenge.
In 2019, Alan Nichols successfully applied for MAID while being hospitalized for suicide ideation. The reason given on his application was hearing loss.
In February 2022, an anonymous Torontonian suffering from extreme chemical sensitivity syndrome with the pseudonym Sophia had a medically assisted death after failing to find affordable housing that was free from tobacco smoke and other chemicals. This case was addressed by her health care provider in testimony provided to the Special Joint Committee on MAID, and was referenced in their final report.
In October 2022, a man from St. Catharines applied for MAID when facing homelessness. After receiving $60,000 from a GoFundMe campaign, he was able to find a place to live and withdrew his application.
In November 2022, an anonymous active Canadian Forces member has alleged he was offered MAID when seeking assistance regarding PTSD and suicidal thoughts.
In December 2022, Paralympian and veteran Christine Gauthier testified that a Veterans Affairs Canada employee offered her MAID as an option when she was fighting for the installation of a wheelchair lift or ramp at her house. Subsequently, VAC claimed they found no record that MAID was offered as an option to Gauthier and that it found four such cases, all involving a single now-suspended case manager.
In August 2022, Vancouver Coastal Health asked patients seeking mental healthcare for suicidal ideation if they would like to consider MAiD, which the patients experienced as undermining their access to suicide prevention care; the hospital stated the suggestion was a method of assessing suicide risk.
In February 2024, a 27-year old woman with autism was scheduled for euthanasia in Alberta. Her father sought a temporary injuction through the justice system to prevent her death.

What medical assistance in dying is, who is eligible, how to make a request, the process, and who can provide medical assistance in dying.

Eligibility for MAID for persons suffering solely from a mental illness has been delayed until March 17, 2027.

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.

There are 2 methods of medical assistance in dying available in Canada.

Method 1: a physician or nurse practitioner directly administers a substance that causes death, such as an injection of a drug. This is sometimes called clinician-administered medical assistance in dying.

Method 2: a physician or nurse practitioner provides or prescribes a drug that the eligible person takes themselves, in order to bring about their own death. This is sometimes called self-administered medical assistance in dying.

Clinical guidelines and practices outline which drugs to use, and are established by:

provinces and territories
organizations that regulate the practice of medicine

Many of the drugs commonly used for this procedure are already available in Canada. Health care providers usually prescribe them at lower dosages for common purposes, such as:

nausea
pain control
anaesthesia

As the regulator of drug products, Health Canada is working with partners to help support access to drugs for medical assistance in dying.

Eligibility

To be eligible for medical assistance in dying, you must meet all the following criteria. You must:

be eligible for health services funded by a province or territory, or the federal government
- You may also be eligible if you meet your province or territory’s minimum period of residence or waiting period.
be at least 18 years old and mentally competent
- This means being capable of making health care decisions for yourself.
have a grievous and irremediable medical condition
make a voluntary request for medical assistance in dying
- The request cannot be the result of outside pressure or influence.
give informed consent to receive medical assistance in dying

Generally, visitors to Canada are not eligible for medical assistance in dying.

Grievous and irremediable medical condition

To be considered as having a grievous and irremediable medical condition, you must meet all of the following criteria. You must:

have a serious illness, disease or disability
be in an advanced state of decline that cannot be reversed
experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable

You do not need to have a fatal or terminal condition to be eligible for medical assistance in dying.

If your only medical condition is a mental illness, you are not eligible for medical assistance in dying until March 17, 2027.

If you have a mental illness along with other medical conditions, you may be eligible for medical assistance in dying.

Eligibility is always assessed on an individual basis and takes all relevant circumstances into account. However, you must meet all the criteria to be eligible.

Informed consent

Informed consent is when you give permission to receive medical assistance in dying after you receive all of the information you need to make your decision. This includes:

your medical diagnosis
available forms of treatment
available options to relieve suffering, including palliative care

You must be able to give informed consent both:

at the time of your request
immediately before receiving medical assistance in dying, unless special circumstances apply

You can withdraw your consent at any time and in any way.

Making a request

Regardless of location, you can request medical assistance in dying if you’re eligible.

If you’re experiencing a lot of pain and suffering due to your medical situation, talk to your physician or nurse practitioner. You can discuss options related to your circumstances and your possible interest in medical assistance in dying.

How and where this service will be offered is determined by:

medical institutions
provinces and territories
the organizations that regulate health professionals

You may have to meet other requirements. Your health care provider can tell you more.

If you don’t have a regular practitioner, your province or territory may have a central coordination service that can help you.

Support and resources

The role of provinces and territories

Policies and procedures may vary depending on where you live. Provinces and territories can create health-related laws or rules that may affect medical assistance in dying services. However, they cannot permit actions that are prohibited under the Criminal Code.

Rules that can affect medical assistance in dying can include:

data and information collection
the use of specific forms to fill out
special medical training for providers of the service
rules or requirements for either type of medical assistance in dying

If you have questions about the law and policies in your specific location, contact your province or territory.

Procedural safeguards

Before a medical practitioner administers medical assistance in dying, they must satisfy certain safeguards. These include making sure that you :

have 2 independent medical assessments
make a written request signed by an independent witness
know that you can withdraw your request at any time
provide final consent before receiving medical assistance in dying
give advance consent, if applicable

They must also meet extra safeguards in the event that your death is not naturally foreseeable.

Medical assessments

When you make your request for medical assistance in dying, 2 independent medical practitioners (physicians or nurse practitioners) must assess it.

Your medical practitioner must make sure that you meet all of the listed eligibility criteria. The second practitioner must also provide a written opinion confirming that you’re eligible.

The medical practitioner providing the original assessment and the one giving the second opinion must be independent. This means they cannot:

knowingly benefit from your death
hold a position of authority over the other
be connected to the other or to you in a way that could affect their objectivity

Making a written request

You must sign a written request that says you want to have a medically assisted death. The request must include your:

signature confirming your request for medical assistance in dying. If you can’t write, another adult can sign the request on your behalf under your clear direction. This adult must:
- be at least 18 years of age
- understand what it means to request medical assistance in dying
- not benefit from your death (for example, they must not be an heir to your estate)
written request must be signed and dated before 1 independent witness, who must also sign and date the request

Some provinces and territories may have a specific request form for you to complete. You can get this form from your health care provider or your provincial or territorial government website.

Support and resources

Independent witness

The role of the independent witness is to confirm:

the signing and dating of the request by the person requesting medical assistance in dying
that the person requesting medical assistance in dying understands what they’re signing

An independent witness:

must be at least 18 years of age
can be a paid professional personal or health care worker
must understand what it means to request medical assistance in dying

To be considered independent means that the witness cannot:

benefit from your death
be an unpaid caregiver
be an owner or operator of a health care facility where you live or are receiving care

Withdrawing your request

You must be informed of your right to withdraw your request for medical assistance in dying at any time and in any manner.

You do not have to proceed even if you’re found eligible for the service.

Final consent

Immediately before receiving medical assistance in dying, you must:

be given the opportunity to withdraw consent
affirm your consent if you do not wish to withdraw it

An exception to this requirement is possible if you have a waiver of final consent. You can waive the requirement to provide consent just before you receive medical assistance in dying, only if:

your natural death is reasonably foreseeable and
while you had decision-making capacity:
- you were assessed and approved to receive medical assistance in dying
- your practitioner advised that you are at risk of losing capacity to provide final consent
- you made a written arrangement with your practitioner to provide consent in advance on your chosen date, if you no longer have capacity to consent on that date

Any arrangement for the waiver of final consent will be considered invalid if, at the time that you are to receive medical assistance in dying, you:

no longer have capacity and
demonstrate refusal or resistance to the administration of MAID by words, sounds or gestures

Reflexes and other types of involuntary movements do not constitute refusal or resistance. Examples of involuntary movements include responses to touch or the insertion of a needle.

Advance consent in cases of self-administered medical assistance in dying

You can make a written arrangement with your practitioner so that they can administer medical assistance in dying in the event of failed self-administration.

This arrangement allows for clinician-administered medical assistance in dying if there are complications during self-administration that cause your loss of decision-making capacity but not your death. This means that your medical practitioner must be present at the time that you self-administer the medications.

Requests where your natural death is not reasonably foreseeable

If the medical practitioners assessing your request for MAID determine that your death is not reasonably foreseeable, there are extra safeguards that must be met before medical assistance in dying can be provided:

One of the 2 medical practitioners who provides an assessment must have expertise in the medical condition that is causing your unbearable suffering.
- If neither of them have this expertise, they must consult another practitioner with expertise in the medical condition during the assessment process.
You must be informed of available means to relieve your suffering, and offered consultations with professionals who provide services including, where appropriate:
- palliative care
- community services
- counselling services
- mental health and disability support services
You and your practitioners must have discussed reasonable and available means to relieve your suffering, and all agree that you have seriously considered those means.
Your eligibility assessment must take a minimum of 90 days, unless the assessments have been completed sooner and you are at immediate risk of losing your capacity to consent.
Immediately before you receive medical assistance in dying, the practitioner must:
- give you an opportunity to withdraw your request
- ensure that you give express consent to receive medical assistance in dying

Medical practitioners

Those who can conduct assessments and provide medical assistance in dying are:

physicians
nurse practitioners (in provinces where this is allowed)

Those who can help provide medical assistance in dying include:

pharmacists, pharmacy technicians and assistants
family members or other people that you ask to help
health care providers who help physicians or nurse practitioners

These people can assist in the process without being charged under criminal law. However, physicians, nurse practitioners and other people who are directly involved must follow:

the rules set out in the Criminal Code
applicable provincial and territorial health-related laws, rules and policies

Provider’s rights

Not all health care providers are comfortable with medical assistance in dying. Federal legislation does not force anyone to provide or help to provide medical assistance in dying.

Provincial and territorial governments are responsible for determining how and where to provide health care services. They may also make policies around where medical assistance in dying can take place. However, they cannot permit actions that are prohibited under the Criminal Code.

Supporting access

We understand that these provider rights could create challenges if you want to access medical assistance in dying. Contact your health care provider for questions about access. You can also contact your province or territory for information on the procedure and other care options.

If you’re a health care provider, contact your provincial or territorial professional regulatory body for information about:

your reporting obligations
specific practice guidelines

Eligibility for medical assistance in dying

241.2(1) A person may receive medical assistance in dying only if they meet all of the following criteria:
- (a) they are eligible — or, but for any applicable minimum period of residence or waiting period, would be eligible — for health services funded by a government in Canada;
- (b) they are at least 18 years of age and capable of making decisions with respect to their health;
- (c) they have a grievous and irremediable medical condition;
- (d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and
- (e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.
Marginal note:Grievous and irremediable medical condition(2) A person has a grievous and irremediable medical condition only if they meet all of the following criteria:
- (a) they have a serious and incurable illness, disease or disability;
- (b) they are in an advanced state of irreversible decline in capability; and
- (c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.
- (d) [Repealed, 2021, c. 2, s. 1]
Marginal note:Exclusion(2.1) For the purposes of paragraph (2)(a), a mental illness is not considered to be an illness, disease or disability.
Marginal note:Safeguards — natural death foreseeable(3) Subject to subsection (3.2), before a medical practitioner or nurse practitioner provides medical assistance in dying to a person whose natural death is reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining, the medical practitioner or nurse practitioner must
- (a) be of the opinion that the person meets all of the criteria set out in subsection (1);
- (b) ensure that the person’s request for medical assistance in dying was
  - (i) made in writing and signed and dated by the person or by another person under subsection (4), and
  - (ii) signed and dated after the person was informed by a medical practitioner or nurse practitioner that the person has a grievous and irremediable medical condition;
- (c) be satisfied that the request was signed and dated by the person — or by another person under subsection (4) — before an independent witness who then also signed and dated the request;
- (d) ensure that the person has been informed that they may, at any time and in any manner, withdraw their request;
- (e) ensure that another medical practitioner or nurse practitioner has provided a written opinion confirming that the person meets all of the criteria set out in subsection (1);
- (f) be satisfied that they and the other medical practitioner or nurse practitioner referred to in paragraph (e) are independent;
- (g) if the person has difficulty communicating, take all necessary measures to provide a reliable means by which the person may understand the information that is provided to them and communicate their decision; and
- (h) immediately before providing the medical assistance in dying, give the person an opportunity to withdraw their request and ensure that the person gives express consent to receive medical assistance in dying.
- (i) [Repealed, 2021, c. 2, s. 1]
Marginal note:Safeguards — natural death not foreseeable(3.1) Before a medical practitioner or nurse practitioner provides medical assistance in dying to a person whose natural death is not reasonably foreseeable, taking into account all of their medical circumstances, the medical practitioner or nurse practitioner must
- (a) be of the opinion that the person meets all of the criteria set out in subsection (1);
- (b) ensure that the person’s request for medical assistance in dying was
  - (i) made in writing and signed and dated by the person or by another person under subsection (4), and
  - (ii) signed and dated after the person was informed by a medical practitioner or nurse practitioner that the person has a grievous and irremediable medical condition;
- (c) be satisfied that the request was signed and dated by the person — or by another person under subsection (4) — before an independent witness who then also signed and dated the request;
- (d) ensure that the person has been informed that the person may, at any time and in any manner, withdraw their request;
- (e) ensure that another medical practitioner or nurse practitioner has provided a written opinion confirming that the person meets all of the criteria set out in subsection (1);
- (e.1) if neither they nor the other medical practitioner or nurse practitioner referred to in paragraph (e) has expertise in the condition that is causing the person’s suffering, ensure that they or the medical practitioner or nurse practitioner referred to in paragraph (e) consult with a medical practitioner or nurse practitioner who has that expertise and share the results of that consultation with the other practitioner;
- (f) be satisfied that they and the medical practitioner or nurse practitioner referred to in paragraph (e) are independent;
- (g) ensure that the person has been informed of the means available to relieve their suffering, including, where appropriate, counselling services, mental health and disability support services, community services and palliative care and has been offered consultations with relevant professionals who provide those services or that care;
- (h) ensure that they and the medical practitioner or nurse practitioner referred to in paragraph (e) have discussed with the person the reasonable and available means to relieve the person’s suffering and they and the medical practitioner or nurse practitioner referred to in paragraph (e) agree with the person that the person has given serious consideration to those means;
- (i) ensure that there are at least 90 clear days between the day on which the first assessment under this subsection of whether the person meets the criteria set out in subsection (1) begins and the day on which medical assistance in dying is provided to them or — if the assessments have been completed and they and the medical practitioner or nurse practitioner referred to in paragraph (e) are both of the opinion that the loss of the person’s capacity to provide consent to receive medical assistance in dying is imminent — any shorter period that the first medical practitioner or nurse practitioner considers appropriate in the circumstances;
- (j) if the person has difficulty communicating, take all necessary measures to provide a reliable means by which the person may understand the information that is provided to them and communicate their decision; and
- (k) immediately before providing the medical assistance in dying, give the person an opportunity to withdraw their request and ensure that the person gives express consent to receive medical assistance in dying.
Marginal note:Final consent — waiver(3.2) For the purposes of subsection (3), the medical practitioner or nurse practitioner may administer a substance to a person to cause their death without meeting the requirement set out in paragraph (3)(h) if
- (a) before the person loses the capacity to consent to receiving medical assistance in dying,
  - (i) they met all of the criteria set out in subsection (1) and all other safeguards set out in subsection (3) were met,
  - (ii) they entered into an arrangement in writing with the medical practitioner or nurse practitioner that the medical practitioner or nurse practitioner would administer a substance to cause their death on a specified day,
  - (iii) they were informed by the medical practitioner or nurse practitioner of the risk of losing the capacity to consent to receiving medical assistance in dying prior to the day specified in the arrangement, and
  - (iv) in the written arrangement, they consented to the administration by the medical practitioner or nurse practitioner of a substance to cause their death on or before the day specified in the arrangement if they lost their capacity to consent to receiving medical assistance in dying prior to that day;
- (b) the person has lost the capacity to consent to receiving medical assistance in dying;
- (c) the person does not demonstrate, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration; and
- (d) the substance is administered to the person in accordance with the terms of the arrangement.
Marginal note:For greater certainty(3.3) For greater certainty, involuntary words, sounds or gestures made in response to contact do not constitute a demonstration of refusal or resistance for the purposes of paragraph (3.2)(c).
Marginal note:Advance consent invalidated(3.4) Once a person demonstrates, by words, sounds or gestures, in accordance with subsection (3.2), refusal to have the substance administered or resistance to its administration, medical assistance in dying can no longer be provided to them on the basis of the consent given by them under subparagraph (3.2)(a)(iv).
Marginal note:Advance consent — self-administration(3.5) In the case of a person who loses the capacity to consent to receiving medical assistance in dying after self-administering a substance, provided to them under this section, so as to cause their own death, a medical practitioner or nurse practitioner may administer a substance to cause the death of that person if
- (a) before the person loses the capacity to consent to receiving medical assistance in dying, they and the medical practitioner or nurse practitioner entered into an arrangement in writing providing that the medical practitioner or nurse practitioner would
  - (i) be present at the time the person self-administered the first substance, and
  - (ii) administer a second substance to cause the person’s death if, after self-administering the first substance, the person lost the capacity to consent to receiving medical assistance in dying and did not die within a specified period;
- (b) the person self-administers the first substance, does not die within the period specified in the arrangement and loses the capacity to consent to receiving medical assistance in dying; and
- (c) the second substance is administered to the person in accordance with the terms of the arrangement.
Marginal note:Unable to sign(4) If the person requesting medical assistance in dying is unable to sign and date the request, another person — who is at least 18 years of age, who understands the nature of the request for medical assistance in dying and who does not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death — may do so in the person’s presence, on the person’s behalf and under the person’s express direction.
Marginal note:Independent witness(5) Any person who is at least 18 years of age and who understands the nature of the request for medical assistance in dying may act as an independent witness, except if they
- (a) know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death;
- (b) are an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides;
- (c) are directly involved in providing health care services to the person making the request; or
- (d) directly provide personal care to the person making the request.
Marginal note:Exception(5.1) Despite paragraphs (5)(c) and (d), a person who provides health care services or personal care as their primary occupation and who is paid to provide that care to the person requesting medical assistance in dying is permitted to act as an independent witness, except for
- (a) the medical practitioner or nurse practitioner who will provide medical assistance in dying to the person; and
- (b) the medical practitioner or nurse practitioner who provided an opinion under paragraph (3)(e) or (3.1)(e), as the case may be, in respect of the person.
Marginal note:Independence — medical practitioners and nurse practitioners(6) The medical practitioner or nurse practitioner providing medical assistance in dying and the medical practitioner or nurse practitioner who provides the opinion referred to in paragraph (3)(e) or (3.1)(e) are independent if they
- (a) are not a mentor to the other practitioner or responsible for supervising their work;
- (b) do not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death, other than standard compensation for their services relating to the request; and
- (c) do not know or believe that they are connected to the other practitioner or to the person making the request in any other way that would affect their objectivity.
Marginal note:Reasonable knowledge, care and skill(7) Medical assistance in dying must be provided with reasonable knowledge, care and skill and in accordance with any applicable provincial laws, rules or standards.
Marginal note:Informing pharmacist(8) The medical practitioner or nurse practitioner who, in providing medical assistance in dying, prescribes or obtains a substance for that purpose must, before any pharmacist dispenses the substance, inform the pharmacist that the substance is intended for that purpose.
Marginal note:Clarification(9) For greater certainty, nothing in this section compels an individual to provide or assist in providing medical assistance in dying.

Conclusion

I have to admit that I am riding the rail on this one. I know I listed it under ow We sold our soul, however, it might not be such a bad thing. I know that we spend billons of dollars in the US treating people that are terminal. We are doing so despite the patient’s wishes. What happens is that the family discontinues the DNR and paliative care filings once the patient can no longer speak for themselves. Many times they are being kep alive so that the family can receive the patient’s pesions or benefits. So what is right, only God knows. By keping the person alive artificially are we going against his wishes? This is way above my pay grade.

Resources

canada.ca, “Medical assistance in dying: Overview.”; laws-lois.justice.gc.ca, “Criminal Code (R.S.C., 1985, c. C-46).”; en.wikipedia.com, “Euthanasia in Canada.” By Wikipedia Ediors;