Ian McIntosh gets emotional thinking about Canada.
He loves his homeland: its beauty, its people.
But reports of Canada’s permissive medical assistance in dying (MAID) laws, and stories of people accessing it due to poverty or disability, fill him with “profound concern and disbelief,” he said from northern Virginia, his home since 2016.
McIntosh, originally from Ontario, says if someone had told him in 2015 and 2016, when Canada’s first MAID law was being crafted, that Canada would eventually allow adults without terminal illnesses to qualify for MAID, he “would have said this is out of some horror novel, some dystopian novel.”
As the director of disability outreach for the Patients’ Rights Action Fund, a non-partisan US organization devoted to stopping MAID, he often hears concerns that America could become like Canada.
Those concerns have grown recently. On June 25, Delaware’s state senate passed a law that would allow terminally ill adults living in Delaware to be prescribed medications to end their lives. The bill passed 11-10. It has not been signed by the governor and is not yet in force.
Ten states introduced laws to legalize medical aid in dying during their most recent legislative sessions. And nine other states — including Delaware — considered legislation introduced previously. Three states where MAID is already legal considered expanding their eligibility criteria.
“When we talk about assisted suicide here, we use Canada as the boogeyman in the closet,” said Jessica Rodgers, the coalitions director for Patients’ Rights Action Fund. Canada, she says, “is the worst-case scenario.”
But American proponents of MAID do not think Canada should be used as a deterrent.
“When people say, ‘slippery slope,’ the implication is that the thing at the bottom of the slope is a place you do not want to be,” said Thaddeus Pope, a bioethicist and law professor at Mitchell Hamline School of Law in Saint Paul, Minn. He often hears opponents raise concerns about the US becoming like Canada.
Pope does not think US laws are advancing rapidly. “I don’t think the thing at the bottom of the slope is actually a thing to avoid, even if we were sliding there,” he said. “I don’t think we are, but even if we were sliding toward Canada, I don’t think that’s a bad thing.”
Most permissive in the world
In America, MAID was first legalized in Oregon, where it has been practised since 1997. Since then, nine other states and the District of Columbia have legalized it. Delaware could become the eleventh state to do so.
Canada legalized MAID in 2016 — nearly 20 years after Oregon. Yet, MAID is more prevalent in Canada. Since 2016, it has accounted for 44,958 deaths in Canada, versus 3,349 in California, a state roughly as populous as Canada and which also legalized MAID in 2016.
The two countries have very different laws, says Pope. “Canada is basically the most permissive in the world, and the United States is the most restrictive in the world,” he said, comparing the countries’ eligibility criteria. “Even though they are right next to each other, they’re about as far apart as you can get in terms of eligibility and who can access it legally.”
In the US, patients must have a terminal illness — meaning medical professionals have determined they are reasonably likely to die within six months. Canada, by contrast, has never had a time-based requirement and removed the requirement that someone’s death be “reasonably foreseeable” in 2021. This created what is known as Track 2 MAID — MAID for people who have serious illnesses, diseases or disabilities and are suffering, but whose deaths are not reasonably foreseeable.
MAID is administered differently in the countries, too. In the US, patients must self-administer lethal drugs. In Canada, most patients receive the drugs intravenously. Fewer than seven people who died by MAID in both 2021 and 2022 self-administered the drugs, according to Health Canada reports.
Do no harm?
Despite differences in law, philosophical arguments supporting and opposing MAID are similar in both countries. So are concerns that MAID will put people in vulnerable situations — including people with disabilities and those living in poverty — at increased risk of being explicitly or implicitly coerced into ending their lives.
Anita Cameron, director of minority outreach at Not Dead Yet, a national disability rights organization, says people with disabilities are scared that what has happened in Canada could happen in America. “We’re trying to sound the alarm here,” she said.
Cameron, who has multiple disabilities, lived in Canada temporarily when she was younger and once considered moving to Canada permanently. “There’s no way in this universe, this multiverse, or the next that I will move to Canada now,” she said.
Dr. Mark Komrad, a practising psychiatrist and medical ethicist based in Maryland, where assisted dying legislation was recently introduced, says any form of MAID represents “a profound and fundamental change in civilization in general, certainly in medical ethics.”
It contradicts a clear medical ethic: that doctors do not harm their patients, he says.
Komrad became interested in assisted dying laws worldwide in 2015 when he heard of psychiatric patients in Europe dying by MAID. Soon, he learned about Canada. He now travels internationally, sharing his concerns about MAID, which he considers to be assisted suicide.
He compares himself to Paul Revere, who warned Americans about British armies during the American Revolution. Only, Komrad warns Americans about the dangers of MAID in Canada and elsewhere.
“Canada is the most compelling case study for anyone who pays attention and is interested in this,” he says. Countries that legalized MAID before Canada, such as Belgium, the Netherlands and Luxembourg, “are easy [for Americans] to dismiss” because of distance and size. Canada is closer to the US — geographically and culturally, he says.
“When you see this galloping [horse] of MAID in Canada, I think it’s a lot easier for Americans to identify that that can happen here,” he said.
At least one state has considered changing its laws to resemble Canada’s. In February, California proposed changes that would replace “terminal illness” with “grievous and irremediable medical condition” — the wording used in Canadian law — and permit intravenous administration of MAID.
The bill was withdrawn while in committee.
Compassion & Choices, a national organization with the goal that half of Americans will live where MAID is legal and accessible by 2028, released a statement opposing California’s bill, and expressing concerns about the definition of “grievous and irremediable medical condition.”
The existing criteria of a terminal illness and prognosis of six months or less “are in place to ensure that people don’t feel compelled to access medical aid in dying because they lack availability to adequate pain management and symptom relief,” the statement says. “Maintaining this balance is crucial to safeguard the well-being of all Californians facing end-of-life decisions.”
No one from Compassion & Choices was available for an interview before deadline. In a statement, the organization’s spokesperson wrote, “the political, ethical, and legal landscapes in the United States and Canada are dramatically different, so comparing how each nation approaches medical aid in dying does not make sense.”
Pope says Americans should pay attention to Canada’s experience with MAID.
“Canada is, in a sense, 20 years ahead of the US on this,” he said. “Obviously, it’s informative to look at what might you authorize. You don’t have to do any of it.”
Pope supports Canada’s current laws, although some aspects of Track 2 MAID make him uncomfortable. He says there should be a way to ensure Track 2 applicants have seriously considered non-lethal options to relieve their suffering.
“I think that generally each person is the best judge for themselves of what is in their best interest,” he said. “I don’t think the right response is to completely ban that option for those people. But absolutely, I think that we should make sure that it’s carefully considered.”
The increasing number of MAID deaths in Canada “is a red flag,” he said. “But that doesn’t mean that anything bad is happening.”
Komrad disagrees. The rapid rise in deaths by MAID in Canada should cause concern, he says. “Just because something is legal, doesn’t [mean] it’s ethical,” he said.
He hopes in the future people will look back at current support for MAID and ask, ‘What were they thinking?’
“Maybe I won’t be alive to see that,” he said. “But one day we may be able to look back and say that.”
Editor’s Note: A previous version of this article said Delaware would be the tenth state to legalize assisted dying. In fact, if Delaware’s law comes into force, it would be the eleventh state to do so. We regret the error.
Sad Canada is pushing maid!!! Totally demonic and discusting!!! What about where is empathy, love and caring!!?? I thought this was a Christian country!!!
I support maid. That is how I plan to die. I do not want to live with severe unmanageable pain only for the sake of saying I am alive. I also don’t want crazy amounts of money spent on me to keep me alive. This is my choice. It may not be the choice of others. I live in Canada.