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Rebecca Vachon: Skyrocketing MAID deaths must prompt urgent reassessment

Commentary

Usually, governments welcome high adoption rates for new policies. But when that new policy is an exception within the Criminal Code for euthanasia and assisted suicide, which then sees more than 30 percent annual growth in use, no government should be celebrating. And when such rates shoot past Health Canada’s official projections by nearly a decade, any government should be deeply worried. 

Health Canada’s 2022 report on deaths by euthanasia and assisted suicide, or medical assistance in dying (MAID), showed the continued, increasing numbers of MAID deaths. They accounted for 4 percent of total deaths in Canada in that year. A joint Toronto Star and Investigative Journalism Bureau (IJB) analysis revealed how this growth outpaces what we see in other countries around the world–including places where euthanasia and/or assisted suicide have been legal for decades. The Star/IJB conclusions match those of a forthcoming Cardus Health report, which provides a detailed look at the rise compared to other jurisdictions.

This high rate of growth is more than a statistical curiosity. It should prompt policymakers and all Canadians to reflect seriously on what the data tells us about the practice of euthanasia.  

For one, the legislation and regulations surrounding MAID aren’t terribly useful because the eligibility definitions are vague. Initially, there was limited eligibility for those whose deaths were “reasonably foreseeable”, without specifying what “foreseeable” meant. This has allowed for a significant range of interpretation when assessing for MAID. Likewise, the criteria for “unbearable suffering” is also highly subjective. 

Without more tightly defined criteria, we cannot ensure a consistent application of MAID. This is something Drs. Tang, Gaind, and Lau discuss in a recent scholarly book (see page 278). Vague criteria with multiple interpretations lead to a system where patients can “shop” for assessors and providers willing to euthanize them if at first they receive a rejection. Without an updated system that would inform MAID assessors of previous requests, they may be unaware of the request history. Without a review function where rejected applications can be sent and evaluated, patients may continue “shopping” until they reach their objective. 

Another built-in problem with the existing criteria for MAID is that it does not require patients to exhaust treatment options. They need only be “informed of” them, “offered consultations,” or “have discussed and given serious consideration” to them. While medical interventions do not require patients to exhaust their options, an intervention meant to cause an early end to a patient’s life is different. It requires a higher standard, particularly considering that patients may have had difficulty getting quality, timely health care already. 

Consider that the trend in the proportion of MAID requests considered ineligible continues to drop, year over year. In 2019, Health Canada reported 8 percent of requests were found ineligible, dropping to 4.1 percent in 2021, and just 3.5 percent in 2022. This suggests a weakness in euthanasia eligibility criteria. 

The federal monitoring and reporting system is based on conflicting interests, making enforcement of the system very difficult. The MAID assessors and providers self-report data. So, while those performing MAID do have criminal liability, they are also the ones reporting on whether all eligibility criteria and procedures were followed. Effectively, they oversee their own legal compliance.

Sadly, there is no independent verification of compliance reports. As documented by Dr. Jaro Kotalik, a health-care ethicist, in his edited volume on MAID, the monitoring system was never intended to ensure compliance. It merely provides information for a “societal perspective ” according to the government. This is unlike other international approaches, including in the Benelux countries, which were pioneers in introducing euthanasia/assisted suicide. Instead, Canada’s federal monitoring via Health Canada has no review function and no ability to refer compliance issues for investigation.

Provincial authorities, meanwhile, provide only limited and partial data on MAID. Only Ontario and Quebec provide publicly available reports on their reviews. And, while Quebec reports have pointed to compliance issues and missing data in some cases, they provide no details about how these cases were investigated or handled.

Perhaps we should not be surprised, then, with the continued growth of euthanasia, when considering the inherent weaknesses of the existing system. This sort of growth is not, however, “destiny.” California, for instance, legalized assisted suicide also in 2016. Despite its slightly larger population size to Canada, only 3,344 Californians died by assisted suicide from legalization in 2015 through to 2021. By contrast, 31,664 Canadians died by euthanasia or assisted suicide within that same period.

And while the government has temporarily delayed further expansions of MAID for mental illness as a sole underlying condition, this staggering rate of growth in the current system should prompt not only reflection but a commitment to investigating what is going on. 

Steve Lafleur: Calm down about 15-minute cities

Commentary

I try to ignore conspiracy theories. They’re a dime a dozen nowadays. But there’s one that drives me crazy that just won’t go away: 15-minute cities.

In our current buzzword-driven media environment, any term that gets traction tends to polarize people. Even the most banal ideas, like 15-minute cities.

The idea behind 15-minute cities is pretty simple: we should build communities where people can fulfill most of their needs within a 15-minute walk. Some terminally online conservatives seem to believe that this would be a radical feat of social engineering that would end our traditional (mostly) free-market way of living. It’s an extreme version of the general sense some conservatives have that encouraging density and walkability (or bikeability) is at odds with freedom.

Of course, 15-minute cities already exist all over Canada. Most neighbourhoods built before the 1950s would qualify as 15-minute cities. You might even say that Canada was built on 15-minute cities!

Take the East Side of Toronto, stretching from the Don Valley to Scarborough. It’s composed of classic streetcar suburbs filled with older, mid-density homes. There aren’t many tall apartments, but there are plenty of small post-war detached houses, row houses, townhouses, and small apartments—the kind of “missing middle” housing that urban planners love. Because there’s a reasonable amount of density, there are plenty of amenities. 

Let’s zoom in to my neighbourhood, Leslieville. I can walk to three full-service grocery stores in under 15 minutes. Within that radius I’ve also got a Canadian Tire; two Shopper’s Drug Marts; three LCBOs; four breweries; two butchers and a fish monger; medical professionals; etc. I could go weeks without leaving my neighbourhood if I had to. I don’t have to hop in a car, fight traffic, and find parking to get a cup of sugar. If this 15-minute city is a prison, I’ll happily take a life sentence.

I’m not just trolling here. This is important to me because I’m a market urbanist. I want more freedom to live the lifestyle of my choosing without top-down planning getting in the way. I want to maximize people’s choices and ensure that we have livable, affordable communities. But I find myself arguing with conservatives who claim to want the very same thing! Often, at least in part, because they buy into the idea that anything other than car-oriented development is central planning.

The 15-minute cities conspiracy hints at a deeper flaw in a certain type of conservative thinking. Suburban conservative politicians often dress up their own flavour of urban planning in the language of freedom. They’ll argue that low-cost subsidized bike lanes are tyranny, but then have no problem with high-cost subsidized highways or stadiums. It’s hard to have a serious conversation about public policy when certain decisions are coded as freedom and others as socialism when in reality they’re all just banal planning decisions involving annoying tradeoffs.

It’s easy to understand how people who don’t spend their time thinking about land-use policy might assume that one-size-fits-all urban sprawl is the free market outcome since it’s most of what we’ve built in North America over the last half-century. 

In reality, car-dependent suburbs are some of the most rigidly planned communities on earth. They tend to be mostly (or entirely) zoned for only one detached unit per lot (often with minimum lot sizes) along with the legally mandated amount of parking, following prescribed building codes. You can’t even open a coffee shop in most of them. It’s hard to imagine a community with no commercial amenities emerging organically. I’m pretty sure most people would like to be able to walk to the corner to get some milk (or mylk, I guess). 

The reality is that all communities are planned to an extent. That’s not a conspiracy—just a statement of fact. Homesteaders of yore didn’t just stumble into communities lined with roads and utility poles. This isn’t Sim City! 

Two cyclists ride in front of Fish and Sips restaurant on Huronatrio St. in Collingwood, Ont., on Thursday, June 30, 2022. Andrew Lahodynskyj/The Canadian Press.

Building and managing cities requires collective action. All collective action entails “social engineering.” Traffic laws are social engineering, but no one would argue that stop signs are tyranny. Planning should be minimally coercive and maximize choice. But there’s no getting around planning!

Sometimes municipal governments do things that sound vaguely communist like building free roads and parks. But that’s the nature of city life. Unless we’re going to create some sort of anarcho-capitalist society that doesn’t exist outside of libertarian science fiction, we’re going to have to accept that municipal government makes decisions that involve tradeoffs between the interests of various groups. 

Recognizing the legitimacy of these tradeoffs helps us get to productive conversations. For instance, what is the right balance between accommodating drivers and protecting pedestrians? What restrictions ought to exist on businesses operating in residential areas? On what basis should cities be allowed to block development? Should it be illegal to open a coffee shop?

There are no easy answers to these questions. But if we want to improve municipal governments, they’re questions we should think about rather than getting sucked down the rabbit hole. It’s dark down there, and there aren’t many answers.