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| Dr Ramona Coelho |
Dear Editor,
Recent BMJ commentary has suggested that Canada’s assisted dying regime involves robust independent assessment and that coercion is not a meaningful concern[1], despite alarms raised by the UN Committee on the Rights of Persons with Disabilities[2] and government oversight reports[3]. A key question is whether introducing assisted dying into medicine is adversely altering clinical practice. Assisted dying is often framed as patient autonomy. Yet this framing minimizes how Medical Assistance in Dying (MAiD) reshapes clinical reasoning, professional responsibility, and interpretations of suffering. Under Canada’s Criminal Code, MAiD is exempt from homicide and assisted suicide offences[4]. Supporters argue this reflects compassionate care. However, legal authorization does not eliminate ethical complexity. Instead, it transfers these judgments into clinical decision-making, where legal categories do not easily align with clinical paradigms.
Societal discourse frequently describes MAiD as a last resort. Yet it has become a leading cause of death in Canada, reflecting normalization within clinical pathways rather than exceptional use[5]. MAiD is fundamentally different from other interventions. It is irreversible, cannot be titrated for benefit, and targets the person, not the disease-process[6].
Advocates often emphasize intolerable physical suffering. However, Canadian reports show that MAiD frequently arises from social and systemic harms rather than strictly medical pathology. Emotional distress, loneliness, fear of being a burden, and loss of independence are commonly reported drivers of MAiD requests[5]. These reflect profound social failures.
MAiD eligibility requires clinicians to assess whether illness is grievous and irremediable, whether death is reasonably foreseeable, and whether the patient has capacity and is acting voluntarily[4]. These judgments may shift clinical focus from treatment and advocacy toward procedural confirmation of eligibility for death.
Oversight reports have identified cases in which patients were deemed eligible not because treatments failed, but because treatment was refused or unavailable[3]. When lack of access to care is interpreted as irremediability, MAiD risks functioning as a response to system failure rather than disease progression.
Interpretations of “reasonably foreseeable natural death” vary among assessors. Some clinicians consider a five-year prognosis sufficient[7]. Others accept patient decisions to stop eating, drinking, or accepting treatment as evidence of foreseeable death[8]. In such contexts, deterioration can become self-fulfilling evidence of eligibility.
Capacity assessment also raises concerns. Reports describe assessments occurring under clinically questionable conditions, including fluctuating cognition, heavy sedation, or minimal psychiatric evaluation[3]. These cases illustrate how clinical norms shift when assisted dying becomes routine rather than exceptional.
Recent BMJ commentary has suggested that Canada’s assisted dying regime involves robust independent assessment and that coercion is not a meaningful concern[1], despite alarms raised by the UN Committee on the Rights of Persons with Disabilities[2] and government oversight reports[3]. A key question is whether introducing assisted dying into medicine is adversely altering clinical practice. Assisted dying is often framed as patient autonomy. Yet this framing minimizes how Medical Assistance in Dying (MAiD) reshapes clinical reasoning, professional responsibility, and interpretations of suffering. Under Canada’s Criminal Code, MAiD is exempt from homicide and assisted suicide offences[4]. Supporters argue this reflects compassionate care. However, legal authorization does not eliminate ethical complexity. Instead, it transfers these judgments into clinical decision-making, where legal categories do not easily align with clinical paradigms.
Societal discourse frequently describes MAiD as a last resort. Yet it has become a leading cause of death in Canada, reflecting normalization within clinical pathways rather than exceptional use[5]. MAiD is fundamentally different from other interventions. It is irreversible, cannot be titrated for benefit, and targets the person, not the disease-process[6].
Advocates often emphasize intolerable physical suffering. However, Canadian reports show that MAiD frequently arises from social and systemic harms rather than strictly medical pathology. Emotional distress, loneliness, fear of being a burden, and loss of independence are commonly reported drivers of MAiD requests[5]. These reflect profound social failures.
MAiD eligibility requires clinicians to assess whether illness is grievous and irremediable, whether death is reasonably foreseeable, and whether the patient has capacity and is acting voluntarily[4]. These judgments may shift clinical focus from treatment and advocacy toward procedural confirmation of eligibility for death.
Oversight reports have identified cases in which patients were deemed eligible not because treatments failed, but because treatment was refused or unavailable[3]. When lack of access to care is interpreted as irremediability, MAiD risks functioning as a response to system failure rather than disease progression.
Interpretations of “reasonably foreseeable natural death” vary among assessors. Some clinicians consider a five-year prognosis sufficient[7]. Others accept patient decisions to stop eating, drinking, or accepting treatment as evidence of foreseeable death[8]. In such contexts, deterioration can become self-fulfilling evidence of eligibility.
Capacity assessment also raises concerns. Reports describe assessments occurring under clinically questionable conditions, including fluctuating cognition, heavy sedation, or minimal psychiatric evaluation[3]. These cases illustrate how clinical norms shift when assisted dying becomes routine rather than exceptional.
Policy structure may also influence clinical behaviour. Canadian guidance encourages clinicians to discuss MAiD proactively and for objecting clinicians to provide referrals[9]. These systems can streamline access, and patients may be funnelled toward more permissive MAiD providers.
When assisted dying becomes a predictable endpoint for complex suffering, it narrows clinician tolerance for uncertainty and complexity. It weakens the obligation to remain with patients through suffering.
This is concerning in a health system with gaps in palliative care, community supports, and disability services. When social and medical supports are unavailable, assisted death may become a structurally shaped choice rather than a voluntary one.
Many MAiD providers act in good faith. The concern is not only individual intention, but that systems shape clinical behaviour. When death is offered alongside, and sometimes before, comprehensive care, medicine drifts from its commitment to healing and accompaniment through suffering.
Assisted dying does not simply end lives. It risks reshaping clinical priorities and professional identity. Medicine is built on the obligation to remain with patients through uncertainty. Compassion in medicine requires more than offering a path to death. Inserting assisted dying into medicine, especially with critical gaps in care, reshapes medicine in response to system failures rather than solving them.
References:
1) BMJ. Patients are coerced to live, rather than die – assisted dying around the world [video]. YouTube. 14 Feb 2026. Available: https://www.youtube.com/watch?v=FMydoyef3Yc&t=11s [Accessed 24 Feb 2026].
2) Shannon D. UN committee rightly calls out Canada’s systemic devaluation of disability. Macdonald-Laurier Institute. 9 Jun 2025. Available: https://macdonaldlaurier.ca/un-committee-rightly-calls-out-canadas-syste... [Accessed 24 Feb 2026].
3) Coelho R, Shannon D, Lemmens T. Safeguard failures in Canada’s MAiD system. BMJ Supportive & Palliative Care. Published Online First: 27 Jan 2026. doi: 10.1136/spcare-2025-006046
4) Canada Department of Justice. Bill C-7: An Act to amend the Criminal Code (medical assistance in dying). 2023. Available: https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html [Accessed 24 Feb 2026].
5) Coelho R. Disabled Canadians should never feel compelled to die: let’s give them the support they need to live. Macdonald-Laurier Institute. Jan 2026. Available: https://macdonaldlaurier.ca/disabled-canadians-should-never-feel-compell... [Accessed 24 Feb 2026].
6) Chochinov HM, Fins JJ. Is Medical Assistance in Dying Part of Palliative Care? JAMA. 2024 Sep 11. doi: 10.1001/jama.2024.12088.
7) Pesut B, Thorne S, Sharp H, et al. Assessors’ decision-making regarding applicant eligibility for Track 2 medical assistance in dying in Canada: a qualitative study. CMAJ 2026;198:E1-E9. doi:10.1503/cmaj.251071.
8) Canadian Association of MAiD Assessors and Providers. The interpretation and role of “reasonably foreseeable” in MAiD practice. Feb 2022. Available: https://camapcanada.ca/wp-content/uploads/2022/03/The-Interpretation-and... [Accessed 24 Feb 2026].
9) Health Canada. Model practice standard for medical assistance in dying (MAID). 2023. Available: https://www.canada.ca/en/health-canada/services/publications/health-syst... [Accessed 24 Feb 2026].
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