Richard Smith: Learning from Canada about assisted dying

Discussions on assisted dying are usually heated and about whether it should be legalised. But I recently found myself in the privileged position of discussing with a well informed group of people from Canada not whether assisted suicide should be introduced in Britain, but what Britain might learn from the Canadian experience of introducing a form of assisted dying. There are many issues to decide. The meeting took place as part of the UK-Canada Colloquium, and the group included a lawyer who took a case to introduce assisted dying to the Supreme Court in Canada, a palliative care physician who provides assisted dying, and other doctors and academics who have firsthand experience of the system.

Canada introduced Medical Assistance in Dying (MAID) in Quebec in 2015 and the rest of the country followed in 2016. It was introduced because of a Supreme Court ruling that said the criminal laws prohibiting assistance in dying limited the rights to life, liberty, and security of the person under Canada’s Charter of Rights and Freedoms. The legislature in Quebec and subsequently the whole country then defined how it would work, but the courts have a continuing role in its evolution.

There was opposition to its introduction by palliative care physicians who opposed it on ethical grounds, but also feared that it would mean that palliative care would be neglected. Palliative care has not worsened, but only about a third of Canadians have access to palliative care and only 15% to palliative care at home. There is an uncomfortable anomaly in that MAID is provided for free, but some parts of palliative care (depending on the province) are only partially funded.

The Canadians at the meeting agreed that despite opposition to the introduction of MAID, it has rapidly become a normal part of Canadian life. There seems to be no serious possibility that MAID will be abolished. Indeed, it is more likely that its availability will be extended. In September last year the Quebec Supreme Court ruled that it is unconstitutional to deny MAID to persons with intolerable suffering who do not meet the criterion for “reasonably foreseeable death,” such as those with incurable degenerative illnesses. The court directed the federal government to make amendments to the MAID law by March 2020.

To qualify for MAID people must meet all the following criteria:

  • Be eligible for health services in Canada. This requirement stops foreigners travelling to Canada for MAID
  • Be at least 18 years old and mentally competent. This means being capable of making healthcare decisions for yourself
  • Have a grievous and irremediable medical condition (see below)
  • Make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence. Those providing MAID must check for coercion, which is not easy
  • Give informed consent to receive MAID

In order to be accepted as having a “grievous and irremediable medical condition” those applying for MAID must meet all the following criteria: 

  • 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 an illness, disease, disability, or state of decline that cannot be relieved under conditions that the person considers acceptable
  • Be at a point where natural death has become reasonably foreseeable

It is this last requirement that the Quebec court has struck down, meaning that MAID will be available not just to those approaching death but to people with intolerable suffering no matter how it may be manifested.

There is no need for a specific prognosis on how long people have to live, and the Canadians thought this wise as trying to judge how long people have to live is notoriously unreliable. Some other jurisdictions do require such a judgment, and bills being considered in Britain require such a judgment.

MAID can be provided by doctors or nurse practitioners, and two independent assessors must agree that MAID can be provided. There is then a 10 day reflection period before MAID is provided. This period can be shortened if it is thought that the patient may lose capacity.

People receiving MAID have a choice of taking drugs orally or having them injected intravenously. Some 99% of people opt for intravenous drugs. Dying is slower if the drugs are taken orally, and the person might vomit.

Sandy Buchman, a palliative care physician and the current president of the Canadian Medical Association, has described in The BMJ how he decided that he would provide MAID. He was a member of the group discussing assisted dying at the colloquium and said that in his experience about 80% of people who request MAID with “unbearable physical or mental suffering” can be offered alternatives to MAID that they find acceptable. It seemed to me that this could be an argument for palliative care physicians being MAID providers as they are the doctors most aware of all the alternatives.

Only about 1% of doctors and nurse practitioners provide MAID, meaning that some must provide for many people. No doctor is obliged to provide MAID, but doctors are obliged to refer patients who are requesting MAID to doctors or nurse practitioners who will provide it or (depending on the province) provide information on how it might be accessed. The group was told of one Canadian doctor who found this requirement to refer unacceptable and left the profession.

I remembered how when abortion was legalised in Britain, women in the West Midlands were unable to get an abortion on the NHS because an influential professor of obstetrics in Birmingham objected strongly to abortion. Nothing on the same scale has happened with MAID in Canada, but there are many places, particularly in rural areas, where MAID is not available because there are no providers. Many faith based hospitals and residential hospices will not allow MAID.

MAID cannot currently be provided to those with dementia, even if they have made clear before losing capacity that they would require MAID if, for example, they reached the point where they no longer recognised their family. People must have full capacity immediately before MAID is provided. This requirement is, however, being reviewed after a report by the Council of Canadian Academies. Most Canadians would like MAID to be available to those with dementia who have made advance decisions.

All cases of MAID have to be reported—to the coroner in Ontario and to a commission in Quebec. The federal government produces regular reports on MAID, and the fourth one was reported in April 2019. It showed that MAID is mostly provided by doctors (93%) rather than nurse practitioners; the commonest settings for MAID are a hospital (44%) and the person’s home (42%); most people receiving MAID are aged between 56 and 90 years old with the average age 72, although there were 49 aged 18-45 and 140 aged 46-55 in the first 10 months of 2018; men and women are equally represented; and cancer is the commonest diagnosis.

Social class is not reported in the national data, but people in the group told me that wealthier people with better education are the commonest recipients of MAID. There is regional variation with some 7% of deaths of people on Vancouver Island attributable to MAID, whereas the Atlantic provinces have a much lower rate. The expectation of those in the group is that the percentage of deaths attributable to MAID will level out at about 4%, a figure similar to that in other countries with assisted dying.

Assisted dying seems to be spreading across high income countries, and it doesn’t seem controversial to predict that it will come in Britain within 10 years, not least as baby boomers with their passion for autonomy begin to die in large numbers. Britain will have the benefit that it can learn from other countries, and Canada, a country with which Britain has deep affinities, will be one of the best from which to learn.

Note: I thank Sandy Buchman for commenting on this article and ensuring that I have everything right.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS favours assisted dying and has no religious faith.