5-year report: Euthanasia in Quebec is no longer an exceptional “treatment”
A report on the situation of end of life care between 2018 and 2023 in Quebec, has shown the important position now held by Medical Assistance in Dying (MAiD), i.e. euthanasia, in Quebec society. The Commission responsible for the report thus states that “Although MAiD remains, in most cases, a last resort act, it is no longer an exceptional treatment, but rather an option considered among other end of life treatments.”
The legal framework for MAiD has constantly been extended over the last 10 years.
In 2014 Quebec adopted a law concerning end of life care (LCSFV) which authorises euthanasia under the term “Medial Assistance in Dying, more commonly referred to as MAiD. Initially, in order to obtain MAiD, one had to be of adult age and able to consent to treatment, to be at the end of life following a serious and incurable disease and subject to constant unbearable and unrelievable physical or psychic suffering. In less than 10 years, the criteria for eligibility to MAiD have constantly been extended:
• Deletion of the end of life or reasonably predictable natural death requirement,
• Eligibility extended to people suffering from a serious and incurable disease leading to incapacitation in 2021 and to those suffering from serious physical deficiencies in the Spring of 2024,
• Possibility since October 2024 of applying in anticipation for MAiD.
Moreover, since December 2023, palliative care homes are no longer able to refuse to practice euthanasia on their premises. Moreover, the data from this 5-year report does not take into account the legal modifications introduced after 2023.
Increase in the number of deaths by MAiD
14,417 people were given MAiD between 1st April 2018 and 31st March 2023. The number of people receiving MAiD has constantly increased since the implementation of the law. The average yearly increase is 41 %. In 2022-2023, the number of MAiD administered was close to ten times that during 2016-2017. Deaths by MAiD represented some 6.2 % of all deaths in 2022.
The proportion of people whose life expectancy exceeds 6 months has increased between 2018 and 2023. In fact, the number of people with a life expectancy estimated at one year or less has increased gradually, from 3.6 % in 2018-2019 to 8.5 % in 2022-2023.
Among the disabilities and suffering reported, the loss of the ability to perform the activities which give a reason to live or the activities of day-to-day life, leading to dependence on others, came out on top; a feeling of loss of dignity was also very frequent.
In Quebec, the rate of deaths by MAiD means that it is no longer an exception. MAiD is now part of the continuum of end of life care.
Shortening of the time delay between the request and administration of MAiD
45.7 % of people received MAiD less than 10 days after signing the MAiD application form. In Quebec, the law does not specify the time delay between submitting the application form and administration of MAiD. However, the members of the Commission consider that “The decision must be considered, thoroughly thought out and include a series of spaced-out doctor consultations”. According to them, MAiD cannot be an emergency treatment administered hurriedly, nevertheless an interval of one day or less between the application and administration of MAiD is rare, but it does exist: it was reported in 3.6 % (514 out of 14,417) of the MAiD cases administered between 1st April 2018 and 31st March 2023.
The percentage of deaths by MAiD is the highest in the world
Compared with Belgium and Holland whose euthanasia eligibility criteria are similar, the yearly increase in the number of euthanasias per million of the population is much higher in Quebec and in Canada (30 % to 50 %) than in Belgium and Holland (10 % to 20%).
For 2022, the proportion of deaths by euthanasia was 5.4 % in Holland, 3.1 % in Belgium, and 4.1 % for Canada as a whole (including Quebec). The Commission has noted the high rate of MAiD in Quebec but can give no explanation.
The data does not enable evaluation of the availability and quality of palliative care
In view of the lack of data for measuring and evaluating the availability and quality of palliative care, the Commission has consulted specialist organisations and experts and a questionnaire was submitted to the participants of the yearly congress of the Quebec Palliative Care Association in 2023. The following results were obtained:
• Disparity in the availability of care and services according to the region and belated referencing.
• Difficulties with the paths of care and services.
• A lack of doctors available to provide palliative care in the home in several Quebec regions.
• An inadequate number of doctors exercising palliative care in relation to the needs.
• Inadequately trained care operatives and teams for the provision of good quality palliative care or for the early identification of those people who could benefit from it.
• A lack of information available to the population.
The lack of data, which it noted and deplores, does not prevent the Commission from stating without any embarrassment that the vast majority of those who received MAiD had benefited from palliative care.
The citizens network Vivre dans la dignité (living with dignity) is justifiably concerned : “What proportion of those people had access to complete palliative care at the right moment and with a multi-disciplinary joint bio, psycho, socio and spiritual approach ? A mere pharmacological approach (such as the simple administration of morphine) could be counted as palliative care whereas it is severely limited. For a true choice on the end of life, the people of Quebec must have access to palliative care worthy of the name, which adequately relieves physical, psychological and existential suffering.”
Moreover certain experts and contributors to the questionnaire expressed their concern that difficulties in obtaining access to palliative care could incite certain people to request MAiD to relieve their suffering which could in fact have been achieved by palliative care.
The observed trivialisation of administered death
10 years after the legalisation of medical assistance in dying, called for as an exceptional treatment, the eligibility criteria have been extended such that today, the percentage of deaths by euthanasia in Quebec is the highest in the world.
The law for end of life care, adopted in 2015 chose to include palliative care and administered death in a continuum of care resulting in the trivialisation of MAiD which is now viewed as a treatment among others at the end of life. From one extension to the next, MAiD could eventually become an on demand “treatment” with no eligibility criteria other than the will of the person.
In an addendum devoted to the ethics of MAiD in Quebec, Eugene Bereza and Véronique Fraser (previous and current members of the Commission) wonder whether it is “Ethically acceptable that poverty, social isolation, refusal to enter a CHSLD establishment (care home) or the lack of access to care should be factors which contribute significantly to the subjective experience of intolerable suffering of a person resulting in a request for MAiD?”.
However, both authors also seem to believe that the ethical principles founded on rules are relative compared with suffering. Ethics and suffering should never however be set against one another. It is essential on the contrary to consider and accompany suffering in respect for the principles of humanity and fraternity which are inseparable from the prohibition against killing.
Conclusion
At a time when discussions concerning the possible legalisation of euthanasia and assisted suicide in France are due to resume in May at the National Assembly, the Quebec example demonstrates how the criteria presented as safeguards are illusory. It also reveals how making euthanasia a care option among others, trivialises administered death and adulterates palliative care.
