How many MAID providers should there be?

A look at the next stage of arguments

Photo by Hal Cooks

Here’s a very short introduction to anti-MAID arguments. Although the legal and moral case for MAID was sorted out well before legalization in Canada—Jocelyn Downie’s book Dying Justice was published in 2004; Wayne Sumner’s book Assisted Death came out in 2011—word hadn’t gotten out that MAID was solved. This meant that, even after Carter, the 2015 Supreme Court of Canada decision that struck down the general prohibition on assisted dying, people were still raising objections to permitting any form of MAID: killing is always wrong, human life is sacred, and so on. Call this stage one. 

After a while, most people realized that these objections just aren’t that good. The basic case for MAID, which is that it prevents suffering and promotes autonomy, is overwhelmingly strong. Indeed, MAID opponents seem to have realized that they were losing the argument, so we stopped hearing so many stage-one arguments and entered stage two. The arguments changed to the effects of MAID instead of MAID itself. I’ve covered most of these arguments: MAID is bad for people experiencing poverty, so we should ban MAID for poor people; MAID is bad for people with disabilities, so they shouldn’t be allowed to get MAID either.

Stage-two arguments are still around, but we’re seeing a new type of argument. In stage three, the focus is on the moral character of MAID providers. This stage began on March 5, 2024 with Christopher Lyon’s article, “Words Matter: ‘Enduring Intolerable Suffering’ and the Provider-Side Peril of Medical Assistance in Dying in Canada”, in which Lyon argues that MAID providers are bad people, not because they kill people and that killing is wrong—that would be stage one—but because of their attitude to their work.

A more general way of distinguishing the stages is that stage-one arguments are deontological (“it’s always wrong to kill people”), stage-two arguments are consequentialist (“the negative consequences of MAID outweigh the positives”), and stage-three arguments are based in virtue ethics, which emphasizes one’s attitude, thoughts, and emotions to one’s acts. For the virtue ethicist, there are virtues and vices—positive and negative dispositions—that make moral conduct not just about your deeds, but also about your mental state. (One’s motive is something deontologists care about, whereas virtue ethicists factor in a broader set of mental states.)¹

I wrote about Lyon’s article when it came out, but my hands were full with his other arguments, so I didn’t spend much time on the one about moral character. But as luck would have it, here’s a section from the recent profile of MAID provider Dr. Ellen Wiebe in the National Post:

But others like Trudo Lemmens are troubled by the small number of providers dominating the practice and the “pseudo-spiritual language” some use to describe doctor-administered death.

“When MAID was legalized, it was framed as a practice that was exceptionally required to ease the dying process or give some control at the end of life,” Lemmens, a University of Toronto professor of law and ethics, wrote in an email.

“We have veered very far from that and now uncritically accept the most aggressive provision of MAID and see growing attempts to describe this as the most meaningful form of medical practice.”

A bit further down, the article quotes Lyon about the number of deaths MAID providers are responsible for:

“Some providers have counts in the hundreds—this isn’t normal, for any occupation,” he said. “Even members of the military at war do not typically kill that frequently. I think that’s a question that we’ve not really ever asked.”

Behold, stage three. The argument isn’t that MAID is wrong (stage one) or that MAID is bad for certain groups (stage two), but that it’s unseemly for so few providers to be involved in so many MAID provisions. The providers speak positively about their experiences providing MAID—Dr. Wiebe more than anyone—but, according to Lemmens and Lyon, that’s the wrong attitude.

Let’s start with Lyon’s empirical claim that no other occupation kills people as frequently. He’s surely right that there aren’t many professions, including soldiers, who take so many lives. Although there are exceptions—the American record for most combat kills is 2,746—most soldiers likely get nowhere close to that number. Still, he’s wrong that no other profession comes close. After all, since disconnecting life-sustaining treatment is killing, and since physicians routinely disconnect life-sustaining treatment, my guess is that some physicians have killed far more people than the record number of MAID provisions, even if they aren’t involved in MAID. So, while killing isn’t normal in general, physicians were already (ethically!) killing people long before MAID became legal.

Lyon then says “I think that’s a question that we’ve not really ever asked”. It isn’t clear what question he has in mind. Perhaps he’s asking whether it’s normal to take so many lives, to which the answer is no, but, as the point about life-sustaining treatment shows, that doesn’t mean something is wrong. MAID is still new. New things can be abnormal without being problematic.

Lemmens seems to have two points in mind. The first, which isn’t from a direct quotation, is the claim that he is “troubled by the small number of providers dominating the practice”. The second is the direct quote about his concern with “growing attempts to describe [MAID] as the most meaningful form of medical practice”.

Why are there so few MAID providers? There are multiple reasons. It’s time-intensive and doesn’t pay well; some physicians and nurse practitioners have professional objections to participating, even if they support its legalization; and some have found that, even if they want to participate, they find it emotionally difficult, so they’re limited in how many they can perform.

Others, including Dr. Wiebe, do more. The problem with the argument is that it’s hard to make the case that there’s something bad about this without already believing that MAID is wrong. The profile describes how Dr. Wiebe has experienced death threats and attacks for providing abortions, which is the other part of her practice. Her colleague, Gary Romalis, was both shot and stabbed for providing abortions (he survived both attacks). While most people would stop in the face of such threats, Dr. Wiebe became even more committed. This, I posit, is an example of courage, and courage of this form is commendable. Other physicians have similarly risked their careers, freedom, and even their lives to offer abortions. Henry Morgentaler—the person the Supreme Court decision Morgentaler refers to—risked imprisonment multiple times to challenge restrictions on abortion access.

Now, if you’re opposed to abortion, you won’t agree with my assessment that Drs. Wiebe and Morgentaler are courageous. You’ll say that it isn’t normal to take so many lives, and you’ll be troubled by the small number of providers who continue to provide abortions. But that’s only because you have a stage-one opposition to abortion. Perhaps you think abortions should be, in Bill Clinton’s famous phrase, “safe, legal, and rare”, something shameful or regrettable. That message no longer resonates with most abortion proponents, including me, and it requires further argument in any case. Similarly, if you aren’t already opposed to MAID, it’s hard to see why some providers performing a lot of MAID provisions is a problem or why they should feel bad about ending suffering and helping people die on their own terms. 

Lemmens says it’s the way MAID providers talk about its meaningfulness. Again, supposing he isn’t just smuggling in a deeper opposition to MAID, what’s the issue? MAID prevents suffering and promotes patient values by allowing people to die on their own terms. Promoting well-being and autonomy are core aims of medicine, so MAID providers are right to see their work as meaningful. And, as Dr. Wiebe and many other MAID providers attest, their patients and the families of those patients similarly see their work as meaningful.

Still, while Lemmens and Lyon are wrong about the reasons, the small number of MAID providers is cause for concern. Fewer providers means worse access for patients and more stress for providers. These access limitations are overcome only because providers are working tirelessly to meet the needs of their communities, which is also virtuous. But this strains them and the system, which is bad for both patients and providers.

I’ve argued that there’s no fact of the matter regarding how many MAID deaths there should be. Instead, it depends on how many people meet the criteria and want it. Similarly, while there are things we should do to make it easier for people to become MAID providers—e.g., pay them more, fix the healthcare system so they have more time—but, you know, physicians and nurse practitioners have a lot going on. Dialectically, I find Lemmens’s and Lyon’s strategy strange, since the solution to their concern that there are too few MAID providers is to, uh, get more, which will lead to more MAID.

Lemmens and Lyon want to see less MAID, and they curiously point to the number of MAID providers as a reason for this. I want to see more MAID, which is why I support a non-medical approach that allows people to have assistance in dying without the current restrictions of the healthcare system. But this is nothing against MAID providers now. They’re doing meaningful work, and it’s a shame that people say otherwise.

 

1. Deontology, consequentialism, and virtue ethics make up the three main ethical theories, so it’s anyone’s guess where the arguments go from here.