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One year later, there’s still a lack of support for Canadians choosing assisted death

Dr. Granger Avery is the president of the Canadian Medical Association.

A year ago, following some of the most emotional debates Canada has seen in recent years, our parliamentarians passed a federal law allowing medical assistance in dying. The discussions on the rights of Canadians to choose how they die were not only high on emotion for everyone involved – including physicians – but also insightful into how our system and our policies remain ill-equipped to support Canadians when it comes to uncharted societal expectations.

A year later, those emotional discussions continue as we all adapt to this new law. Legal challenges were launched this week in Quebec and Ontario. For some, the federal law goes too far, and for others, it's not enough to serve the needs of those who suffer.

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One thing is clear: These discussions shine a bright spotlight on how our system and our policies remain ill-equipped to support the needs of Canadians who suffer.

The reality is that access to palliative care in Canada remains entirely too inconsistent. The Canadian Medical Association (CMA) has pressed for a national strategy for palliative care as part of a comprehensive seniors strategy for Canada for many years. Two years ago, the CMA released a report on palliative care in Canada that provided a clear call to action and concrete examples of palliative-care models that work well.

With the very recent passage of Bill C-277 through the House of Commons, we are cautiously optimistic that much-needed action will be coming. Studies show that where patients and their families have access to high-quality palliative care, their perception of the dying process changes significantly. Palliative care is also critical to enhancing patient autonomy and control at the end of life.

However, it is also clear that some people feel that no amount of palliative care will help them attain full autonomy and that the capacity to choose where and when they will die, with medical assistance, may be needed in certain situations. This recognition led to the passing by Canada's Parliament of federal legislation on medical aid in dying one year ago.

This federal law closely followed the recommendations that the CMA developed in consultation with its physician-members and the public. While that was a unique moment in Canadian history, the CMA anticipated that further revision would be necessary and indeed, many questions persist a year later. Some of these will be examined by a new expert panel on medical assistance in dying, chaired by Marie Deschamps, former justice of the Supreme Court of Canada and adjunct professor at McGill University and Université de Sherbrooke.

How would – or should – medical assistance in dying apply to mature minors? How do we manage advance requests? How do we deal with requests where mental illness is the sole underlying medical condition for medical assistance in dying? These questions are uncharted territory for Canada and require serious study and discussion, taking into account the clinical, legal, cultural, ethical and historical context. These issues will also be discussed in detail during the upcoming 150th CMA annual meeting in Quebec City, Aug. 20-23, a discussion that will provide a critical physician-patient perspective on the way forward.

There is also more work to be done to address serious gaps in the legislation, gaps that physicians, patients and families struggle with every day. For instance: What is the definition of "unbearable suffering" and what does that mean in terms of the timing or deferral of medical assistance in dying? Similarly, what does the current requirement that "natural death has become reasonably foreseeable" mean? These are not abstract points for theoretical discussion, but rather real life and death issues that are grappled with every day.

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Canada's doctors remain committed to engaging and leading this debate just as we remain committed to ensuring all Canadians have access to the best care that we can offer in their journey of living and dying, best exemplified, perhaps, by Hippocrates's words some 2,000 years ago: "A physician's role is to cure sometimes, treat often and comfort always."

Video: Kim's Choice: One woman’s decision to starve herself in order to die on her own terms
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