Comparing euthanasia in Canada to assisted suicide in California.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Daryll Pullman

The Journal Bioethics published an article on May 11, 2023 by Daryll Pullman comparing Canada's experience with euthanasia to California's experience with assisted suicide. 

The research article: Slowing the Slide Down the Slippery Slope of Medical Assistance in Dying: Mutual Learnings for Canada and the US provides a significant comparison. Canada legalized MAiD in June 2016 and California legalized assisted suicide in June 2016. In 2021, California's population was 39.24 million and Canada's population was 38.25 million.

Pullman outlines his article by stating:

Despite the rapid rise in the number of MAiD deaths during the brief time Canada has had this legislation, not all are convinced Canada is on a slippery slope; many take comfort in the fact that various lower court decisions expanding access to MAiD have gone largely unchallenged by government, taking this as an indication that all is well... Many who in principle are not opposed to MAiD in all circumstances, are nevertheless concerned about the rapid liberalization of MAiD law in Canada that is effectively medicalizing suicide.

Pullman continues:

MAiD became legal in Canada in June 2016, the same month and year that the End of Life Option Act became law in California. While California’s legislation is modeled closely on that of other US jurisdictions which have taken a decidedly conservative approach to the legalization of physician assisted death, Canada looked to established European examples such as those of Belgium, the Netherlands and Luxembourg, all of which have embraced more liberal approaches. California has a slightly larger population than Canada, so the two jurisdictions provide a natural comparison of how medical assistance in dying has played out over the first 6 years in two North American liberal democracies.

Pullman compares the Canadian euthanasia data to the California assisted suicide data. There were 10,064 reported euthanasia deaths in Canada in 2021 and 31,664 since legalization in 2016. In California there were 486 reported assisted suicide deaths in 2021 and 3,344 since legalization in 2016.

Pullman begins with the first factor, access to an assisted death.

All US jurisdictions with a legalized end-of-life option require that those who wish to exercise it must have an incurable, terminal condition with a life expectancy of six months or less. Although the Canadian legislation enacted in 2016 did not specify a 6 month time frame per se, it did state that to qualify an individual must have a “reasonably foreseeable natural death” (RFND). However, from the outset in Canada, for a variety of reasons, the RFND criterion was interpreted loosely.

Pullman explains that in Canada, the "reasonably foreseeable natural death" requirement that was interpreted loosely, was struck down by a Quebec lower court in the Truchon decision 2019. Pullman states:

The Quebec judgment effectively separates “suffering” from “end-of-life.” It is now clear that the Canadian legislation is not primarily about hastening death for the terminally ill, but more expansively about ending suffering irrespective of the proximity of that suffering to a patient’s natural death.

Since the Truchon decision was not appealed by the federal or Quebec governments, the decision created a more expansive availability for euthanasia in Canada's law and resulted in the passing of Bill C-7 which further expanded Canada's euthanasia law in March 2021. Pullman explains:

Bill C-7, the revised legislation introduced in the wake of the Quebec decision, reiterates the original legislation in emphasizing that whether suffering is deemed unbearable is up to the individual patient to decide. However, under the expanded criterion virtually any person with an irremediable disease, illness or disability deemed to be experiencing an irreversible decline of capability is now eligible. There is no obligation for medical practitioners to ensure that all other medical options for relief of suffering have been explored

Pullman points out that: 

Once suffering is separated from end-of-life, and MAiD becomes a first line option for ending subjective suffering, however it is construed, MAiD becomes an efficient solution to a variety of complex problems, medical, social, or otherwise.

Pullman continues:

While MAiD is a fully insured service in all Canadian jurisdictions, there is no guaranteed access to medication, housing, or other social determinants of health that ostensibly contribute to the suffering of Canadians everywhere. In one recent disturbing case, a 51-year old woman suffering from multiple chemical sensitivities received an assisted death when her attempts to find adequate housing, free of cigarette smoke and other chemicals, were unsuccessful (Favaro 2022). Although access to MAiD for those suffering from mental illness will not be permitted legally until 2024, already in 2019 an individual suffering from chronic depression was granted MAiD despite the protests of his family. While such troubling cases are reported in the media from time to time, there appears to be little appetite or capacity among various oversight bodies to challenge them. While continuing efforts are being made to ensure that the revised legislation removes “barriers to access,” the matter of effective monitoring and oversight has been neglected. Indeed what are now described as “barriers” were characterized previously as “safeguards”.

Pullman explains that Bill C-7 led to the medicalization of suicide. It also created a two-tier law whereby people whose "natural death is deemed reasonably foreseeable" could be killed without a waiting period but a person whose natural death is not deemed reasonably foreseeable would have a 90 day waiting period.

Canada's euthanasia law may contravene Article 10 of the UN Rights of Persons with Disabilities that Canada ratified in 2010. Pullman writes:

Human rights observers from the United Nations, including the Special Rapporteur on the rights of persons with disabilities, echoed the concerns of disability rights advocates across the country when they expressed alarm that the proposed expansion of Canada’s legislation would put vulnerable persons at risk. While not speaking on behalf of the United Nations per se, the observers nevertheless worried that the proposed expansion was based on ableist assumptions that devalue the lives of persons with disabilities and suggest the revised legislation might contravene Article 10 on the Rights of Persons with Disabilities, a document Canada had ratified in 2010.

Pullman explains the difference between euthanasia and assisted suicide deaths.

Another significant difference between Canada and California concerns the mode of death offered under the respective legislations and the role of medical professionals in the process. California, like all US jurisdictions that allow physician assisted death, permits physicians to prescribe a lethal dose of medication, but prohibits them from actively participating in terminating their patient’s lives by administering the medication. This is described as the oral protocol; terminally ill patients are responsible for filling the prescription, and then ingesting it at a time of their choosing should they decide to complete the act. Canada’s legislation is more liberal in that it permits physicians and nurse practitioners to actively end patient’s lives through the administration of a lethal dose of medication intravenously, irrespective of whether the patient is suffering from a terminal illness. While all Canadian jurisdictions (except Quebec) allow for the oral protocol, it is rarely used. Only 7 of the 7,588 MAiD deaths reported in 2020 and 7 of the 10,064 deaths in 2021 utilized the oral protocol.

Another difference between California's assisted suicide law and Canada's euthanasia law is the percentage of people who are approved for an assisted death who change their mind or die a natural death.

Pullman explains that in California 30–35% of individuals who were approved for an assisted death either never filled the prescription, or, having filled it, decided against using it, thus dying of natural causes whereas in Canada. In Canada, only 2.5% of individuals deemed to have met the criteria for MAiD in 2020, and 1.9% in 2021, withdrew their request. Health Canada’s 2021 report indicates that 13.1% of those deemed eligible for MAiD died of natural causes before MAiD could be initiated.

Once approved for death, Canadians are far more likely to die an assisted death than those in California. Pullman suggests that the low percentage of people who change their mind in Canada suggests a need for closer scrutiny. He writes:

The foregoing raises the question of what constitutes a truly autonomous choice. In light of the dramatic difference in the total numbers of medically assisted deaths in Canada as compared to California and other US jurisdictions, as well as the relatively low number of Canadians who decide against completing the process once initiated, the role of the medical professional in these respective processes demands closer scrutiny.

Pullman further questions the nature of autonomy in Canada's euthanasia law.

Put otherwise, the California protocol aims to ensure that this most momentous and final decision is indeed an autonomous one. The Canadian approach is more ambiguous in this regard. While the proponents of MAiD insist that honoring patient autonomy and individual choice is their driving principle, the role of the health care practitioner in first assessing whether the patient meets the increasingly expansive criteria for an assisted death, and then acting as the direct cause of the patient’s death by administering the lethal medications, renders this claim suspect.

The expanded MAiD criteria has led to nearly every Canadian who request MAiD being approved. Pullman states:

Physicians and other health professionals ostensibly involved in their care can serve as a controlling influence by virtue both of their perceived powerful role in society in general, as well as their direct involvement as care providers, however that care is construed. It is notable in this regard that while only 75% of requests for MAiD in Canada were approved in 2020, 99% were approved in 2021 indicating that assessors are becoming increasingly comfortable with the expanded criteria... This will become a particularly acute concern when the eligibility criterion are expanded yet again to include those suffering from a mental illness, but with no other underlying physical ailment.

Pullman points out the difference with assisted suicide from euthanasia.

California and other US jurisdictions that permit only the oral protocol, mitigate the physician’s potentially coercive influence to some extent by legislating their arms-length participation in the process. While the oral protocol is an option in Canada, it is almost never used, hence its mitigating effects are negligible at best.

Daryll Pullman does not end his article by suggesting that legalizing euthanasia (homicide) is the problem, but rather he suggests that the lack of oversight and the liberal interpretation of the law has led to Canada's acceptance of killing.

I disagree Daryl Pullman's point of view. I am convinced that there is only one clear line, that being, is it acceptable to kill a person or is it not acceptable to kill a person. If it is acceptable to kill a person, even under stringent rules, killing has been approved and the line has been crossed.

The pro-euthanasia lobby will claim that the rules are unjust and demand expansions to the law.

Euthanasia and assisted suicide must never become legal because it permits one person to kill another person. If it becomes legal then the law must be reversed.

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