This article contains discussions of suicide. If you or someone you know is having a suicide crisis, please call Talk Suicide Canada (1-833-456-4566), which offers 24/7 support. There is also Kids Help Phone (1-800-668-6868), the Hope for Wellness Helpline for Indigenous people across Canada (1-855-242-3310), and 1-866-APPELLE (for Quebec residents).
Tarra carlson’s plan for her old age is simple: to die before her husband.
She’s been nearly inseparable from him since they met thirteen years ago on a dating site. After a few messages and video chats, they learned they lived just blocks apart. The revelation led to a long midnight drive together. Soon, he moved in. They got married a few years later. He is, without a doubt, the greatest and best thing in her life, she says. He is also, in some ways, her guarantee of life.
Carlson, forty-eight, has autism and ADHD. She didn’t get a formal diagnosis until she was thirty-nine—“Only boys in my time had those disabilities,” she says—but her whole life has been marked by social exclusion. She says that, when she was growing up, her teachers and school administrators sensed there was something different about her, but they didn’t know exactly what; some, she says, would use the r-word to describe her. Carlson attended separate classes for students with disabilities throughout elementary and parts of high school. She struggled in college because of a lack of disability accommodations. She remembers that when she was a child, a doctor suggested her parents send her to an institution; doctors also warned she’d never be able to live independently as an adult.
Despite the warnings, she did achieve some degree of independence: at twenty-three, she moved to Alberta from British Columbia on her own. She makes a living as a caregiver for people with disabilities and people who hire and train their own support staff rather than rely on agencies.
For several years, she also received payments under Assured Income for the Severely Handicapped, a provincial social assistance program for disabled adult Albertans. It’s not a lot of money to live on—the maximum 2023 rate is $1,787 per month; in 2017, when Carlson last received it, it was $1,588. (By that time, she says, she was personally receiving well below that amount because of her husband’s salary and her pension plan disability benefits.) The amount decreased when she earned money, so the program did little to maintain her independence or help her plan for the future. By mid-2017, she lost access to the program entirely; her husband’s income made her ineligible. She says she still receives about $800 a month in Canada Pension Plan disability benefits and can get by with her husband’s support, but the situation feels temporary.
“I’m petrified of growing old with a disability,” she says. If her husband dies before her, she may have no way to access financial support. She’ll lose her biggest advocate and support system—and her home. She’s worked in long-term care facilities and never wants to live in one. Applying for disability support programs, such as home care, can be cumbersome. There’s no one-stop shop for disability services; they’re spread across government agencies and ministries. Wait lists are long. Paperwork can be complicated. Carlson doesn’t think she’ll be able to understand how to navigate social assistance programs without her husband to explain them to her. But if she dies first, she reckons, she won’t have to.
Compared with disability support, medical assistance in dying, or MAID, seems relatively easy to request. Written applications differ by province or territory but are fairly straightforward; most are only a few pages long. For some of them, to confirm eligibility, an applicant simply has to sign and initial certain statements—for example, that they have an irremediable and grievous medical condition and are in a state of advanced decline. If any more health conditions were to crop up on top of her disability, eroding her independence completely, says Carlson, she’s pretty sure she’d qualify for MAID. “It’s a one-way ticket,” she says, “because you have no choice.”
Before 2015, providing medically assisted deaths was a criminal offence. That year, the Supreme Court of Canada declared the Criminal Code’s prohibitions on assisted suicide unconstitutional insofar as they did not permit physicians to provide medically assisted death to consenting adults. The following year, legislation came into effect that legalized MAID, allowing physicians to administer lethal drugs to patients who, as the law put it, had a “grievous and irremediable” sickness, disease, and disability and whose “natural death” was “reasonably foreseeable.” (Interpretations of the term “reasonably foreseeable” and what sort of timeline it denotes can vary, but it is generally understood by clinicians that it can mean several years.) This would, presumably, allow individuals with terminal illnesses to end their lives when they wanted and on their own terms.
Until recently, most of the public discourse and reporting about MAID has described it in positive and, some would argue, romantic terms. (A 2015 editorial in The Walrus called MAID “the last human right.”) Proponents say MAID gives suffering individuals a painless end. Some say they feel relief knowing that their death will be controlled and that they can anticipate a peaceful exit. MAID, they say, has given them an option other than prolonged suffering or a violent suicide—or perhaps an unsuccessful and traumatic attempt at one.
That rosy perception began to darken when, in 2021, the legislation was expanded to include people whose deaths are not considered reasonably foreseeable—an option now known as Track Two. The development particularly angered many disabled Canadians. The change in legislation made it possible for disabled people to qualify for MAID even if they weren’t terminally ill. Over the past year, according to news reports, people have considered applying for or have died by MAID for reasons such as insufficient housing and meagre social supports that have left them in perpetual poverty. Carlson knows people with disabilities who have applied for MAID because they couldn’t find proper supports to live. “Canada has made it so that it’s become the only resource or recourse that people who are marginalized or poor have,” she says.
In 2024, Canada plans to further extend eligibility to people whose sole underlying condition is mental illness, prompting many to question whether MAID has gone too far. (The government was due to introduce this expansion in March 2023 but passed a law earlier this year to extend that deadline, citing the need to give medical professionals more time to prepare.) Ostensibly, there are legal and administrative safeguards in place to keep MAID from being abused, whether by patients or providers. But, for a growing chorus of critics, it’s unclear whether any such measures can suffice to protect vulnerable people from being all but forced into MAID.
Concerns about the legislation aren’t new. Some say it was flawed from the outset and that Canada’s assisted dying laws have always singled out disabled people by listing “disability” as a type of medical condition that could guarantee eligibility. In 2019, before Track Two was legalized, Catalina Devandas-Aguilar, then UN special rapporteur for the rights of persons with disabilities, wrote that she was “extremely concerned about the implementation of the legislation on medical assistance in dying from a disability perspective.” In her report on the country’s compliance with the United Nations Convention on the Rights of Persons with Disabilities—which Canada ratified in 2010—she mentioned troubling accounts of people with disabilities who were institutionalized and offered MAID. She recommended the government investigate such claims and “establish adequate safeguards to ensure that persons with disabilities do not request assisted dying simply because there are no community-based alternatives or palliative care.”
In February 2021, three UN experts on the rights of seniors and people with disabilities as well as on human rights and extreme poverty wrote a letter to the federal government, urging it not to legalize Track Two. “There is a grave concern,” the letter stated, “that, if assisted dying is made available for all persons with a health condition or impairment, regardless of whether they are close to death, a social assumption might follow (or be subtly reinforced) that it is better to be dead than to live with a disability.”
The Canadian government nevertheless stayed its course. There are restrictions that are meant to keep the practice in check: for those deemed eligible for Track Two, for example, there is a mandated ninety-day period between when an assessment begins and when MAID can be provided. (For those whose applications fall under Track One, there is no required reflection period; someone could theoretically be approved for MAID in the morning and be administered the lethal drugs in the afternoon.)
But ninety days isn’t long enough for comprehensive reflection, says Virginia Duff, a Toronto-based psychiatrist. Most people, she says, would not likely reverse or even reconsider such a decision within that time frame. This is especially true, she adds, for people who have recently acquired a disability and are adjusting to its impact on their lives. “They’re in a crisis at the beginning,” says Duff. “They’re going to be regarding their future in a certain light and often in a negative light. But they don’t know at that point what they don’t know. And they don’t know that life with a disability can be very different from what they imagined it to be.”
The Special Joint Committee on Medical Assistance in Dying (AMAD), established by the House of Commons and Senate in 2021 to review MAID law and proposals for further expansions, received 358 written submissions from organizations and individuals. One of them was from an elderly woman who wrote to the committee about her degenerative eye condition, saying there is a need for MAID to be expanded to include people who aren’t experiencing pain as a form of suffering—whether that be physical or psychological. She wants to apply for MAID once she is considered legally blind. Society, she wrote, isn’t built for blind people; she has no desire to learn Braille or how to use adaptive technologies.
For Duff, who is visually impaired, the way we talk about MAID expansions ignores the complexities and years it may take to treat conditions such as mental illness. The language we use around it is also euphemistic: “The title of the act is ‘medical assistance in dying,’” she says. “But these aren’t people who would otherwise be dying. We’re not just assisting them. We’re actually making it happen, which is very different.” (Some jurisdictions where medically assisted death is legal use terms such as assisted suicide, in which patients are given fatal drugs to ingest, and euthanasia, the process by which medical practitioners directly administer a lethal intravenous injection. MAID effectively covers both, although the vast majority of MAID deaths in Canada are clinician administered.)
For some, the availability of MAID isn’t so much a concern as the ease with which this country offers it. According to Health Canada, 31,664 people died by MAID in the five years after legalization. In 2021 alone, the number of medically assisted deaths in Canada—just over 10,000—was about twenty times higher than in California, a state with an assisted suicide program and similar population size. (In California, eligibility is granted only to those who are terminally ill.) Track Two was introduced in Canada in March 2021, and in less than a year, 219 people who were presumably not imminently dying had received it.
“Canada has become a poster child for how bad MAID can become,” says Heidi Janz, a long-time disability rights activist and playwright. An associate adjunct professor at the University of Alberta, she studies and teaches the ethics around end-of-life care and disability. Janz, along with Catherine Frazee, a professor emerita of disability studies at Toronto Metropolitan University, started the GRIM Project in 2022 to document the stories of disabled people who have considered MAID or have died by it. (Both Janz and Frazee appeared as witnesses for the AMAD committee, as well as several other sources I interviewed for this story.) The project takes its name from the Criminal Code’s language of a “grievous and irremediable condition.” Janz and Frazee have spent years listening to the stories of disabled Canadians, many of whom live in poverty and struggle with social isolation. MAID, says Janz, “has become an acceptable solution to poverty for people with disabilities.”
“These problems predate the MAID system,” says Frazee. She frequently hears stories of disabled Canadians turning to MAID out of desperation and thinks about them every day. They tell her they don’t want to die yet the government seems to be pushing them to. “But the MAID system makes it all a perfect crime because the MAID regime destroys the evidence,” she says. “It destroys the lives of the people who were here to report their experience of poverty and alienation and stigmatization and devaluation.”
In September 2020, the federal government announced its intention to create a financial benefit for disabled Canadians who are working-age adults. Bill C-22 passed unanimously in the House of Commons in early February this year and, as of mid-April, was still in the Senate. When it was being debated in the House of Commons, Bloc Québecois MP Luc Thériault questioned the reliability of stories that report Canadians seeking MAID because of socio-economic hardships: “No one who appeared before the Standing Committee on Health told us up front that [these] claims are common practice,” he said. Others said issues of disability, poverty, and MAID were “intertwined”—that it was impossible to discuss reducing poverty for disabled Canadians without also recognizing that many are requesting MAID because they live in poverty.
Carla Qualtrough, the minister of employment, workforce development, and disability inclusion, responded to Thériault’s criticisms in an interview I recorded for Now with Dave Brown, a national TV show and podcast produced by Accessible Media Inc. “I believe that when someone says a decision was motivated by a socio and economic factor like poverty that it was,” she said. “There’s no reason why somebody would ever say it wasn’t. . . . It keeps me awake at night.”
Some advocates argue that Bill C-22 could keep disabled Canadians from applying for MAID. (The details around how much the benefit will amount to and who exactly will be eligible for it are yet to be worked out.) But poverty is just “one piece of the puzzle” of why disabled Canadians are considering or are being approved for MAID even when they’re not dying, says Kerri Joffe, a staff lawyer with Arch Disability Law Centre, a Toronto-based legal clinic that focuses on disability rights law and policy in Ontario. The problems of disability poverty and the lack of affordable, accessible housing and proper home-care supports need to be addressed, she says. But Joffe, and others, have raised concerns that Canada’s MAID legislation denies disabled Canadians equal rights to life. The government needs to address this, she says, by removing Track Two altogether or changing the law “fundamentally so that it would comply with international human rights law.”
“I think that disability should have been absent from [the original MAID legislation],” says André Schutten, director of law and public policy at the Association for Reformed Political Action (ARPA) Canada, a Christian legal organization and lobby group. The phrasing of a “reasonably foreseeable” death is also too vague, he says. ARPA wrote to the joint committee requesting that a “reasonably foreseeable” death be defined as one backed by a prognosis that the patient is likely to die within six months. The organization also wants Track Two deaths eliminated so that only individuals whose natural deaths are reasonably foreseeable can die by MAID. ARPA isn’t alone in this request. Inclusion Canada, a secular organization that represents people with intellectual or developmental disabilities, has also called on the government to remove Track Two for MAID. Arch Disability Law Centre, another secular organization, has expressed similar concerns about Track Two.
In fact, ARPA disagrees with MAID wholesale. As a “foundational principle,” says Schutten, doctors should not be able to end patients’ lives. “When you say, ‘No, there are some situations where a doctor should have a licence to end the life of a patient,’ then it’s very difficult to say, ‘Well, in this situation, you can. In this situation, you can’t.’ Every safeguard becomes arbitrary in a sense.”
But there is an understanding among the organization’s leaders that MAID has become a part of Canadian society, one that seems immovable. “We also recognize the political reality that we live in,” says Schutten.
This past February, the parliamentary joint committee released a report that recommended, among other things, that the government consider removing the word “disability” from the legislation altogether. It echoed the need for greater social and financial supports for disabled Canadians.
Yet the report also spoke favourably of further expansions, such as permitting advance requests for MAID. This would potentially allow people to stipulate under what circumstances they would want to receive MAID should they lose their capacity to consent to it. The committee also suggested that MAID be made available in certain circumstances to “mature minors,” though it recommended further consultations. (Currently, Belgium and the Netherlands are the only countries with comparable provisions for those under eighteen.) There should be no age limit to who can consent to receiving MAID, the report states; applicants should qualify if they are deemed capable of making the decision, though it does not go further to define “capable.” The committee also recommended that parents and guardians be consulted during the process, though not that they be required to approve of their child’s decision: “the will of a minor who is found to have the requisite decision-making capacity [must] ultimately take priority,” the report states.
The majority of Canadians—three out of five, according to a recent Angus Reid poll funded by Cardus, a Christian think tank that opposes MAID—are in favour of the legislation in its current state. This apparent public support doesn’t shock physicians who have been providing MAID in Canada almost since the beginning. When it was legalized, Konia Trouton, a doctor and MAID provider who was then practising in BC, had patients phoning her, asking for more information about medically assisted dying. “The legislation came about not because doctors were going to the courts and saying we need this option,” she says. “It’s because patients went to the court saying, ‘It is my right to die.’”
That’s what motivated Trouton to start assessing patients for and performing MAID back in July 2016. “Patient autonomy and choice is really important,” she says. She has since helped found the Canadian Association of MAID Assessors and Providers, where she’s now vice president, and is a member of the clinicians’ advisory council for Dying with Dignity Canada, a pro-MAID lobby group. (Trouton also submitted a written brief to the AMAD committee.)
Trouton, who now lives in Ontario, says she’s aware that some Canadians have received MAID even when the main cause of their suffering was a socio-economic factor not directly related to their qualifying medical condition. But that doesn’t technically make those cases ineligible. “The suffering and the irremediable disease don’t have to be the same,” says Trouton, citing the law’s language around safeguards: it does not explicitly state the need for suffering to be caused by a medical condition.
She points to other safeguards meant to ensure MAID applications are vetted appropriately. Applications go through at least two rounds of review. Two clinicians have to separately assess the MAID request to determine whether the applicant meets the medical criteria for it as outlined in the law, a step that can be done virtually.
Requests that qualify for Track Two require an opinion from someone with expertise in the applicant’s medical condition, and that expert can be one of the two reviewing clinicians. The assessors also have to determine whether a patient has reasonably considered all the treatments, therapies, or supports that could help alleviate their suffering. “We don’t have to have proof that you’ve tried [them],” says Trouton. “But we have to feel that you’ve given reasonable consideration.” Some patients require multiple assessments; for Trouton’s most complex case to date, five consultations were completed before she was assured the patient was eligible for MAID. She would like to see more training about MAID assessments incorporated into medical education so that clinicians—regardless of their area of practice—feel comfortable broaching the subject with their patients.
Trouton usually calls her patients the day before their scheduled death to make sure they still want MAID. On the day of, to confirm that they understand what will happen to them, she asks them to tell her who they are and why they are there. “We do the same thing in surgery,” she says.
Even if the government does not expand MAID for those with mental illnesses or mature minors, and even if it doesn’t allow for advance requests, Trouton sees the number of Canadians dying by MAID only rising. “There’s been an increase already in the past seven years in MAID across the country,” she says. “It doesn’t look like that trajectory is stopping.”
Other MAID providers are looking at MAID expansion differently. Madeline Li, a psychiatrist at Princess Margaret Cancer Centre, which is part of Toronto’s University Health Network (UHN), says she has “grown increasingly concerned” about how MAID is practised in Canada. “I’ve never been in favour of expanding MAID to non-terminal [cases],” she says.
Li developed the MAID program at UHN and says the law has always lacked sufficient safeguards, and this has only become more apparent as MAID has expanded. Specifically, the law needs to be more clinically informed, says Li, who is also a scientific researcher. The terms “reasonably foreseeable” and “incurability” must be defined medically, with specific time frames attached to the former and further explanations around the latter. A patient shouldn’t be deemed to have an incurable illness, for example, if they’ve refused treatments, she says. And providers need a clearer interpretation of what constitutes suffering in the context of MAID. “There needs to be clarification that the suffering needs to be medical suffering directly related to the medical condition,” she says. “And that sources of suffering indirectly related to the medical condition don’t qualify.”
Li would also like an oversight body to qualitatively review complex cases. What she’s proposing currently doesn’t exist on the federal level in Canada. She thinks clinicians need to be legally required to have more detailed conversations with patients who say they want MAID—conversations that don’t take the patients’ request at face value and aim to get at the best medical option for them.
“I genuinely think clinicians are doing their best to help patients,” she says. But the law itself is inherently flawed, and that puts people at risk. If concerns aren’t addressed through amended legislation, “they’re not going to be addressed [fully] through practice guidelines or training,” she says.
“The problem has been that the people who first entered MAID work are now very experienced, but they’re confusing experience with expertise. They’ve been very focused on ‘Does a patient qualify?’ and not ‘Should a patient have MAID?’”
The looming expansion of MAID, under Track Two, to include people with mental illnesses has raised red flags for several psychiatrists, who say that allowing people with mental illnesses to die by MAID could rob them of the chance to find treatments that enhance their lives. According to Duff, it could violate the principles of suicide prevention. “One of the tools that we use to help prevent suicide is to eliminate the means,” she says. And if assessors comply with only the minimum requirements for the MAID expansions, “we’re just handing [patients] the means and not questioning why they want to kill themselves.”
“To say this is not suicide inducement or that it’s not suicide, I find bizarre,” says John Maher, a Barrie, Ontario, psychiatrist who has spent twenty years working with assertive community treatment teams. These twelve-person multidisciplinary teams work with people who have severe mental illnesses, including schizophrenia. There’s no consensus among psychiatrists that mental illnesses are irremediable, that they never get better. Maher argues that even patients with serious mental illnesses can improve; they often just need more time to find the right treatments that work for them—and for those treatments to be available to begin with.
“If you’re saying ‘irremediable’ means they can’t be cured completely, sure, there are people who are irremediable,” he says. “If you’re saying it means there are people where you can’t reduce suffering . . . I don’t buy it.” The Centre for Addiction and Mental Health has echoed these concerns. Its June 2022 brief to the government committee that reviewed MAID states, “We do not believe that eligibility for MAID should be extended to people whose sole medical condition is mental illness at this time.”
Mitchell Tremblay says he plans to apply for MAID as soon as it becomes available for people with mental illnesses. Based in Guelph, Ontario, he has a disability and has been vocal online about his financial hardship. He has had suicidal ideations since he was eleven; he has experienced cycles of homelessness; he doesn’t speak to his family; he says he has very few friends—and even those relationships are strained—and he doesn’t want to try to make more of them. He’s keeping careful records of his mental health diagnoses: social anxiety disorders, generalized anxiety, and post-traumatic stress disorder, among others. He doesn’t want his MAID request to be denied, so he intends to show that his condition truly is lifelong—that he’s not applying because he’s in a temporary situation of depression. But even though he wants MAID for himself, he’s concerned that some other MAID applicants will be approved when they don’t actually have a serious, diagnosed, chronic mental illness—people who are experiencing a major depressive episode, brought on by events like a romantic breakup or the loss of a job or home, and whose mental health might improve with the right treatment.
“I think it’s going to be a national blight,” he says about expanding MAID eligibility while people don’t have proper supports. “There has to be all the avenues explored before MAID is the final option there for them.”
Maher fears that if MAID for mental illness becomes legal, it won’t be clear how doctors should determine which suicidal patients will receive psychiatric care and which will be assessed for MAID.
“Suicide prevention work is about giving people hope: helping them make sense of suffering, giving them a sense of purpose in life, putting in speed bumps at those points in time when things look like there’s no hope of recovery,” says Maher. “The whole point of my team—our services, our care philosophy—is we don’t quit. We don’t go away. We don’t stop helping. We don’t stop trying to reduce suffering, we don’t stop helping people heal. We’re a recovery model.”
Even those who want to support people in vulnerable situations can be left in the dark about their intentions to seek MAID—and feel powerless to stop it. Gary Hertgers has spent months trying to piece together the final days of his older sister Wilma’s life. She was sixty-three when she died on January 30, 2022. The first indication that something was off was a cryptic voicemail message from a doctor he didn’t know—someone he would later find out was Wilma’s MAID provider. He phoned the doctor back and left a voicemail. Then the manager of Wilma’s apartment building called to inform him that the coroner had just left. That’s how he learned Wilma had died by MAID.
He’d last seen Wilma two days before, at her apartment in Chilliwack, BC. “She never mentioned a single thing about what was all organized and scheduled for that Sunday,” he says. Currently, there is no requirement that family be informed of a MAID applicant’s request to die.
Wilma had been increasingly despondent since 2008, when her twin and long-time roommate, Jenny, died of cancer. Once a small business owner, Wilma had stopped working full time in the years after Jenny’s death. She increasingly complained of pain, Gary says. He remembers that she always seemed to be rotating through appointments with various specialists—oncologists, cardiologists, rheumatologists. Gary wanted to help his sister, and he and his family tried. But Wilma could be difficult at times, and he needed to set up boundaries for himself, he says. Still, his grief over Wilma’s death is unlike anything he’s ever experienced.
This is Gary’s third time grieving a sibling—and perhaps the most complicated. When he was almost sixteen, he watched his older brother, Martin, drown. It took him years to find some peace with respect to Martin’s death. He hasn’t come to that peace yet about Wilma’s.
Gary called the numbers on a contact list Wilma kept by her phone and learned she had an “army” of people ready to help if she needed meals or company. She had friends from church and her volunteer work. But Gary doesn’t know whether any of them were aware that Wilma had scheduled her death.
A semi-retired farmer, Gary isn’t sure what he can do to raise awareness about MAID’s overreach. He wrote to the government committee studying MAID, asking its members to reconsider the legislation. “Rather than expand their definition [of who is eligible for MAID],” he says, “they need to retract it.”
There are some questions raised by Canada’s MAID laws that can’t be addressed through increasing mental health supports, reducing poverty, reverting to the previous MAID laws, or even eliminating MAID altogether. Fundamentally, says Thomas De Koninck, a professor emeritus in the faculty of philosophy at Université Laval in Quebec City, MAID forces people to think about death and what comes next. It also forces people to consider the meaning of suffering in life and whether suffering and hope can exist together. And those are questions that laws can’t answer.
“What people desire most is to be loved,” especially when they’re dying or are in pain, says De Koninck. “And so many people are left alone in hospitals or in big houses, where nobody comes to see them. So they’re just stressed. They need friendship. They need concern. They need palliative care in that sense.”
For De Koninck, the existence of MAID should prompt questions about what is causing people to decide that death is better than life. The law’s vast acceptance in Canadian society, he says, is evidence that people have lost hope, that they are alone, or that they don’t have meaningful relationships.
Tarra Carlson is determined to enjoy her life with her husband. A voracious learner, she spends much of her free time reading the latest research in disability studies and psychology. She loves learning about cultures around the world, including various beliefs around death and the afterlife. She’s pulled different pieces from what she’s come across and has settled on a form of reincarnation. She likes the idea that the soul finds a new body after death, that every life is a chance to learn more about being a better person. It’s a reminder that life goes on.
She’s in no rush to die—“I want to live a very long and cantankerous life,” she says—but when she finally does die, she wants her ashes sprinkled in San Josef Bay at the northern tip of Vancouver Island.
Until then, rather than dwell on her predicament of living in a world that doesn’t understand or accept her disability, she prefers to tell jokes, to laugh, to consider all the ways she’s “privileged”: her job, her home, and her husband—always, her husband. For her, at least, “not everything’s doom and gloom,” she says. She pauses. But, she says, “what is happening to people with disabilities is doom and gloom.”