Canada’s federal government introduced legislation Tuesday that would expand Medical Assistance in Dying (MAID) to cover patients who have lost the mental capacity to give informed consent at the moment of the procedure, provided they authorized it in advance while still of sound mind.
Justice Minister Sean Fraser said the bill allows Canadians to pre-authorize euthanasia “so their wishes could be respected if they are diagnosed with an incurable illness that could take away the ability to make this decision.” He said the measure includes “rigorous safeguards to protect people and ensure the decision remains voluntary and free from external pressure,” and that MAID would still require patients to be experiencing “intolerable suffering” even after losing mental capacity.
Fraser said a parliamentary study found the change necessary so patients in an “advanced state of irreversible decline in capability” would not be denied life-ending procedures they had requested earlier, under rules that currently bar euthanizing people who can no longer give consent. He said provinces would “determine the extent to which they wish to embrace the next frontier on Medical Assistance in Dying,” calling the bill the start of “a national conversation that will largely play out at the provincial level around the extent of access.”
Belgium, the Netherlands and Spain already allow advance requests for euthanasia, as does Canada’s own province of Quebec.
A Bill Tied to a Separate, More Contentious Issue
The legislation also closes what officials described as a regulatory “gap” that has allowed MAID to be authorized for people suffering purely from mental illness — an expansion the Liberal government had moved to halt earlier this month amid domestic and international criticism that Canada has pushed assisted suicide too aggressively.
Officials paired the two issues deliberately: barring MAID for the mentally ill, they argued, would also block people with diminished mental capacity from accessing it even when they otherwise qualified. The National Post reported that advocates have long said people with dementia or Alzheimer’s feel pressured to end their lives early, before they lose the capacity to give final consent.
Critics argue the two questions should not have been bundled together. “If you are a member of Parliament who is concerned, as I am concerned, you have to concede which issue matters more to you, and the fact that they’re unwilling to separate these is major cause for concern,” said author Alicia Duncan, whose mother Donna was euthanized in British Columbia in 2022 despite suffering mental impairment from a concussion, in defiance of a court injunction her daughters had obtained.
Who Speaks for the Patient?
The bill arrives amid unresolved questions about how doctors should handle patients with diminished capacity who appear to resist euthanasia after authorizing it in advance — including disputes over whether body language or hand gestures from patients who can no longer speak should count as refusal.
That scenario has already played out publicly. Brigitte Stegemann, 83, was euthanized despite her family’s claim that she had failed cognitive tests and had changed her mind beforehand; her death, in what her family described as a botched procedure, left her covered in blood.
Heather Campbell Pope, founder of Dementia Justice Canada, told the National Post the bill’s safeguards “don’t go far enough.”
“Our question is, when the doctors, the nurses, the social worker, and the family members are around the table discussing whether to carry out MAID, who is in the seat representing the patient?”
University of Toronto health law professor Trudo Lemmens went further, warning that “a law that allows MAID on the basis of advance requests clearly crosses further the line between voluntary and involuntary euthanasia.”
Not everyone thinks the bill goes too far. Helen Long, CEO of Dying with Dignity Canada, argued the opposite problem exists — that the rules make it too easy to override a patient’s written advance consent if their condition deteriorates.
“Individuals should be allowed to define what they consider to be physical and psychological intolerable suffering, as part of the advance request, and medical practitioners should base their decision on that objective standard.”
CTV News noted there remains “persisting disagreement among experts over whether practitioners can safely assess an individuals’ circumstances when seeking MAID on the basis of a mental illness,” a dispute the new bill does not resolve.
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