Canada’s ‘slippery slope’

The so-called “slippery slope” argument has a bad reputation among those advocating for euthanasia.

Often, this totemic phrase is enough to shut down the debate there and then: ‘it’s a well-known fallacy, those arguments don’t count, come back when you have something substantive to say’. But we now know the slippery slope is not bad faith rhetoric or a piece of ill-informed sophistry. We now know it is true, because we can observe it happening in Canada in real time.

It has been less than eight years since the very first patient died under Canada’s Medical Assistance in Dying (MAiD) laws. Yet in that short time, the country’s euthanasia regime has slipped down the slope with alarming speed. The numbers choosing to die have soared. Eligibility for MAiD has been vastly expanded. Those opting out on conscience have been forced to comply.

Already the government has amended the law once, and in 2024, more expansions will come into force. MAiD was originally billed as a tightly restricted new procedure for exceptional cases with layers of in-built safeguards. But as soon as the bill was signed into law, this changed. Today it is becoming a general right for all. Before 2017, nobody was able to demand help to take their their own lives. Now, if anyone in a hard circumstance is denied this it is seen as cruel, unfair or discriminatory.

The original MAiD law laid out a clear and supposedly rigorous process before someone was given access to lethal drugs, or a lethal injection. To be eligible you had to be 18 or older, mentally competent, suffering from a serious physical health condition, in an advanced state of decline, and someone whose natural death was “reasonably foreseeable”.

Your written request then had to be approved by two, independent doctors. If they both agreed, a 10 day cooling off period began, before the earliest point you could access assisted death. At the moment before the doctor administered the lethal injection, you had once again to give consent.

These provisions and safeguards were the product of years of extensive consultation and parliamentary and legal debate. At the time MAiD became law they were hailed as thorough, thoughtful, and rigorous; meeting Canada’s needs for a well-regulated assisted suicide and euthanasia system. 

But very quickly almost all of them have been decried as oppressive and unjust. Most of those advocating for MAiD insisted, much as their UK counterparts do today, that all they wanted was a modest system for exceptional cases. However, the moment such a process was established, they began demanding more and more.

Even at the point of legalising MAiD, the scope of Canada’s experiment had grown. The 2012 court case that started it all argued the families and doctors of terminally ill patients should be permitted to help them take their lives. In other words, they were asking solely for assisted suicide.

But by the time the Supreme Court ruled in 2015, this had expanded to include euthanasia – where a doctor does not simply supply a patient with the material needed for them to die by their own hand, but actually administers the a lethal injection themselves.

Today’s MAiD framework offers both assisted suicide and euthanasia. But government figures show euthanasia immediately came to predominate. In the first two years after the law changed, just six people self-administered lethal drugs, a total of 0.09% of all deaths under MAiD. Effectively, MAiD is a euthanasia programme and that alone.

Next, there has been a staggering increase in the numbers of people taking up MAiD since the law changed. When it was first legalised, 115 people a month took up the new option of an assisted death. But just three years later in 2019, that figure had surged to 469 a month (an increase of more than 300%). The rate of increase has continued year on year, with no indication yet where the death numbers will settle.

But the most significant, and perhaps most alarming, changes since MAiD came into force have been around who is eligible for a state-assisted death. The original legislation restricted access to those who were terminally ill and close to death. Although there was no specified time limit in the legislation, a “reasonably foreseeable natural death” was interpreted to mean at most a few months left to live. But this was not enough for ‘assisted dying’ campaigners.

Shortly after MAiD came in, one government minister said off-hand that Kay Carter, whose death at the Dignitas clinic sparked the court case which led to MAiD, would not have been eligible for the new procedure. Seizing upon this remark, Canada’s most famous pro-euthanasia doctor Ellen Wiebe used actuarial tables to establish that Carter would have on average lived another five years at the time of her death, and then unilaterally decided this was the new cut-off point for MAiD eligibility.

Overnight, the MAiD access timeline expanded ten-fold, from approximately six months before death to 60 months. She was not investigated or prosecuted by the authorities when she began to sign off MAiD requests under this radical new interpretation of the law, prompting other doctors to follow suit.

Then, in 2017 an Ontario court ruled that a woman known as AB was eligible too for MAiD even though her degenerative osteoarthritis was not expected to cut her life short. Wiebe, again using actuarial tables, concluded AB was at least ten years from death at this point and thus the eligibility for MAiD expanded again. The government did not appeal the Ontario ruling and nor was there any effort made to restrain Wiebe and others from reinterpreting the law yet again.

The end game came in 2019 with another court case, the Truchon ruling. In this case, two disabled Quebeckers challenged the MAiD regulations which required patients to be terminally ill at all. The court ruled in their favour, telling the government that euthanasia had to be available even to those at no risk of dying from their conditions. As a result, in March 2021 an amended MAiD bill was passed by parliament, which struck out any requirement to be terminal.

The original MAiD law was also clear that only adults aged 18 or over could be approved for euthanasia. But this prohibition is under extreme strain. A report by the Canadian Paediatric Society in 2018, just two years after legalisation, found parents of sick children were already asking doctors for MAiD regularly. In one survey, 11% of paediatricians said they had had exploratory discussions about MAiD with parents, despite such a prospect being entirely illegal. Over half of the children whose parents had requested they be euthanised were under the age of one.

A separate poll of paediatricians found almost half (46%) supported extending MAiD to so-called “mature minors” – children aged under 18 who are deemed to have the capacity to consent to serious medical procedures. A third of paediatricians (32%) said they backed making euthanasia legal for younger children who could not request it themselves, solely on the wishes of their parents.

Most of the leading activists for MAiD are on the record arguing in favour of extending euthanasia to teenagers, and the amended law which was passed earlier in 2021 set up commissions to study whether to expand eligibility to mature minors.

Other taboos are speedily being worn down as MAiD becomes more and more commonplace. At first the palliative care system was strongly opposed to adopting euthanasia – a 2015 statement by the Canadian Society of Palliative Care Physicians (CSPCP) said MAiD was antithetical to the ethos of hospice care.

Initially, almost nobody died of MAiD in hospices (most deaths took place in hospital wards or at home) but over time as palliative care doctors found more of their patients demanding euthanasia and more activists attacking them for refusing, their resistance began to crumble. By 2019, the CSPCP was so concerned it put out a further position statement, insisting euthanasia could play no part in traditional and compassionate end of life care, and asking that doctors’ rights to conscientiously object to MAiD be respected.

But so far this resistance has failed to halt the creep of MAiD into the palliative care system. In 2019, the annual figures showed 21% (more than one in five) of all deaths were in hospices, a figure which continues to rise.

At conferences for pro-MAiD doctors, activists have spoken of their intent to wear down palliative care physicians and hospices over time, gradually eroding their resistance to the new normal until no institution feels able to claim their legal right to conscientiously object. Others insist the government should defund any part of the healthcare system which refuses to carry out MAiD.

A similar process is underway with faith-based hospitals and clinics, which are a significant feature of Canada’s state-funded healthcare system. Currently, institutions which have moral objections to MAiD (mostly Christian-founded hospitals) can opt out entirely from fulfilling patient requests. But from almost day one there has been a fierce campaign to abolish this right.

Cases where severely-ill patients have needed to be transferred from their Christian hospital to another which will fulfil their desire to be killed have received prominent attention in the media. Wiebe, the leading pro-euthanasia doctor in Canada, has even said she has pretended to be a relative bringing flowers onto a ward, in order to slip undetected inside Christian institutions and carry out forbidden MAiD assessments on site.

In one infamous example, a hospital in Nova Scotia which was founded by nuns was handed over to the provincial health authority in the 1990s on the proviso their Christian convictions would be upheld. But once MAiD was legalised, critics argued this exemption was unfair as it forced locals to travel further afield to find a doctor willing to give them a lethal injection. Dying With Dignity, Canada’s leading pro-euthanasia lobby group, threatened to sue the hospital and prominent bioethicists strongly criticised religious exemptions. In the face of this campaign, the hospital management caved in and now allows both assessments and the administration of MAiD on its site.

The Canadian experience reveals one thing very clearly. Once a law is passed, even a strictly limited one, the cat is out of the bag. Once the universal prohibition on doctors assisting suicide is relaxed a little, previous certainties are up for grabs. Once euthanasia is out there for some, more and more people will insist they must have it too, and many doctors will feel unable to resist.

The trajectory of the Canadian Medical Association (also discussed in another article on how MAiD was legalised) exemplifies this. For decades the CMA was firmly opposed to doctors having anything to do with assisted suicide or euthanasia. When its members were polled in 2014, some 72% of doctors backed this position. But shortly afterwards, the body drifted into formal neutrality, arguing its members were too divided on the issue. Then in 2015 the CMA went further, contributing evidence to the Carter Supreme Court case.

MAiD followed in 2016, and by 2017 the hearts and minds of doctors, who had been mostly opposed before the law changed, had shifted. At a conference that year, delegates voted not only to back MAiD, but to radically expand it. Some 83% backed giving euthanasia to patients with dementia if they had made an advance written request. Two-thirds of delegates supported extending MAiD to children under 18, and more than half (51%) said psychiatric patients should also be eligible.

And there is evidence many more concerns may be slipping under the radar. An official report from Quebec found an astonishing one in ten cases of MAiD there did not comply with the legal criteria for eligibility and safeguards. Failures of reporting meant the authorities were not even sure exactly how many Quebeckers were being euthanised each year. In Ontario, Canada’s most populous province, more than one in four (27%) of all deaths are now coming before the statutory 10-day waiting period after an approved request.

So, what do we find has happened in Canada since euthanasia was legalised? In just eight years, eligibility has been widened enormously and is still being pushed further. The requirement to be terminally ill has been abolished, and the exclusion of mental health conditions will lapse soon. The numbers dying each year climb steadily, and there is no sign of this slowing. Conscience protections for faith-based hospitals have counted for little in the face of ferocious public pressure to allow MAiD, while the almost century-old tradition of palliative care has partly dropped its opposition to euthanasia.

The slippery slope, far from being a logical fallacy or hackneyed trope, is real and Canada is careering down it at speed.