Perspectives in Medical Assistance in Dying (MAiD) amongst Indigenous Women, Two-Spirit, Transgender, and Gender-Diverse People in Canada: An Exploratory Study
Press Release
Within the context of Indigenous communities in Canada, Medical Assistance in Dying (MAiD) raises unique and critical questions. In 2016, Canada introduced MAiD as a legally authorized medical procedure that offers a peaceful and painless end to the lives of consenting adults who are facing grievous and irremediable medical conditions (Provincial Health Services Authority [PHSA], 2023). Eligibility for MAiD requires individuals to be at least 18 years of age, have access to publicly funded health care services in Canada, and provide voluntary, informed consent (Vancouver Coastal Health [VCH], 2023). Individuals seeking MAiD must be experiencing unbearable physical or mental suffering, however, their medical condition does not need to be terminal (VCH, 2023). The process involves a request form, two assessments, and placement into Track 1 (for foreseeable natural death) or Track 2 (for cases without this prognosis). Both tracks incorporate specific procedural safeguards, including witness presence, assessment periods, and expert consultations, ensuring an ethical and meticulous process (VCH, 2023; Health Law Institute, n.d.).
Amendments under Bill C-7, termed the “Medical Assistance in Dying (MAiD) Act,” have significantly changed the MAiD process. These changes include the implementation of advance requests, expanded eligibility criteria, a two-track system, and enhanced safeguards (University of Toronto, 2021; Government of Canada [GoC], 2021b; GoC, 2023; GoC, 2024; Centre for Effective Practice, 2021). In 2023, 15,343 people in Canada received MAiD, accounting for 4.7% of all Canadian deaths with 5.96% of applications denied due to ineligibility (GoC, 2024). Some critics have raised concerns about the ease of access following the amendments. The potential negative impact on marginalized populations and apprehension towards allowing MAiD for individuals not facing terminal illnesses remain key issues (Honderich, 2023).
In response to these concerns, there is a growing conversation about the potential for coercion and the risk of devaluing lives in certain circumstances. The utilization of MAiD has been exponentially increasing since its introduction, which raises ethical questions about its compatibility with the healthcare system’s commitment to promoting well-being (Cardus, 2023). While some advocate for an autonomy-centered approach to healthcare, others argue for a stance that challenges ableist assumptions and emphasizes the importance of increased health support, such as palliative care (Baril, 2022).
It is essential to acknowledge the multifaceted layers that impact attitudes toward end-of-life care, such as disparities in knowledge, socioeconomic status, and structural barriers within Canada’s healthcare system (Berube et al., 2022) . This includes observed imbalances among different socioeconomic, age, language, and family groups. For example, lower education levels and financial hardships are linked to lesser knowledge about end-of-life practices, raising concerns about potential inequities in accessing MAiD (Berube et al., 2022; Tran et al., 2022). Additionally, structural barriers, including systemic
racism within Canada’s healthcare system, pose significant obstacles to accessing MAiD, which particularly impacts Indigenous Peoples and those facing increased barriers to accessing end-of-life options (GoC, 2021a, 2022).
Addressing these challenges involves recognizing the diverse perspectives among Indigenous communities regarding MAiD and seeking guidance from Elders and spiritual leaders to ensure culturally sensitive practices (GoC, 2021a) . The unique views of death within Indigenous communities underscore the need for a nuanced approach. Some individuals perceive medically assisted deaths as ceremony and view MAiD as
a community-involved event, while others experience discomfort with MAiD due to historical, intergenerational, and contemporary trauma (Special Joint Committee on Medical Assistance in Dying [SJCoMAiD], 2023).
In existing literature, views and perspectives of MAiD within Indigenous communities have varied. Some Indigenous leaders and communities have expressed concerns that MAiD might be more accessible than obtaining essential resources that are crucial for quality of life (GoC, 2022). Similar worries have been echoed by Indigenous Elders and parliamentarians, who emphasized the importance of discouraging suicide and cautioned against broadening eligibility for assisted dying, as it may inadvertently send problematic messages (Brydon, 2016). Given the elevated rates of suicide among Indigenous youth, MAiD availability also raises concerns about the potential for misinformation. When the Government of Canada conducted roundtable MAiD engagement sessions in 2020, Indigenous individuals stressed the need for more health care services, including medical, mental health, and cultural safety training for health care providers (GoC, 2021a). This notion is particularly significant in remote communities where there are increased obstacles to palliative and end-of-life care provision. These include a lack of nursing staff, medical personnel, and psychologists, high turnover rates, insufficient programs and training opportunities, and decreased access to necessary narcotic medications (Hotson et al., 2004).
These initial perspectives highlight a complex interplay between culture, historical experiences, and contemporary challenges. MAiD availability further highlights the lack of comprehensive health care services, training, and resources in many communities. It is critical to engage Indigenous Peoples to address these intricate concerns while also addressing the need for culturally safe and enhanced health care provisions (SJCoMAiD, 2023).
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