Ottawa’s recent consultation on advance requests for medical assistance in dying presents itself as a careful, transparent discussion about autonomy and end-of-life choices. However, as I read it, I was struck more by spin than balance.
The consultation assures Canadians that medical assistance in dying (MAiD) operates under “strict criteria,” and the government has taken a “cautious approach” to expansion, while advance requests “are anchored in the recognition of the principles of respect for the person and self-determination.” In reality, our Canadian experience does not support these claims: safeguards have not held, eligibility has expanded, and the system is already failing those it claims to protect.
In my opinion, as a family physician serving marginalized patients and as a member of Ontario’s MAiD Death Review Committee, the problems and non-compliance we have observed in MAiD stem from multiple issues, including misplaced trust in procedural safeguards and insufficient oversight of clinicians. Despite its compassionate framing, investigative journalists and government reports reveal troubling patterns where Canadians ended their lives through MAiD because reversible suffering—such as lack of access to medical treatments, poverty, loneliness, or feelings of being a burden—was not addressed. This consultation is flawed in its framing and shapes the societal discussion in ways that put people who cannot consent at risk.
An “advance request” would allow a person to pre-authorize their own death through MAiD, before they are eligible or want to receive it, for a future time when they lose decision-making capacity. The government frames this as an act of self-determination—honouring your “future self’s” presumed wishes. But this framing masks serious ethical and legal problems. Under the Criminal Code, assessing for MAiD without consent remains illegal. Yet Health Canada’s language implies that advance requests are a logical next step, even as it seemingly lauds Quebec for moving ahead despite current federal prohibitions.
The consultation offers a comforting example of “Charlie,” who says he would want MAiD if he could no longer feed himself or recognize his children. But such a hypothetical scenario—based on fear of the future rather than lived experience—ignores reality. My own father, who had advanced dementia, did not recognize his grandchildren and needed help with all his care, yet he still experienced daily joy, laughter, love, and dignity. To suggest he lacked dignity is to discriminate against him and others like him. Living through an illness offers perspectives that others might not possess. For this reason, experts suggest that advance consent can never be a fully informed choice.
Many people with dementia adapt and find meaning in ways they could not have imagined years before—something noted by experts and documented in research on patient quality of life. Patients with dementia are currently receiving MAiD because they fear decline and fear being a burden. This is particularly distressing given that most of them did not receive palliative care or other support to help them cope, adjust, and overcome these fears before MAiD. Allowing fear of decline to dictate one’s future death increases the risks and is not autonomy. It is internalized stigma, disguised as choice.
Jonas-Sébastien Beaudry, writing in Policy Options, captures this contradiction well. The rhetoric of choice and compassion conceals a troubling bias: that life with disability, dependence, or cognitive decline is less worth living. Advance requests rely on this assumption, reinforcing the discriminatory notion that some lives are inherently undignified. True equality demands we reject such ableist framing, not enshrine it into Canadian law and policy.
Beyond these concerns, the consultation’s data also deserve scrutiny. Over 90 per cent of respondents were English-speaking, 75 per cent were women, and most were over 55 and urban—hardly representative of Canada’s diversity. These participants overwhelmingly supported advance requests, but public opinion shaped by fear of decline is not the same as informed ethical consensus. Fears are not facts. And asking Canadians to make complex decisions about law, medicine, and end-of-life care through a misleading online survey trivializes the gravity of what’s at stake.
The report acknowledges “concerns about safety” and the “critical importance of final consent.” Yet Health Canada treats these concerns as just one theme among many—folding them into a narrative that normalizes advance requests as inevitable, just as it has done with previous MAiD expansions.
Perhaps most strikingly, the consultation admits that healthcare systems are already failing to meet end-of-life needs. It acknowledges gaps in dementia care, home supports, and palliative services, but offers no detailed plan for how to meaningfully expand them—while proposing an increase in MAiD assessors as a necessary solution to the current state of affairs.
Advance requests may appear to protect autonomy, but they do the opposite. They let past fears authorize ending the life of a future self—one who can no longer speak for themselves and may want to live. This is not compassion; it is abandonment dressed up as choice. The reality is stark: we would be authorizing the death of people whose past decisions may no longer reflect their true wishes.
Dr. Ramona Coelho is a family physician whose practice largely serves marginalized persons in London, Ontario. She is a senior fellow at the Macdonald-Laurier Institute and co-editor of the new book “Unravelling MAiD in Canada” from McGill University Press.