In 2023, one out of 20 Canadians who died received a physician-assisted death, making Canada the No. 1 provider of medical assistance in dying (MAID) in the world, when measured in total figures. In one province, Quebec, there were more MAID deaths per capita than anywhere else. Canadians, by and large, have been supportive of this trend. A 2022 poll showed that a stunning 86 percent of Canadians supported MAID’s legalization.
But in some corners, MAID has been the subject of a growing unease. While MAID in Canada was initially restricted to patients with terminal conditions — people whose natural deaths were “reasonably foreseeable” — the law was controversially amended in 2021 to include people who were suffering but who weren’t actually dying: patients who might have many years or even decades of life ahead of them. This new category includes people with chronic pain and physical disabilities.
For The New York Times Magazine, I interviewed dozens of clinicians, ethicists, lawyers, advocates and patients about how MAID in Canada works. Here is what I learned:
The criteria for MAID in Canada is among the broadest in the world
When Canada’s first MAID law, Bill C-14, passed in 2016, it had strict eligibility criteria: Patients needed to be over 18, eligible for Canadian health care and mentally competent to consent to death. They needed to have a “serious and incurable illness, disease or disability”; be in an “advanced state of irreversible decline in capability”; and have “enduring physical or psychological suffering” that was “intolerable.” Their natural deaths also had to be “reasonably foreseeable.” In other words, they had to be dying. Early MAID patients were often people in their 70s or 80s with terminal cancer.
In 2021, the Canadian government passed Bill C-7, which removed the criteria that a patient’s death be “reasonably foreseeable.” Now Canadians who are chronically sick or disabled — with conditions ranging from quadriplegia to multiple sclerosis to blindness to early-stage Parkinson’s to chronic back pain — can receive assisted deaths from doctors or nurse practitioners. Within Canada, this newer kind of MAID is known as Track 2.
Track 2 is controversial, even among MAID supporters
Some clinicians who are involved with MAID objected to the legal expansion. They argue that it isn’t really “assistance in dying” if the patient isn’t dying.
Even some seasoned MAID assessors are hesitant to get involved with Track 2. Dr. Madeline Li, a cancer psychiatrist in Toronto who has personally overseen hundreds of MAID assessments for dying patients, told me that the Track 2 process did not fit within her larger understanding of medicine and its purpose. “If you want to allow people to end their lives when they want to, then put suicide kits in hardware stores, right?”
Proponents argue that the expansion of Canada’s legislation was an act of mercy
To supporters, the passage of Bill C-7 was an act of profound empathy, granting relief to patients who might otherwise suffer for years.
In 2017, two plaintiffs challenged the original Canadian MAID law in a Quebec court as being too restrictive. One was Jean Truchon, a 51-year-old who had suffered from spastic cerebral palsy from birth and who was almost completely immobile. Truchon lived in an assisted-living facility, where, in his description, he experienced constant pain and muscle spasms — and where he could do very little, apart from watching hours of television each day.
Truchon was granted a legal exemption and died by MAID in 2020. His story was shared widely, and with great sympathy, in the Canadian press — and inspired the passage of Bill C-7.
Critics argue that poor and marginalized patients are being driven to request MAID
Critics argue that Canadians are being driven to request MAID because of socioeconomic suffering. Even some MAID defenders acknowledge that financial factors can play a role in a MAID application. A 2023 academic paper collected testimony from 20 MAID providers. The clinicians explained that unmet needs were rare, but that some MAID patients were impoverished and lonely — and that this led to an “ethical dilemma,” because providers knew “that some of their suffering was due to society’s failure to provide for them.”
Different MAID assessors can come to different conclusions about the same patient
Assessors sometimes disagree about whether and when a patient should be approved to die under the Track 2 MAID program. Dr. Donna Stewart, a psychiatrist at Toronto General Hospital, told me about a patient in his late 20s who jumped from a building after taking hallucinogenic drugs — and who ended up quadriplegic. He applied for MAID almost immediately.
Some of Stewart’s colleagues thought the man should be found ineligible. They pointed to research showing that over time, often years, people with spinal-cord injuries acclimate to their new lives. Other clinicians thought the man had the right to decide that he didn’t want to suffer anymore.
In the end, Stewart asked the patient to wait a year and to go to rehab. A year later, the man asked for MAID again, and Stewart approved him.
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