MAiD is not driven by socioeconomic vulnerability or poor access to palliative care

A new study of people who received medical assistance in dying (MAiD) in Ontario found that about three-quarters were cared for by palliative care practitioners at the time of their request for MAiD, and MAiD recipients were younger, wealthier and more likely to be married than the general population at time of death. These findings dispel concerns that MAiD requests are driven by lack of access to palliative care services or by socioeconomic vulnerabilities.

MAiD was legalized in Canada in June 2016, and as of October 2018, 6749 Canadians received MAiD.

The federal government and the government of Quebec are currently in consultation around drafting new eligibility criteria for MAiD, after a decision of the Quebec Superior Court that one provision of the previous laws violated the Canadian Charter of Rights and Freedoms.

“There has been and will be much discussion about socioeconomic vulnerability and access to palliative care, and how these factors influence requests for MAiD,” says Dr. James Downar, lead author of the study and a specialist in critical care and palliative care at The Ottawa Hospital and University of Ottawa, Ottawa, Ontario. “Since this study represents the comparison of MAiD recipients to all deaths overall, and uses Canadian data, it could help inform this discussion and the upcoming legislation.”

Researchers analyzed clinical and socioeconomic data from 2241 Ontarians who received MAiD, and compared this with data from all 186 814 people in the province who died between June 2016 to October 2018, from databases kept by the Office of the Chief Coroner for Ontario and ICES. Among those who received MAiD, the median age was 75 years and half were women; almost two-thirds of patients (64%) had cancer, 12% of patients had neurodegenerative disease, 8.5% had cardiovascular disease and 7.5% had respiratory disease.

Patients who received MAiD reported both physical (99.5%) and psychologic (96.4%) suffering.

“[W]e found that people who chose MAiD reported physical or psychologic suffering as the primary reason, despite engagement of palliative care in [77%] of patients, which suggests that for many patients the MAiD requests were not because of poor access to palliative care,” write the authors.

Almost half of MAiD recipients were married and the majority (85%) lived in a private home before receiving MAiD. They were younger than people who did not receive MAiD and more likely to live in a higher income neighbourhood, which suggests that MAiD requests are unlikely to be driven by social or economic vulnerability, say the authors.

Requests for MAiD can be emotionally difficult for patients and families, and any delays can exacerbate distress. The study found that only 6.6% of families reported challenges with access to MAiD and these delays were not associated with socioeconomic status. The authors noted, however, that the MAiD data set included only people who actually received MAiD, so these findings would not reflect the experience of patients who requested MAiD but never received it.

“The data presented here do not address the moral question of whether any amount of suffering can justify the hastening of death. However, the growing trend toward legalization and use of MAiD in many parts of the world should prompt the health care and research community to improve our understanding and treatment of the type of distress that leads to a MAiD request,” the authors conclude.

In a related editorial, Dr. Andreas Laupacis, CMAJ’s editor-in-chief, writes, “Downar and colleagues’ findings should allay fears that people living in Ontario are choosing MAiD because they have little social support or have poor access to health care. This study found the opposite, which suggests that more attention needs to be paid to ensure that those who are socially or economically vulnerable and eligible for MAiD are aware that MAiD is an option.”

He cautions that as we move into a new era in which the Canadian government is considering expanding eligibility to MAiD to minors, people with severe mental illness and to those who anticipate losing the capacity to request MAiD in future, Canada will need new safeguards.

“If access to MAiD is expanded, new safeguards, specifically tailored to each new indication for MAiD, should be put in place. Then, we must once more proceed with caution, measure carefully and reassess,” concludes Dr. Laupacis.

The study was conducted by researchers from The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario; Sunnybrook Research Institute, The Joint Centre for Bioethics, University of Toronto, Office of the Chief Coroner, Government of Ontario; Queen’s University, Kingston.

“Early experience with medical assistant in dying in Ontario, Canada: a cohort study” is early-released February 12, 2020.