Trudo Lemmens

Canada’s euthanasia law and practice—which the federal parliament termed “medical assistance in dying,” resulting in the awkward acronym MAiD—continues to be a dominant theme in Canadian and international health law and bioethics scholarship. If MAiD had remained the “exceptional practice” the Canadian Supreme Court originally envisaged, the attention it receives would be perplexing. But ongoing legal expansion—mental health was scheduled to become a basis for MAiD in March 2024 but Parliament suspended this introduction at the last minute until at least 2027—and the staggering increase in the number of people who have died with a health care providers’ lethal injection, explain this attention. In less than 7 years, about 45,000 Canadians—13,241 in 2022 alone—have died by MAiD, more than 4% of all deaths. Quebec, the second largest province, has become the jurisdiction with the highest euthanasia practice in the world, with around 7% of people dying by MAID.

International parliamentary committees, policy makers, and commentators are increasingly paying attention. A new interdisciplinary volume in Springer’s International Library of Bioethics Series, Medical Assistance in Dying (MAiD) in Canada: Key Multidisciplinary Perspectives, edited by Jaro Kotalik and David W. Shannon, should help inform any jurisdiction contemplating some form of legalization. With 31 chapters by experts in law, medicine, social science, philosophy, and bioethics, as well as practitioners and community advocates, the book provides unique, explicitly critical perspectives on various aspects of Canadian MAiD law, policy, and practice.

In a first legal and regulatory part, the book sets out the legal framework and the unique legislative history of the Canadian law. The chapters in this section critically examine the assumptions underlying the Supreme Court’s decision in Carter v. Canada (Attorney General) and subsequent legislative action, and the reasons why the first law, focused on a broad end-of-life context, was subsequently expanded to include disabled persons not approaching their natural death. International readers will find sufficient details here to understand the legal context: the ruling of the Supreme Court, subsequent parliamentary initiatives and court cases, and the intersection between federal and provincial laws and regulations.

A second part documents in five chapters operational challenges of Canada’s MAiD practice. The chapters reveal some remarkable deficiencies in the federal and provincial monitoring and reporting of MAiD. International readers will be surprised, for example, to read how some professional regulations instruct health care providers to state on death certificates the disease that underlies the MAiD request as the cause of death, rather than MAiD itself, even though there is still an obligation to report MAiD separately. With current MAiD law allowing the ending of life of persons who are not even remotely approaching their death, say a person with paraplegia, the absurdity and arguably fraudulent nature of such official policies stand out. In another chapter, a practitioner reflects in an interview on what MAiD may mean for medical practice in remote communities. A last chapter discusses organ donation following euthanasia, for which Canada has become the world leader—unsurprisingly so, considering the emphasis in Canadian MAiD law and policy on facilitating access to, not protection against, death.

Separate sections, each consisting of four to five chapters, are devoted to MAiD and palliative care, MAiD and mental health care, and disability perspectives on MAiD. There are chapters by health care providers, persons involved in community-based suicide prevention, disability scholars, and legal scholars and practitioners. From a health law perspective, a chapter by disability advocates Kerri Joffe and Roberto Lattanzio stands out for its persuasive argument that Canada’s law violates international human rights law, particularly the International Convention on the Rights of Persons with Disabilities. This chapter joins other recent legal publications that put forward detailed legal arguments about the discriminatory nature of Canada’s MAiD law. Other interesting legal analyses are also provided in this book by scholars Jonas Beaudry and Mary Shariff, and by two legal practitioners.

A fourth section contains divergent topics, ranging from the impact of MAiD on trust in the doctor-patient relationship and the right to conscientious objection to perspectives from Indigenous communities and various religious and spiritual groups. The inclusion of reflections by Indigenous, Muslim, Jewish, Roman Catholic, and Protestant religious leaders is a welcome exception in the recent Canadian literature on MAiD, which generally excludes, and sometimes even explicitly rejects, the relevance of religious and spiritual perspectives on MAiD. This is somewhat surprising, considering that 68% of Canadians have a religious affiliation. It likely reflects how religious views are much less part of public and political discourse in Canada than, for example, in the United States.

Notwithstanding growing emphasis in Canada on the need to engage meaningfully with Indigenous communities as part of a Truth and Reconciliation process, MAiD was legalized and subsequently expanded without significant consultation with and involvement of Indigenous people. Two chapters on Indigenous perspectives merit therefore special attention. As one of the chapters points out, while there are different perspectives within Indigenous communities, there is clearly a very serious concern about what the promotion of medical access to death may mean for some Indigenous communities confronted with high suicide rates, as well as about the clash between the medicalized practice of MAiD and Indigenous worldviews.

The book concludes with broader reflections by two prominent participants in Canada’s MAiD debate. Tom Koch, a medical ethicist, warns that public support may be shifting in the wake of several controversies, and that legal challenges may lead to a judicial review of components of the practice. Harvey Schipper, an emeritus professor of medicine, reflects on how the legalization and subsequent rapid expansion of MAiD in Canada has been driven by ideology, not by cautious step-by-step evidence-informed evaluation and adjustment. As he reminds the reader, he speaks from experience when it comes to witnessing polarized politization of the debate in Canada. In 2018, he was appointed to chair a working group on Advance Requests for MAiD of the Council of Canadian Academies (equivalent to the National Academy of Sciences). But a strategically placed national media article, “Doctor who compared assisted dying to Nazi genocide to chair review of advance requests,” came out the day before the first meeting. It undermined his position and he had no choice but to resign. The article referred to a 2014 op-ed in which he simply observed that, as a Jewish physician, he was particularly wary of what can happen when physicians are legally permitted to cross a clear moral line in the sand when it comes to death. While he accepts that MAiD has found “a place in our society,” Schipper lauds the other authors for raising key questions about Canada’s law and practice, which demand answers and political and legal responses, not political posturing.

Readers should not expect a carefully balanced academic dialogue for and against the legalization of euthanasia and assisted suicide, or a comparative review with discussions of the advantages and disadvantages of various legislative models. What they will find instead is a broad spectrum of critical reflections, some more academic in nature, others more practice oriented, and further information about the law and practice in the jurisdiction with arguably the most open-ended system of medically-administered death. Some authors are more explicitly opposed, while others recommend significant adjustment and improvement of specific aspects of Canada’s law and practice. Overall, the book should make it clear why a growing number of people have legitimate concerns about at least some components of Canada’s MAiD law and practice and why, in my view, it is a model to be avoided.