Patients who choose medically assisted death are wealthier, younger, more likely to be married and less likely to live in long-term care than those who die naturally, according to a major study of assisted dying in Canada’s most populous province.
The authors of the new Ontario research say its findings – which are based on reviews of every assisted-dying case in the province over two years – counter fears that the procedure would become a final refuge for patients too poor and vulnerable to access high-quality health services, including palliative care.
Instead, the opposite has proved true: It is the affluent, not the marginalized, who most often avail themselves of the assisted-dying law that Canada enacted nearly four years ago.
"These were people who very obviously had socioeconomic means,” James Downar, lead author of the new study, said of the patients he helped to die in the early days of legal medical assistance in dying (MAID).
“It was very unusual to see anything but well-educated [patients] who were well aware of their rights and options and definitely had access to good palliative care.”
The new research, published Wednesday in the Canadian Medical Association Journal, comes at a critical moment in the evolution of the country’s approach to assisted dying.
The Trudeau government is aiming to table legislation by the end of this month to bring the law in line with a Quebec court decision that last fall struck down a clause that limited MAID to people whose natural deaths had become “reasonably foreseeable.”
The federal government also held public consultations last month on the possibility of making MAID more widely available, including to mature teenagers; to people whose only underlying condition is mental illness, and to those who want to request assisted death in advance, including dementia patients.
“What we’re hoping is that these findings will be able to provide some reassurance to parliamentarians that, at least in Ontario, MAID practice is concordant with the objectives of the law," said Jennifer Gibson, a co-author of the study and director of the University of Toronto Joint Centre for Bioethics.
The new study reviewed coroner’s files for every assisted death in Ontario between June 7, 2016, and Oct. 31, 2018 – 2,241 cases in all.
There were 6,749 assisted deaths across the country during that time period, according to Health Canada.
The researchers then compared patients who received MAID to the 186,814 Ontarians who died naturally during the same period.
Patients who received an assisted death were more likely to be wealthy, with 24.9 per cent of MAID recipients earning enough to be in the highest of five income brackets. By contrast, 15.6 per cent of patients who died naturally were in the top income bracket.
The study found that Ontario MAID recipients were, on average, two-and-a-half years younger when they died, and less likely to have been living in an institution, usually a nursing home, before they died.
Of those who died naturally, 28 per cent lived in institutional settings, while only 6.3 per cent of MAID recipients did.
The study also concluded that, in 74.4 per cent of cases, a palliative-care provider was involved in the patient’s care at the time of the MAID request, which Dr. Downar said shows that patients are not resorting to MAID because they can’t access palliative care to ease their physical suffering.
“Nobody’s saying that there’s perfect access to palliative care, or that there’s no such thing as socioeconomic vulnerability,” said Dr. Downar, head of the division of palliative care at The Ottawa Hospital. “Those things absolutely are issues. They’re just not driving MAID.”
Ebru Kaya, a palliative-care specialist at Toronto General Hospital and a member of the board of the Canadian Society of Palliative Care Physicians, disagreed with the authors’ conclusions on the interplay between palliative care access and MAID.
“We don’t know what they mean by palliative care,” said Dr. Kaya, who was not involved in the study. “They use this blanket term. Palliative care providers could mean anything. The MAID assessor who is also a palliative care physician may use that clinical encounter to assess for MAID as a palliative care encounter, but the two are very different.”
The authors of the new study say there are still plenty of unanswered questions about assisted-dying access, including why the affluent seem likelier than other demographics to have doctors hasten their deaths.
It could be that the well-off are simply better at navigating the health-care system and MAID is no different, Dr. Gibson, the U of T bioethicist, said.
“It may be signaling a more general concern about availability and access to health services based on socioeconomic class."