What We Think About When We Think About MAID

Talking about Medical Assistance in Dying ("MAID") is divisive, emotionally charged, and extremely personal. Discussing it is scary, riddled with pitfall traps, and likely to offend people. So naturally, I want to dig into it.

For many Canadians, just thinking about this topic is a no fly zone. We tend to have an aversion to such negative things. It is a necessary conversation though, So this is my attempt to describe how I think about MAID and the conclusions that I do (or don't) come to.

MAID is especially difficult because it short circuits the Canadian psyche. It’s justifying philosophy sits at the nexus of fundamental values that underpin Western ideology, and pits them against each other.

The first value is the sanctity of life - We must preserve life in all instances, and do everything in our power to prolong it.

The second is the notion of personal autonomy — giving people control to do what they want with their lives and their bodies. This idea is the foundation for the basic premise of consent.

Thus, MAID can be looked at as the battle for supremacy between the sanctity of life and our respect for personal autonomy. It is where the unstoppable moral force meets the immovable moral object.

In addition to these two fundamentals, MAID necessitates deep consideration and attention to suffering (quality of life) and a fourth more abstract metaphysical fear around the concepts of death and dying.

Yes, it is a big conversation.

To orient myself, learn more, and to help educate my local community, I facilitated a symposium on this topic back in February. The speakers panel included a palliative care doctor, a legal expert, and a faith leader. That experience taught me that this issue is constantly evolving, and that most people don't feel comfortable asking questions about MAID.

The issue is far from settled in the hearts and minds of Canadians. There is little clarity or common language on how to approach the conversation: when to have it, if you should have it, and how to navigate the social taboos. Then there is much unknown on how to best approach friends, family members, and love ones who are considering the avenue.

The medical expert, palliative care doctor and order of Canada recipient, Dr. Sandy Buchman led the symposium off with an extremely powerful anecdote. He told the story of one of his first exposures to MAID, when he walked into a patient's home for a consultation.

Dr. Buchman was received by an elderly gentleman with a European accent, who, upon his arrival, rolled up his sleeve and revealed the numbered tattoo on his arm. He said — and I'm paraphrasing — "Hitler and the Nazi's wanted to take away my right to choose whether I lived or died. Today I am exercising that right. Will you support me in making my choice?"

That moment helped settle the debate in the mind of Dr. Buchman.

In my personal life, I have a friend whose father was suffering but not terminally ill. He had a clear quality of life issue that caused him physical and emotional pain. What's more, he felt his pain was the responsibility of a doctor who had performed surgery on him earlier that year. In my friend's estimation, that physical pain and the emotional sense of betrayal drove the decision for this individual to pursue MAID. He was suffering badly. He got the procedure done less than a month later.

In the days after their father's death, that patient's family received a voicemail from the health ministry: a social worker had been assigned to their father's case and would be getting in touch to set up an appointment to figure out next steps for treatment.

At the end of his life, this person was let down by the health system. Universal healthcare failed him, and supports did not arrive quickly enough to help. He felt he had lived his life, was miserable, and only had one way out.

It is impossible to know what would have happened if the social worker had been put in place two months earlier, it might have made all the difference in the world. Or maybe, the same conclusion would have been reached. Was this fate or destiny? This man was exercising the exact same right that the holocaust survivor did, after all.

We can't know for sure but we can certainly acknowledge that there are real gaps in Canadian healthcare. Therefore, we must conclude that there is a risk that MAID is providing people a way out of, and giving cover to, a broken and degraded system.

The unfortunate reality is that Canadians are at the mercy of institutions that have gaps. Autonomy is one thing, but if even one person falls through the cracks, compelled to ending their life prematurely, that ought to be considered unacceptable. A single life that could have been saved is a tragedy that should give us serious pause before forging ahead.

It is likely impossible to completely eliminate mistakes, but we need to be absolutely committed to the best outcomes. Add it to the list of reasons to improve the healthcare system. Ultimately, we must be hyper cautious not to allow MAID to cover for the government's shortcomings.

This is a particularly poignant criticism given the trend we see in the number of Canadians receiving MAID. The latest statistics (from 2024) are that since legalized, approximately 2% of deaths in Canada happen via MAID. Saliently, that number is on the rise.

In 2024, that number was all the way up to 5% on the year. 16,000 people. Those numbers feel jarring. But before we draw conclusions, we need to ask, what should that number be? Really, what % of Canadian deaths should be happening via MAID?

What can we find when we dig into the numbers? For Starters, 95% of people who get MAID are on what is called "Track 1", which means a person whose death is "reasonably foreseeable".

What's more, 20% of MAID requests in 2024 were never completed because those people died from other causes before getting the procedure done. That suggests that physicians might actually be too conservative about approving patients.

A couple more key numbers that really stand out: 63% of MAID recipients had terminal Cancer, and their median age was 78. These statistics seem reasonable and signal that MAID is doing what it was designed to do, alleviate suffering for people with no other option.

On the other hand, outliers and anecdotes don't care about these numbers. The famous Stalin line comes to mind: a million deaths are a statistic, one death is a tragedy. My friend from earlier will always have to wonder if the system was responsible for losing his father.

The consequences of making a mistake here are therefore all the more serious. Realizing that even one person received MAID when they shouldn't have, has the ability to call the entire system into question. The data is fascinating and illuminating, but it doesn't tell the whole story. If you’re curious, It's all public, and you can see the 2024 numbers here.

The data implies that for the most part, we are getting MAID right. But what about when we're not talking about senior citizens? There is a big difference between a 90 year old with terminal Cancer, and a 30 year old living with extreme depression.

As of today, that 30 year old with depression could not seek MAID. But in a year's time, (March of 2027) they will be eligible to pursue it. This development changes the landscape significantly, because mental illness is much trickier to reckon with than a physical disease like cancer.

No matter how many years of "Bell Let's Talk" days go by, there is still and will always be a massive stigma around mental health issues.

But, if we accept that mental health is health, which we try to do, then what really is the difference between mental suffering and pain versus that caused by a condition like cancer? Perhaps there isn't one. That is the line of thought that suggests we should allow MAID when the only underlying condition is a psychiatric one.

The big caveat here though is that many mental health issues are by their very nature subjective. Depression for example, is almost never a clear-cut diagnosis. It is often times determined by a combination of self reported behaviours and feelings.

Depression can be heavily influenced by external factors, seasonal changes, lifestyle, and so on. So if literal sunlight might be a valid medication, then the burden of proof needs to be sky high. If death is not reasonably foreseeable, there could be a realistic chance that a positive development is in store and that the patient's outlook might change.

We trust our physicians, but doctors are human beings. They make mistakes too they and can be influenced. You need two to sign off, but are two professional medical opinions enough when the stakes are this high?

If you find the right doctor, they could bias towards an "any reason is good enough for me" mentality. We balk, but that could be argued as a valid medical opinion. Many doctors won’t give the recommendation for MAID. They’ll say, they got into medicine to preserve the sanctity of life, and to prolong it. Cognitive dissonance once again. But it only takes two signatures to be approved. Those physicians who lean all the way towards autonomy are out there, and they might be right.

With mental health issues, there is still so much of the science undiscovered. To give a practical example, postpartum depression wasn't fully recognized or understood as a genuine condition until the 1990s and 2000s. There are many psychiatric disorders where we do not have the full picture yet.

In that same vein, completely new treatments and drugs could come on the market that change the landscape of mental and physical health dramatically. Is it moral for us to end someone's life when help could be just a few difficult years away?

On the other hand - should we, or the state, be able to dictate to anyone that they don't have personal autonomy? Can we tell a person that they cannot end their life if that's the choice they want to make?

The personal autonomy side is winning the battle in both public opinion and the law. MAID is legal after all. It continues to evolve though as lawmakers and healthcare professionals wrestle with more emerging challenges. That next frontier of MAID are the notions of advanced directives, and access to assisted dying for minors.

Advanced directives are the ability to say something along the lines of "If I am so unhealthy that I can't communicate, or if I get Alzheimers and can't recognize my family, I want to get MAID".

At first pass, this seems reasonable. But how do we know if while unable to communicate, that person didn't change their mind? Isn't that murder? What if the post-dementia version of the person is happy and otherwise healthy? Do we, or could we ever respect the advanced directive?

Minors can't consent to many things, they can't drink and they can’t vote. So how can they have the mental maturity to decide if they live or die?

In the case of kids and teenagers, we all mature at different rates. Should there be different rules for a 17 year old in immense pain than for an 18 year old? Probably not. But what about 16? 14? 12?

Where do we draw the line? The questions only get harder.

Then we can add another layer of complexity; elements of faith and feeling. Suicide is of course prohibited in many religions. This isn’t legally suicide, a life insurance company it turns out, will treat it as a natural death.

Within different sects of the most popular religions there are disagreements. Some will permit MAID, while others will treat it as heretical. Different faith groups have different pressures and parameters both for and against based solely on moral grounds within their world views. Can we say with authority that either is right or wrong?

We can go further still, and examine concerns that family members might actually be leveraging MAID to pressure their elders into making the decision to die sooner. Those family members might think that a quicker outcome will alleviate personal obligation, hardship, or in the worst cases, expedite or preserve an inheritance.

On the flip side of that line of thinking, there are potential MAID recipients who simply don't want to feel like a burden on loved ones, caregivers, or the already taxed healthcare system. Can we deny those people their autonomy? Should we be obligated to convince them they aren't a burden?

The debate rages on.

I think about this issue a lot, and the more I consider, the more I am conflicted. Ultimately, the conclusion I have come to isn't for or against - it's more of an approach:

The key is keeping an open mind, being brave about the realities of being human, and to have the maturity to actually have the conversation.

On the micro scale, when speaking to friends, family, and loved ones, you need to position yourself so that you can have an honest discussion without judgement. It's probably best to go in with no opinion yourself, and to start by listening. If you're young, you may be surprised by how much your parents or grandparents have thought about this topic. They may be surprised you're curious to know what they think.

The greatest lesson from my career is that candour and openness in personal and family relationships almost always leads to better outcomes. Making private decisions without clear communication often leads to surprises. In matters of family, surprises are often tremendously difficult.

On the macro scale (the societal conversation), the key is to have respect for other people's perspectives. We never know exactly what someone is going through, or has gone through. We can't assume to know someone another person's capacity to withstand hardship, the value they put on their own human life, or that of others.

When engaging in such minefield laden discussions, I try to always start from a position that everyone has everyone else's best interests in mind. We just might disagree on what those best interests are.

This conversation will continue for decades. There will always be people who claim in the name of the sanctity of life that MAID is simply state-sponsored suicide. On the other hand, there will be those who believe strictly in personal autonomy - "my life, my choice" after all.

Sanctity of Life. Personal Autonomy. The cognitive dissonance abounds.

We will never have a perfect understanding of what is right and wrong on this one, so my final advice, is that when approaching matters of literal life and death, we must come to them with open minds, humility, and above all, empathy.

** This piece is dedicated to the grandmother of Max and Taylor, may she rest in peace. In a quirk of the cosmos, I learned she had died via MAID while doing the final edit on this article. **