We are psychiatrists who work with patients with advanced cancer. It’s no wonder, then, that when Canada legalized medical assistance in dying a decade ago, it quickly became a major topic of conversation in our clinics. We’ve counseled patients about the procedure and assessed whether they were eligible. One of us has administered the drugs to end patients’ lives. We’ve also researched what leads people to choose this option. And together, we created an institutional framework that determined how one of Canada’s largest medical centers would respond to requests for assisted death.
We know that medical assistance in dying can be dignified and profoundly meaningful for everyone involved. We remember a man in his 30s in our palliative care unit who, thanks to the procedure, was able to choose to die before he became even sicker and potentially lost the ability to communicate. He said a final goodbye to everyone he loved, including his 5-year-old son, and died with his wife beside him and a music therapist singing Leonard Cohen’s “Hallelujah.”
But Canada’s system for assisted death is no longer an option of last resort. Too many people are receiving the procedure without the opportunity for careful reflection about it with a health provider. In some cases, patients are being approved who should not be. Reports have emerged of people seeking assisted death in the context of poverty or loneliness, raising concerns that they may feel they have no other options. In other cases, including for many of our cancer patients, medical assistance in dying may be the right choice eventually, but there’s a risk of rushing into it and shortening what can be a meaningful period in patients’ lives.
Canada’s medical assistance in dying program started in 2016 as an option only for patients with a “reasonably foreseeable” natural death. In 2021, Parliament removed the foreseeable death requirement. Today, Canada’s system is one of the most permissive in the world, allowing assisted dying for almost any form of subjectively intolerable suffering that has a medical basis, or even for medically unexplained physical symptoms. This latitude may contribute to Canada having the fastest growth rate of assisted dying in the world, increasing 16-fold in the eight years since legalization. The procedure now accounts for over 5 percent of all deaths in the country.
How did we get here? Within the Canadian system, medical assistance in dying is the result of a decades-long campaign aimed at enshrining it as a human right — often in the face of strong pressure from groups who opposed the procedure on religious or other grounds. Activists who support the procedure are still understandably wary of anything that could make it harder to get, often warning of unnecessary “gatekeeping” that might interfere with a patient’s autonomy. These activists helped shape the laws that govern the procedure and were instrumental in supporting the first medical networks that emerged to administer it.
Perhaps as a result of this influence, many doctors have come to see their primary role to be making sure their patients meet the legal eligibility requirements to qualify for assisted dying. They must, for instance, be experiencing intolerable suffering and have the mental capacity for informed consent. The problem is that there has become far more focus on whether patients can get an assisted death and not enough on whether they should.
A study published earlier this year looked at how Canadian physicians involved in medical assistance in dying understood their role. One provider described being “just a conduit really for someone’s desires and someone’s choices.” In a separate but similar study, another provider professed to have no role in evaluating suffering — though one of the legal requirements to receive the procedure is that a clinician must confirm that the patient is experiencing intolerable suffering. Determining that degree of suffering “is entirely up to the patient — 100 percent,” that provider said.
While it is critical that patients are able to make decisions about their bodies, doctors have an important role in guiding those decisions. There is an old saying about surgeons that is apt here: Good ones know how to operate, better ones know when to operate and the best know when not to.
Our research shows that the suffering of patients with an advanced disease arises from a complex interplay of physical and psychological distress, family strain and a slow erosion of identity and meaning. In this context, the loss of the will to live is not a fixed state. It fluctuates. It can be treated. And it can be misread.
Here’s how Canada’s medical assistance in dying program works: Two clinicians (either physicians or nurse practitioners) are required to approve an assisted dying request. The vast majority of cases are what is known as Track 1, in which the patient must have an illness that will lead to a “reasonably foreseeable death” (although no time frame is specified in the law). In these cases, they can request the procedure and get it quickly — sometimes even on the same day. Track 2 cases, in which the person does not have a life-threatening illness, are much less common. In these cases, patients are required to wait 90 days before receiving the procedure.
The law, however, does not require clinicians to engage in deeper conversations that explore the complex meaning of the request. We’ve seen cases where people request medical aid in dying in the face of a new cancer diagnosis or flare-up of an existing illness and get the procedure within a matter of days. There is no requirement in either track that patients attempt treatment to relieve their suffering. Nor does the law specify adequate safeguards to protect vulnerable individuals whose decision may be affected by social disadvantage.
We wonder whether inadequate consideration of such factors helps explain why in 2024, 98 percent of people assessed for medical assistance in dying in Canada were found to meet the criterion of “intolerable suffering” and over 92 percent were approved for the procedure.
In contrast, in the Netherlands, which legalized medical assistance in dying nearly 25 years ago, it’s common for cases to be rejected because a doctor judged that the patient’s suffering was not unbearable or that they did not pursue alternate treatment options.
We’ve seen how beneficial it is to pause and reflect with our own patients. One of them, a woman in her 70s, was the matriarch of her family, the one who made Sunday dinners. She sought and received approval for assisted dying after she lost the ability to cook. She felt she had lost her value to her family. Through counseling, she came to understand that her family valued who she was, not what she did for them. She decided not to go through with ending her life, at least for now. That Christmas, her family gathered and she sat proudly at the table, while others did the cooking and serving.
Another patient, a man in his 80s, refused a new treatment that might extend his life and instead requested and was approved for assisted dying. He survived the Holocaust as a child and viewed the freedom to choose the timing of his own death as a way of reclaiming what Hitler had taken away from his parents. However, his living family’s grief mattered to him, too, and they had concerns about him giving up too soon. With counseling, he chose to delay. Months later, he had adapted to his illness and continued to find meaning in his life. Eventually he got sicker and Dr. Li told him he was at risk of losing capacity to consent to assisted dying. This time, he chose the procedure, fully supported and surrounded by his family.
Cases like this are not arguments against assisted dying, and we do not seek to dissuade patients from going forward with the procedure. We are arguing instead that medical providers pause, that they help their patients (in both Track 1 and Track 2) consider and truly understand alternatives that might relieve their suffering and allow them the possibility of more time to live meaningfully.
What form should that pause take? We do not believe patients requesting assisted dying need to be assessed for a psychiatric disorder as a matter of course. We do, however, find that most benefit from counseling and reflective conversations. Unfortunately, psychological care of this kind for patients requesting assisted dying is not routinely offered by doctors or other health care providers, nor is it routinely covered by insurance. It should be the standard of care and fully funded.
We have developed and demonstrated the effectiveness of one such approach, which we have called Managing Cancer and Living Meaningfully, or CALM. This approach helps patients with advanced cancer sustain engagement in life, while approaching and preparing for the end of life.
Physicians are expected to explore what is driving a patient’s stated preference, whether it might change and what alternatives exist. This is called shared decision-making. It is standard practice in medicine — except for assisted dying in Canada.
A society that permits assisted dying should also ask whether it has done enough to help people sustain their sense of dignity and meaning in life. Death must not become the only kind of relief people can imagine.
Madeline Li and Gary Rodin are professors of psychiatry at the University of Toronto.
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