We’re way beyond the slippery slope. We need new criteria for MAID
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There’s a big difference between what we imagine about Medical Assistance in Dying (MAiD) in Canada and what actually happens to patients. What began as a highly controlled and limited option for those with terminal illnesses has transformed into something far broader and more troubling.
In 2015, the Supreme Court of Canada’s Carter decision overturned the ban on physician-assisted suicide and voluntary euthanasia for specific patients. It cited “grievous and irremediable medical conditions” and “enduring suffering that is intolerable to the individual” as the criteria for obtaining MAiD. The 2016 legislation that followed upon the decision required that death be “reasonably foreseeable.” At the time, this seemed like a carefully defined and compassionate response to the suffering of a small group of patients.
But today, the reality of MAiD looks very different. It is now proactively offered to vulnerable patients as part of the range of “treatment” options, even in situations where death is nowhere in sight. What was once limited to cases of terminal illness has expanded significantly. If we were initially slipping down the slope of terminal illness with increasing MAiD usage, we’re now skiing down a much steeper hill.
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Leaving aside the inherently vague and non-medical nature of terms such as “intolerable suffering,” the actual experience of patients often diverges dramatically from the law’s original intent. For instance, Canada recently made international headlines (again) after a 51-year-old woman in Nova Scotia was offered MAiD twice during two separate pre-operative assessments for breast surgery, 15 months apart. This example highlights how far the practice has shifted from its original intent.
As reported in the National Post, Dr. Gus Grant, registrar and chief executive officer of the College of Physicians and Surgeons of Nova Scotia, acknowledged it was “clearly inappropriate and insensitive” for a doctor to raise MAiD as a person was being rolled into a surgical suite. “I can understand why the patient was upset,” Grant said. Yet cases like this are not isolated.
Similar cases abound: veterans being offered MAiD for PTSD, a Paralympian offered MAiD after delays in getting a wheelchair lift installed, a patient whose sole reason for MAiD was hearing loss, and a 41-year-old man receiving MAiD for a debatable diagnosis of COVID “post-vaccination syndrome.” These examples demonstrate the troubling ways MAiD has been applied far beyond its original intent.
In 2022, MAiD became the sixth leading cause of death in Canada, behind cancer, heart disease, trauma, COVID-19, and strokes. Absent COVID, MAiD becomes fifth. Dr. John Keown, professor of ethics at Georgetown University, argues Canada is “skiing down euthanasia’s slippery slope.” He notes that what began as voluntary euthanasia for terminal diseases in adults has expanded to chronic diseases, mental health issues, and even, in some cases, discussions around eligibility for children.
The slippery slope concept explains some of what has happened, but it leaves out too much. It assumes all points along the slope are similar, but terminal illness and chronic disease – or physical and mental suffering – pose fundamentally different challenges. This distinction has largely been ignored in Canada’s evolving approach to MAiD.
We are now far beyond the slippery slope. MAiD is now considered a viable treatment option for any condition deemed to cause intolerable suffering. “Intolerable” is entirely subjective, determined by a vulnerable and likely distressed patient. Moreover, the suffering does not even need to be real; the mere fear of future suffering is now enough to qualify for MAiD.
Initially, MAiD was envisioned as a service that patients would actively seek out. However, the reality has shifted. Medical regulatory colleges now require physicians to inform patients about MAiD as a treatment option. For instance, in Nova Scotia, physicians are mandated to discuss MAiD in certain circumstances. The College of Physicians and Surgeons of Ontario’s policy on Human Rights in the Provision of Health Services reinforces this obligation, stating: “Physicians must provide patients with accurate, complete and unbiased information about all available and appropriate options to meet their clinical needs or concerns … Physicians must not withhold information about the existence of any relevant service, treatment or procedure because it conflicts with their conscience or religious beliefs.”
This shift has redefined the criteria for accessing MAiD, the timing of requests, and the qualifications for eligibility. Voluntary euthanasia and assisted suicide are no longer solely patient-initiated choices; they are now embedded in regulatory mandates obligating physicians to present them as options. This is no longer a “slippery slope”– it is an entirely new framework.
The right-to-die lobby spent much of the 20th century trying to normalize euthanasia as a “good death,” but these efforts failed to gain widespread public acceptance. Framing death as a positive choice proved hard to defend. In the Carter case, the strategy shifted. Rather than emphasizing euthanasia as a positive choice, the lobby introduced new language focused on “grievous” and “irremediable” conditions accompanied by “intolerable suffering.” This reframing of the issue positioned the prohibition of assisted suicide and voluntary euthanasia as tantamount to forcing patients to endure unbearable suffering, opening the door for physician-assisted dying to gain legal and societal traction.
Yet this framework does not reflect medical reality. Pain can often be managed effectively, and when it cannot, terminal sedation can eliminate conscious suffering without intending death. Despite this, the court accepted the bait and adopted their language in its ruling.
We need to revisit MAiD criteria based on the actual experiences of patients and the realities of medical conditions. No one equates hearing loss – an irreversible but manageable condition – with terminal cancer. We must establish criteria that account for such distinctions and create mechanisms to ensure these standards are strictly followed.
Limits on MAiD must reflect the real-world consequences of its application, not the theoretical images conjured in the Carter case a decade ago.
Shawn Whatley is a physician, past president of the Ontario Medical Association, and a Munk senior fellow at Macdonald-Laurier Institute. He is the author of When Politics Comes Before Patients – Why and How Canadian Medicare is Failing.
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