Detailed analysis of the costs of medical assistance in dying in Canada.
According to a study published in 2017 prior to the vote on law C-14, budgetary cost savings had been estimated at between 35 and 137 million dollars per year. In 2016, law C-14 authorised euthanasia for people whose death was reasonably predictable in the short term. In 2020, prior to voting on law C-7, extending the conditions for access to MAD, an official report estimated that the extension of access to MAD would result in cost savings amounting to 149 million dollars.
According to its authors, these estimates are part of an initiative for transparency and the evaluation of the budgetary impact of legislative measures. Whilst quantifying the cost savings which would result from the establishment of a euthanasia system, they reject any idea that the legalisation of MAD is aimed at cost savings.
A recent study on the Canadian measures, published on the Cambridge University Press web-site and analysed by a previous expert report, however identified the risk that access to euthanasia could be promoted at the detriment of access to appropriate but costly treatments.
How reliable are such estimates?
At the request of a Senator, in order to estimate the costs resulting from bill C-7, this report by the parliamentary budget director’s office shows “a breakdown of the costs resulting from the current law (C-14) and the additional costs which would result from the proposed extension of access to MAD (bill C-7)”.
It uses the same methodology as the 2017 study and adjusts it by extrapolating the statistics established since the application of MAD in 2016. The cost savings resulting from law C-14 (taking into account the administrative costs of MAD) were thus estimated at 86.9 million dollars in 2021, by considering that 6465 deaths were attributable to MAD. If law C-7 were to be adopted, 1164 deaths would result from the extension of MAD, representing a cost saving of 62 million dollars. In total, the extension of access to MAD would enable total cost savings of some 149 million dollars.
These estimates and in particular those from the 1st study by Trachtenberg and Manns are based on the methodology from an article[1] published in the United States 20 years earlier, which was based on 3 factors to evaluate the potential cost savings resulting from the legalisation of medical assistance in dying:
- The proportion of the number of patients applying for euthanasia,
- The effects of the procedure, i.e. euthanasia, on the patients’ remaining life expectancy,
- The total costs incurred for the end of life.
When viewed in the light of statistics, the estimates made against each of these factors are found to be at best unreliable and even incorrect
Such as the number of “patients” applying for euthanasia. Whereas the 2020 report predicted 6465 deaths due to euthanasia in 2021 i.e. 2.2% of the total number of deaths, 9845 deaths by “MAD-C14” were recorded in 2021 (i.e. 3.3% of deaths) according to the official statistics. These same statistics also reveal the incorrect estimate of the number of additional deaths attributable to MAD in the context of extension C-7. 1164 deaths by MAD C-7 were estimated in the report. In fact, 219 deaths were recorded in that context.
In order to estimate the “remaining life expectancy”, the study by Trachtenberg and Manns was based on a study conducted in the Netherlands founded exclusively on predictive medical estimates from surveys, with no possible checks and intimately dependent on the pathology and the person. On the other hand, it ignores the [British%20Medical%20Journal%20(nih.gov)] data showing that the diagnosis by doctors on the remaining life expectancy of a patient at the end of life, is accurate in a mere 20 % of cases: in 63% of cases the life expectancy is overestimated. The tendency to overestimation has the effect of not only inflating the assumed cost savings but also has consequences on the late admission date in the end-of-life care wards which can result in the use of heavy and very costly treatments instead of directing the patients to palliative care facilities for example to improve their quality of life.
Whereas the 2020 report estimated that “the life expectancy of patients would be shortened by 3 months in 45% of cases”, in 2019 the official statistics revealed that 60% of those who requested MAD but without obtaining it die within 10 days of making the request.
Finally, in order to evaluate the end-of-life healthcare costs, the 2020 report uses an estimate of the palliative care costs and applies a 50% reduction factor. This calculation is based on the fact that, according to the official statistics for 2019, “82 % of those who received MAD had been given palliative care during the previous weeks”.
In the final analysis, the estimated potential cost savings resulting from the Medical Assistance in Dying procedures in Canada is based on unreliable assumptions with no scientific or statistical foundation. This type of publication nevertheless causes concern. In aging nations, where the healthcare costs are weighing heavily on public funds, the legalisation of euthanasia could be interpreted as an approach by governments seeking to make cost savings at the expense of the well-being and accompaniment of its citizens.
[1] Emanuel EJ, Battin MP. What are the potential cost savings from legalizing physician-assisted suicide. N Engl J Med 1998;339:167-72, 1998
