June 5, 2023

Why is California lagging behind Canada in assisted dying?

In 2016 both Canada and California legalized assisted dying. But from then to 2021, 31,664 Canadians – 3.3% of all deaths — died under Bill C-14 , compared to 3,344 Californians under the End of Life Option Act. What explains the difference?

This is the subject of a fascinating (and open access) article the American Journal of Bioethics by Canadian bioethicist Daryl Pullman.

He identifies several possible factors.

The criteria for access to an assisted death are different. All US jurisdictions where it is legal require that the patient have “an incurable, terminal condition with a life expectancy of six months or less”. In Canada, all that was needed was a “reasonably foreseeable natural death” – although this criterion steadily expanded and no longer applies. All that is needed now is “a grievous and irremediable medical condition”, which need not be terminal. “It is now clear that the Canadian legislation is not primarily about hastening death for the terminally ill,” comments Pullman, “but more expansively about ending suffering irrespective of the proximity of that suffering to a patient’s natural death.”

In these circumstances, medical assistance in dying “becomes an efficient solution to a variety of complex problems, medical, social, or otherwise”.

The mode of death and the role of medical professionals. In California, doctors can prescribe a lethal dose of medication, but they are forbidden to actively participate in terminating a patient’s life. The patient has to swallow it himself.

About 30–35% of individuals never filled their prescription, or, having filled it, decided against using it and died of natural causes. In Canada, only 1.9% of patients approved for euthanasia withdrew their request. Pullman comments:

The fact that a significant percentage of terminally ill patients in the US who initiate the process never follow through, suggests that the process itself serves as a safeguard ensuring that only those fully and consistently committed to ending their lives will experience a physician assisted death. Put otherwise, the California protocol aims to ensure that this most momentous and final decision is indeed an autonomous one.  

In California, then, doctors are at arms-length from the process of dying. But in Canada, they are the main agents. This does not mean that Canadian doctors are coercive. But their attitudes matter more:

But when a patient approaches a medical professional intent on exploring the option of an assisted death, how that professional interacts with the patient can do much to influence the patient’s decision, irrespective of the intent to be non-directive. Indeed, the very effort to be non-directive out of some narrow view of what it means to respect “patient autonomy” could be perceived as an endorsement of that option.

Pullman believes that the Canadian system is effectively medicalising suicide. “Canada is descending rapidly on [a] slippery slope, and so-far the sled seems only to be gaining speed.” And he concludes that “the US should keep a wary eye on Canada so as to avoid the precipitous slide now happening there.”