What we Heard: National Conversation on advance requests for medical assistance in dying.

https://www.canada.ca/en/health-canada/programs/consultation-advance-requests-medical-assistance-dying/what-we-heard.html

Health Canada Report published 29.10.2025

Consultation took place between November 2024 and February 2025, on-line public questionnaire, public opinion research and virtual roundtables.

We are doing two things at once here, summarizing the content of the report and evaluating

Co-pilot generated summaries, human emphasis added.

Purpose: Summarize Canadians’ views on allowing advance requests for MAID (currently prohibited federally).

Methods: – Online questionnaire (46,000+ responses) –

Public opinion survey (1,000 participants) –

Virtual roundtables (200 participants)

Key Findings:

– Strong Support: Majority favor advance requests for incurable conditions leading to incapacity (69% questionnaire; 67% survey).

– Motivations: Autonomy, dignity, avoiding prolonged suffering

– Concerns:

Safeguards, informed consent validity, risk to vulnerable populations.

– Opposition: 17–26% cite ethical risks of binding future selves and uncertainty about disease progression.

– Values: Individual choice (76%), dignity (73%).

 Implications:

– Canadians want autonomy but expect robust safeguards and system readiness.

– Ethical complexity requires clear frameworks and professional guidance.

If you ask co-pilot to provide an ethical analysis you get the following:

(Human commentary added in red)

Briefing Note: Ethical Concerns on Advance Requests for MAID

Subject: Ethical Dimensions of Advance Requests for MAID

Background:

Advance requests challenge the current requirement for contemporaneous consent under the Criminal Code. Quebec’s model signals growing interest, but federal law remains restrictive.

Ethical Issues Identified:

1. Autonomy vs. Vulnerability – Respecting prior wishes vs. protecting individuals who may change their mind or be influenced by others. – Risk of coercion or undue pressure from family or societal expectations.

I wouldn’t put this point quite like this.  The report clearly identifies that the motivation for wanting MAiD for advance requests is a desire to expand individual choice and to provide another tool for advance care planning.  This is autonomy all the way.  The basic concept of autonomy entails that I am entitled to make my own choices.  In effect, autonomy assumes that we can/have answered the questions concerning vulnerability – e.g. to external pressure, or to circumstances.  The AI generated response confuses this issue by talking in temporal terms about “prior wishes” and “changing one’s mind.”  This is an important point, but better dealt with below in 2.

2. Validity of Prior Consent – Ethical tension: Does consent given years earlier remain morally binding? – Disease progression and personal values may evolve, making prior decisions ethically questionable.

There are two really important issues engaged here.  We often talk about the first as a puzzle about continuity of the person.  What gives me the right now to say what happens to me then?  Roughly, it is that I am the same person then as I am now.  But what if the disease fundamentally changes who I am?  If I no longer recognize those who have meant the most to me, or now value different things from the whole of my previous life am I the “same person?”  What does it mean to say my values may evolve? If I “change my mind” I must be able to hold in my mind two (or more) separate possibilities, “weigh” or otherwise evaluate them and choose one over the other(s).  This may require a high degree of cognitive functioning – exactly what my future self may lack.

3. Beneficence and Non-Maleficence – Ensuring decisions minimize harm and maximize well-being amid uncertainty about future suffering.

This is included as a tick box requirement given the pervasiveness of the so-called four principles of bioethics (Beauchamp and Childress originally.)  If “autonomy” is the principal principle (if the “entitlement” exists) then maximizing benefits/minimizing harms is beside the point.  What matters is what I want.

4. Justice and Equity – Access disparities: marginalized groups may lack resources to make informed advance requests. – Risk of systemic bias in interpreting requests.
5. Professional Integrity and Moral Distress – Clinicians may face ethical conflict between honoring autonomy and perceived patient best interests. – Need for clear guidelines and conscience protections.

This is a big deal.  What if the person seeking MAiD seems OK?  Seems happy with the way they live their life.  What if, in my advance request for MAiD, I say now that my greatest future suffering would be, is not having the sense of self I have now, not knowing what I don’t know and have lost?  The Quebec approach is to have the clinician providing MAiD evaluate the patient’s suffering at the time:

• in a medical state that gives a competent professional cause to believe, based on information at their disposal and their clinical judgment, they are experiencing enduring and unbearable physical or psychological suffering that cannot be relieved under conditions considered tolerable

This is a significant departure from current practice where the patients themselves evaluate their own suffering.  This potentially externalizes that judgment.  It remains to be seen how this plays out in practice in Quebec.

Policy Considerations:

– Robust safeguards (periodic reaffirmation, capacity assessments).

– Transparent processes for revocation and interpretation of requests.

– Education for patients, families, and providers on ethical implications.

Rob’s evaluation.  The AI generated text provides a launching point – a sort of checklist of the issues, but it does not do too much in unpacking or evaluating the competing values and principles.

Rob Butcher:  rbutcher@healthethics.ca