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Isabel Fattal: In Canada, an emphasis on patient autonomy is the guiding principle of MAID. How does that emphasis define the country’s specific culture around assisted death?
Elaina Plott Calabro: In Canada, to receive MAID, a patient does not have to have exhausted all other reasonable options to alleviate their suffering. They just have to be made aware of them. In the Netherlands, by contrast, a doctor and a patient do have to agree that the patient has exhausted all reasonable options of care before they move ahead with euthanasia. Distinctions like that brought home for me just how central autonomy is to this regime.
Isabel: You write about how, in the end, Canada’s medical providers are the ones who have to bear this complex ethical responsibility. How were some of the clinicians you met dealing with that?
Elaina: At the outset, there were a lot of clinicians in Canada who were in theory quite supportive of a patient’s right to die but were nervous about actually participating, because the standards turned to a large extent on a clinician’s individual discretion. The law itself did not give terribly specific criteria as to what would qualify a patient to be eligible for euthanasia.
I spoke with one doctor, Dr. Madeline Li, a cancer psychiatrist in Toronto. This is someone who, following the law's passage, played a leading role in building out the actual practice of MAID. She developed the MAID program at the University Health Network, the largest teaching-hospital system in Canada. About two years after MAID was legalized, she came across a patient who had cancer, but it was a pretty curable cancer—the doctors gave him a 65 percent chance of survival with treatment. But the patient said that he wanted MAID. And the surgeon was kind of alarmed and thought, Well, you know, maybe the patient just doesn’t want surgery; maybe he wants chemo instead. The patient was sent to other specialists, but he continued to insist that he didn’t want treatment; he wanted MAID.
This patient finally ended up meeting with Li. She asked, What if you had a 100 percent chance of survival? Would you want treatment? And he said, No, I want MAID. That crystallized for her the spectrum of interpretations a doctor could rely upon when trying to understand this law. To her, it seemed that this was a patient whose death, given the fact that he did not want treatment, had become “reasonably foreseeable.” His disease was technically incurable because according to prevailing interpretations of the law, a disease is considered incurable if it cannot be cured by means acceptable to the patient.
All of this made Li conclude, Okay, well, he is technically eligible for MAID, but this doesn’t feel right. She did end up honoring his wish to receive MAID but regretted it, she told me, almost as soon as his heart stopped beating, and from that point on had to make a decision for herself, for her own comfort level, that she would not let the definition of incurability turn solely on a patient’s discretion. But clinicians across Canada are all making these sorts of decisions for themselves.
Isabel: Demand for MAID in Canada surged beyond the government’s initial predictions. Did your reporting suggest anything to you about what broader demand for something like MAID might be if it were offered in more places?
Elaina: A lot of officials and clinicians in Canada are still not entirely sure why demand surged so rapidly and why it has not yet leveled out. One MAID clinician I spoke with spent a lot of time trying to understand the various regimes in Europe. A major difference between those regimes and the one in Canada is to some extent cultural. In European countries with legalized assisted death, your primary-care physician is usually the one you’re applying to in order to receive assisted death. In the event that your application is rejected, you typically won’t go on to seek another doctor’s opinion. But in Canada, the system largely developed around MAID-coordination centers, and so, for the most part, clinicians have no previous relationship with the patient they’re assessing. If you have one person say, No, I don’t think you’re eligible, there’s no taboo about going to seek another assessment immediately.
There’s also an awareness of MAID in Canada that has helped propel and sustain demand. At this point, many clinicians told me, it’s very hard to come across someone who doesn’t know, by some degree, someone who has received MAID. There’s a great deal of emphasis in Canada on ensuring that patients are made aware of it as an option, whereas in some countries, clinicians are either prohibited or generally discouraged from initiating conversations about assisted death.
Read Elaina’s full feature.
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