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A new report from Health Canada shows strong support for allowing advance requests for medical assistance in dying (MAID).
A survey of more than 46,000 Canadians found nearly 70 per cent favour allowing advance MAID requests for patients diagnosed with incurable conditions that will cause them to lose decision-making capacity.
But advance requests for MAID remain controversial, even among doctors who support MAID.
“There’s many concerns,” said Dr. Mathieu Moreau, a family doctor and professor at the University of Montreal who has been involved with MAID since it became legal in Quebec in 2015.
No decisions made
In an advance request, a person requests to have MAID in the future when they have lost their ability to consent. They still must meet all other legal requirements for MAID. A person lists the symptoms they must be experiencing before they can receive MAID, for example, not recognizing their family.
A person must be able to consent at the time they make the advance request, but not at the time they receive MAID.
Advance requests are illegal under the Criminal Code, but have been allowed in Quebec since October 2024 for patients diagnosed with diseases that cause loss of capacity, such as dementia. Only people diagnosed with such an illness can make an advance request for MAID.
In 2023, a joint House of Commons-Senate committee recommended the federal government legalize advance requests for MAID for people diagnosed with diseases that will lead to loss of capacity.
This past March, a United Nations committee recommended Canada not allow advance requests for MAID.
A Senate bill to legalize advance requests for MAID is at second reading in the Senate. To become law, it needs to pass second and third reading in the Senate and then three readings in the House of Commons.
“The Government of Canada has not yet made any decisions about expanding eligibility to allow for advance requests,” Mark Johnson, a spokesperson for Health Canada, told Canadian Affairs in an email. “It is currently reviewing the results of the consultation and wants to thank everyone who contributed to this important work.”
Dying with Dignity Canada, a charity that advocates for MAID access, wants Canada to legalize advance requests.
“Dying With Dignity Canada believes the federal government must prioritize amending the Criminal Code of Canada to include advance requests for MAID within national legislation,” Helen Long, the organization’s CEO, told Canadian Affairs in an email.
At the end of October, the charity co-hosted an event exclusively for parliamentarians to discuss MAID legislation.
Challenging evaluations
Some doctors are wary of advance requests.
Patients with advance requests still need to be assessed and approved for MAID before MAID is administered, says Moreau. This means confirming that a person experiences what they consider to be intolerable suffering that cannot be relieved in a way they consider acceptable.
“It’s very challenging to evaluate, to assess the suffering of someone else that is not able to communicate their suffering, which will be the case of many patients,” he said.
He said it is also unclear when health professionals should discuss MAID with patients who appear to meet the conditions of their advance request.
“Some of the patients, because of their illness, are more prone to suggestions, and if a professional talks to them about [MAID], could see it in a more favourable light then they would have seen it if they did their research by themselves.”
However, Moreau says advance requests are important to respect patients’ autonomy. None of Moreau’s patients have asked for advance requests.
According to the Quebec government, 1,676 individuals have filed an advance request and 1,511 were accepted as meeting all the criteria for advance requests. It is not known if any of these patients have received MAID, a spokesperson for the ministry of health and social services said in an email.
‘Abdicating choice’
Dr. Catherine Ferrier, a geriatric doctor and assistant professor of family medicine at McGill University, opposes advance requests.
Patients must be informed about their current situation and medical options to provide true consent, she says. That is not possible with an advance request.
“In advance, you cannot have the facts about your situation,” she said.
In an advance request, the patient is “abdicating [their] right to decide.”
Advance requests for MAID are “a different concept” from advance care directives that direct doctors not to use life-saving measures in particular situations, said Ferrier, who opposes MAID.
“Advanced directives are saying, ‘Refrain from doing certain things.’
“[An advance request for MAID] is saying, ‘Do something [that] will end my life.’”
Underlying values
Health Canada’s survey asked Canadians which values inform their opinions on advance requests. The most popular responses were individual choice at end of life and a dignified death. Those values had 76 per cent and 73 per cent support respectively.
Only 51 per cent of respondents listed protection of vulnerable people as an important value.
That response was “very concerning” for Heather Campbell Pope, an elder law lawyer and founder of Dementia Justice Canada, a non-profit focused on ensuring people with dementia are protected by the law.
“One hundred per cent of us should be concerned about how our MAID laws impact vulnerable people,” she said.
Some people with dementia may be pressured to make an advance request for MAID so they do not burden their caregivers, she says. Adult children may subtly pressure their parents to make an advance request because they want an inheritance, she says.
A recent report from Ontario’s chief coroner’s office shows patients with dementia have been approved for MAID in the earlier stages of their diagnosis, and that requests have been motivated by fear of future decline or difficulty transitioning to life in a long-term care facility.
In criminal law, there is a very high threshold to determine if someone is guilty, Campbell Pope says. The same needs to be true with MAID.
“How many cases are we willing to get wrong when it comes to MAID?,” she said. “For me, morally, that answer should be zero.”
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