Recent news reports have highlighted faith-based hospitals in Canada which decline to offer medical assistance in dying (MAID). Such hospitals—which are best understood not as mere “facilities” but as communities of people advancing a shared mission of healing and care—view the termination of life as contrary to basic principles of medicine. Others, concerned about MAID access, are calling for the government to require these communities to provide MAID on-site (rather than transferring patients to other facilities), or to terminate their service agreements.
But whether to participate in MAID is a profound and complex ethical question—a question on which the B.C. Supreme Court recognized that “thoughtful and well-motivated people can and have come to different conclusions.” Those who conclude that they can not offer MAID are not medical outliers. They hold a legitimate ethical position, shared by health-care professionals, associations, and ethicists around the world, and recognized by Canadian courts as deserving of respect.
To understand why MAID remains ethically contested, it is important to clarify exactly what it involves. Contrary to what its name might suggest, “medical assistance in dying” is not the provision of medicine, personal care, or symptom management as a patient approaches their natural death (that is palliative care, which “intends neither to hasten nor postpone death”, and which the federal government, the Canadian Hospice Palliative Care Association, and the Canadian Society of Palliative Care Physicians have all recognized as distinct from MAID).
MAID is the intentional termination of a patient’s life, at their request, through the administration of a lethal substance, in response to their suffering. Because it “inflicts death” on another person (in the words of the Criminal Code), MAID (or voluntary euthanasia) was a criminal act until seven years ago and could have resulted in imprisonment. Even now, MAID requires detailed “exemptions from the offences of culpable homicide, of aiding suicide and of administering a noxious thing”, as well as “robust safeguards, reflecting the irrevocable nature of ending a life”.
In other words, MAID is not a routine or ordinary health-care service. In many countries, it is viewed as contrary to the basic principles of health care, as well as the Hippocratic Oath to “do no harm”. The World Medical Association, for its part, is “firmly opposed to euthanasia and physician-assisted suicide” and states: “No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end.”
None of this is to suggest that those with differing views about MAID aren’t also thoughtful and well-meaning. A serious danger in this debate is to claim a monopoly on compassion and care when people from all sides are sincerely motivated by it. It is simply to explain why some health-care communities have concluded that they can not provide euthanasia and how theirs is hardly a radical position.
Still, some assert that faith-based hospitals must offer MAID because they are publicly funded and MAID is constitutionally protected. But nothing in Carter (the Supreme Court ruling that sparked the decriminalization of MAID) suggested that every health-care facility must provide it. While the trial judge was satisfied that some physicians, in some circumstances, “would find it consistent with their ethical principles to assist patients with hastening death if it were legal to do so”, the judge also recognized that, for others, intentionally ending the life of a patient is “ethically inconceivable”. The question of forcing physicians, or the communities in which they care for patients, to participate in MAID was never at issue.
Similarly, the Supreme Court, for its part, emphasized that nothing in its decision “would compel physicians to provide assistance in dying” and that “the Charter rights of patients and physicians will need to be reconciled”. In short: the Carter decisions only said that willing physicians may offer MAID in some circumstances, not that all health-care communities must do so, contrary to their medical ethics.
It is also important to situate this debate within the current “matrix of legislative and social facts”, in the words of Carter. Legislatively and socially, MAID has evolved drastically in Canada, and its expansion continues. With Bill C-7, which in 2021 removed the initial requirement in 2016 that a patient’s death be “reasonably foreseeable”, MAID was transformed into a procedure that can end the life of a person who is not dying and whose underlying medical condition will not cause their death. This move was criticized by UN human rights experts, who expressed concern about its discriminatory effect and messaging that “it is better to be dead than to live with a disability”.
MAID is set to be further transformed in March 2024, when it is scheduled to become available to Canadians suffering solely from a mental illness. A Parliamentary committee has further recommended that MAID be available to children deemed to have “requisite capacity”. That same committee was also urged by Quebec’s college of physicians to permit euthanasia for infants in certain cases (though it stopped short of adopting that recommendation).
If or when these practices become legal, should all health-care communities be forced to facilitate them? Must psychiatric MAID be available in all health care centres supporting patients with mental illness? Or pediatric euthanasia in every children’s hospital? If freedom of conscience doesn’t protect the medical ethics of diverse health-care communities now, why should it in those future scenarios?
When MAID was contemplated in Carter, it was on the premise that it would be “stringently limited” and subject to an “almost-absolute prohibition”. Yet, over seven years, MAID has evolved from being a crime that could send doctors to jail to a practice that all health-care communities are expected to provide. Some MAID proponents, along with the federal government in a new guideline, now insist that physicians should sometimes initiate conversations about MAID, even where the patient has not requested it—despite the Standing Senate Committee’s observation that “Requests for MAiD should be strictly patient-initiated.”1That committee “heard from many witnesses that the inherent power imbalance between patients and their medical practitioners constitutes a big challenge for ensuring that patients are making free and informed choices and are not inappropriately coerced into seeking access to MAiD.”
The data from the federal government about MAID deaths in Canada since Carter is also troubling. In 2021 alone, of the 10,064 Canadians who had their lives ended by MAID, over 35 percent listed “perceived burden on family, friends, or caregivers” as a factor contributing to their decision to die, and over 17 percent cited “isolation or loneliness”. Media reports have revealed how MAID has been seen as a response to suffering experienced by persons with disabilities —suffering that is often related to extraneous and societal factors, such as poverty, systemic ableism, inadequate housing, and socioeconomic distress. UN experts have raised concerns that there is “no protocol in place to demonstrate that persons with disabilities deemed eligible for assistive dying had been provided with viable alternatives”. In fact, the federal government’s own reports reveal that hundreds of Canadians have died by MAID who needed but did not have access to disability supports or palliative care.
Do we really want to force every health-care community to offer euthanasia in this social and legislative environment? Would it not be prudent to preserve some spaces where patients know they will never risk experiencing “sanctuary trauma” by having euthanasia suggested as a possible solution for their medical—or even existential—crisis? Intentionally or not, troubling reports indicate that this risk is becoming a reality.
Framing conscience as a source of tension between physicians’ rights and patients’ rights is problematic. It sidelines marginalized patients who benefit from conscience protection, such as those seeking life-affirming support in health-care communities unfettered by practices with different goals and outcomes. The proper reconciliation of rights, called for in Carter, should protect spaces for such patients. Conscience protection, properly understood, can help offer patients sanctuary from trauma.
Conversely, demanding that health-care communities either violate their ethics or effectively shut down results in a net loss of care, depleting an already under-resourced system. This undermines Charter rights, including the s. 7 rights to life and security of patients seeking care and healing in these communities.
The trial judge’s recognition in Carter bears repeating: “thoughtful and well-motivated people can and have come to different conclusions about whether physician-assisted death can be ethically justifiable.” This includes faith-based health-care communities. Not everyone will agree with their approach. But in a country that cherishes diversity and dignity for all, we must support diverse communities of care and, in turn, better options and outcomes for all patients—many of whom seek, and deserve better access to, medical assistance in living.
