Assisted Dying and Poverty

The quest for a policy solution

Photo by Everett Bartels

Many people are concerned about the connection between medical assistance in dying and poverty. One worry is that people will choose MAID not because of their medical condition, but at least in part because of social factors, such as lack of housing, that don’t affect higher-income people. A related worry is that people can’t choose freely when such structural factors play a role, so they’re unable to give valid informed consent.

Any story connecting MAID and poverty does well in today’s media landscape, but despite that, there just haven’t been that many of them. As I’ve written before, one of the most commonly cited ones, involving an Ontario woman pseudonymously known as Sophia, doesn’t seem to have been about poverty. Other cases that got a lot of media attention involved people who applied for MAID, citing poverty as a factor, but were denied. But this isn’t to say that poverty can’t play a role. Access to resources, including housing and healthcare, will influence some people, meaning their decision won’t be purely about their medical condition, and there are documented cases of this.

I’ve written a bunch of posts arguing that banning MAID because of housing and long wait times would be a mistake (here, here, and here). In this post, I want to take a different approach. For the sake of argument, suppose that, contrary to the evidence, poverty is a major factor driving MAID requests. In real life, my argument is that housing costs are about housing, so we should build more houses, give more income support to low-income people, and implement policies to decrease healthcare wait times. But suppose that the opponents of MAID are right and we should change MAID policies so that poverty doesn’t play a role. How should we do this?

Despite the large number of “we must do something about MAID and poverty” takes, the people making this point are usually thin on details. Consider a recent Globe article by Blake Murdoch, a research associate at the Health Law Institute at University of Alberta. Murdoch’s article, “Canada’s Broken Social Safety Net Pushes People Toward Assisted Dying,” makes the familiar point that, as he puts it, “People who can’t afford to live or can’t get the care they deserve are now being structurally pressured into assisted dying.”

Murdoch offers this suggestion:

So, how can we address the issue? A key criticism of MAID is the vagueness of the eligibility criteria. For example, the requirement to be enduring intolerable suffering is a contradiction in terms, because suffering must technically be tolerable in order to be endured. This nonsensical criterion opens the door to completely subjective clinical and legal judgments. And when the criteria for MAID are fundamentally subjective, socioeconomic pressures can become powerful forces in life-or-death decision-making.

First, about those eligibility criteria. Words matter, so I must point out that Murdoch is making a basic mistake when he says “the requirement to be enduring intolerable suffering…”. As I’ve written—remember this one?—the criminal code lists three criteria one must meet to meet the grievous and irremediable medical condition criterion. The last is: 

(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

‘Enduring’ here is an adjective meaning ‘lasting’. The law is not using ‘enduring’ as a verb, as in ‘to be enduring’, which is how Murdoch uses it.

But even if Murdoch got the law right, it’s unclear how we go from subjective criteria to “socioeconomic pressures can become powerful forces in life-or-death decision-making.” Or, to put it another way, we need to know which objective criteria will fix the problem. This is the part that Murdoch and others leave out. Just as there are some unstated premises that get us from “the housing crisis is bad” to “banning MAID is the answer”, MAID opponents need to do a better job of showing their work. They don’t, and I think I know why.

It’s worth noting that, while I’m using the term ‘MAID opponents’, most of them don’t argue explicitly that MAID should be banned wholesale. Instead, they argue that it needs more restrictions. I take them at their word about this, so let’s consider some options. 

Reasonably Foreseeable Death

The most common story we hear about MAID going astray concerns Truchon, the Superior Court of Québec decision that struck down the requirement that a person’s death be reasonably foreseeable to receive MAID. (I’ve written about Truchon here and here.) This decision brought the law more in line with Carter, the Supreme Court of Canada decision that first struck down the general prohibition on assisted dying. Since Truchon, it’s now possible to qualify even if you might not die soon, though you still have to meet all the other criteria. 

Opponents argue that Truchon went too far, since it enables the kinds of cases that have made the news: people who are experiencing intolerable suffering due to their medical condition and who have other life factors, such as poverty, that play a role in their decision. So perhaps we ought to turn back the clock and require reasonably foreseeable death once again.

What impact would reintroducing the ‘reasonably foreseeable natural death’ condition have? The most recent data we have is from 2022, when 3.5 percent of MAID deaths were track two, meaning natural death wasn’t reasonably foreseeable. Of these 462 people, the average age was 73.1, and 50 percent of them had a neurological condition such as multiple sclerosis.

We don’t have income data for those 462 people, so we can’t know how many were experiencing poverty. And, even if we had those data, we wouldn’t know whether poverty played a role in their decision. On average, MAID is more common among high-income people, so it’s likely that most of those 462 people weren’t poor. So, requiring a reasonably foreseeable natural death would make only a small difference. If we generously assume that a quarter of those deaths were of people experiencing poverty, that’s 115 people. By comparison, in 2022, there were 189 deaths of people experiencing homelessness just in Toronto. The City of Toronto says that, due to data collection limitations, this undercounts the number. Therefore, since banning MAID does nothing to help these people, we should focus on something that does.

Additionally, reimplementing the reasonably foreseeable natural death condition won’t stop people experiencing poverty from accessing MAID. It’s still possible that someone could include their economic status as a factor in their MAID decision while also being likely to die soon. So, not only is this approach ineffective, it doesn’t solve the problem MAID opponents are trying to solve. It does this all while condemning people with MS and other serious conditions to years of suffering.

The Case for Consistency

Murdoch says that people living in poverty are being “structurally pressured” into MAID. The argument, which isn’t new—Sara Jama calls it “systemic coercion”—is that poverty prevents voluntary choice, so people in poverty aren’t choosing freely if poverty plays a role in their decision, so we shouldn’t let them make that decision. Notice that this isn’t about MAID per se. Poverty will obviously impact lots of decisions, and if it makes MAID involuntary, it should make other decisions involuntary as well. I addressed this is in a post last year, so allow me to quote myself at length:

If we should ban MAID when finances play a role—perhaps because we worry that it isn’t actually a free choice—then we should ban other healthcare decisions when finances play a role. So we might ask how often money plays a role in abortion decisions. In a U.K. survey last year, 60.5 percent of respondents who had an abortion in the last five years said that the high cost of childcare was a reason for their decision. Almost 20 percent said it was the main reason. For women of colour, over seventy percent said money was a factor.

If they’re coerced by circumstance, then we should ban abortion. But we shouldn’t ban abortion, because, even when people are put in bad situations, they can still make informed decisions in line with their values. Abortion decisions are still autonomous, so MAiD decisions are too. The alternative in both cases is worse.

MAID opponents can’t have it both ways.

A Reductio

The problem is as follows. Some restrictions, such as reimplementing reasonable foreseeability, won’t solve the problem and will be overbroad: i.e., preventing high-income people from accessing MAID even if they have a grievous and irremediable medical condition. Other restrictions, such as arguments about voluntariness, encounter consistency problems.

There’s another choice. The most effective option—the one that will best accomplish the goal—is to ban MAID for poor people. It would be pretty simple: set a point, such as the poverty line, and prevent anyone from accessing MAID if they don’t make enough money. If MAID is bad for poor people, and if being sufficiently low-income means they can’t make their own decisions, then this is the best option. After all, it directly targets the issue. All other solutions will either be ineffective, too narrow, or too broad. It also has the benefit of being objective, so it avoids Murdoch’s complaint that current MAID criteria are “fundamentally subjective”. (You can run this same argument, mutatis mutandis, for disability.)

But, like, this is a bad idea. I mean really bad. We all see that this is bad, right? Access to MAID or any type of healthcare shouldn’t be predicated on income. It’s discriminatory and disempowering. And given that people who get MAID are primarily high-income, we should already be worried that it skews too much to the wealthy. 

So, why have MAID opponents been so reluctant to make concrete proposals? Why is it all bad legal takes and claims about structural problems? I suspect that some of them see the bind they’re in. The only way to fully address their concerns about poverty means using income as a criterion, which is a reductio of the view they hold. There are other options, but they all miss the mark or are indefensible for other reasons.   

The actual best option is clear: fix housing, improve income support, and decrease healthcare wait times. MAID isn’t the problem here.

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Quick Hits

• Katie Engelhart won a Pulitzer! Read the story! Buy her book!

• I’m looking forward to reading Carl Elliott’s new book. Here’s an excerpt.

• Paying Off People’s Medical Debt Has Little Impact on Their Lives, Study Finds

• I enjoyed Scott Alexander and Robin Hanson’s multi-part debate on the effectiveness of medicine.

• Greenpeace proving once again that it’s a force for bad in the world.

• An older piece on “The Great Cat and Dog Massacre” during the Second World War. (h/t to The Browser, which I recommend.)

  • One part: “A British soldier fighting at Dunkirk remembered seeing “horses and carts blown sky high, it was terrible. I remembering seeing people mutilated, blown to pieces.” But while the people were beyond help, “[w]e could do something about the animals. We saw a horse that had its guts blown open, and we could shoot it. But there was nothing we could do about the human beings. We couldn’t stop and give first aid.” Unlike humans, suffering animals can be taken care of “humanely”: one group of creatures could be put out of their misery, the other could not.”