The Logic of Elimination: Canada’s MAiD Regime and the Collapse of Moral Limits
From last-resort mercy to systemic response—how assisted dying expanded beyond the dying, beyond the ill, and into the redefinition of human worth
Canada did not arrive at its present position by accident. It arrived by argument—legal, moral, and cultural—each step presented as reasonable, compassionate, and tightly controlled. What was once introduced as a narrow exception has, within less than a decade, become a system whose internal logic now presses steadily against every remaining boundary.
The decisive turning point was the judgment of Carter v Canada, in which the Supreme Court invalidated the blanket criminal prohibition on assisted suicide under specific and carefully delimited conditions.¹ The Court spoke of competent adults, grievous and irremediable suffering, and the necessity of respecting autonomy in exceptional cases. Parliament responded with Bill C-14 in 2016, embedding these criteria into law while insisting repeatedly that the measure was tightly constrained. Central to that constraint was the requirement that natural death be “reasonably foreseeable.”² That phrase was not incidental. It functioned as the moral hinge of the entire regime, tethering assisted death to the end of life.
The hinge did not hold.
With the passage of Bill C-7 in 2021, the “reasonably foreseeable death” requirement was removed, dividing MAiD into two tracks and extending eligibility to those who were not dying.³ This was not a minor amendment. It represented a structural transformation. The justification for assisted death shifted from proximity to death to the presence of suffering itself. Once that shift is made, the category of eligible persons is no longer naturally bounded. Suffering admits of gradation, interpretation, and expansion. The law, having detached itself from the imminence of death, must now continually determine which forms of suffering are sufficient.
The scale of the change is now visible in the data. Health Canada reports that 13,241 Canadians died through MAiD in 2022, representing 4.1% of all deaths, with subsequent reporting indicating a continued rise to approximately one in twenty deaths nationally by 2023.⁴ This is not the statistical profile of an exceptional practice. It is the profile of a normalised one. In less than a decade, MAiD has moved from the margins of medical care into its mainstream.
Yet the most serious questions arise not from the number of deaths, but from the conditions under which those deaths occur.
The annual reports of the Ontario Office of the Chief Coroner provide a window into the lived realities behind MAiD requests. These reports do not claim that socio-economic factors determine eligibility; the law remains formally medical. But they do record, with increasing clarity, the presence of circumstances that any humane society would ordinarily seek to remedy: isolation, inadequate housing, fear of institutionalisation, lack of access to adequate supports, and the perception of being a burden.⁵ One review noted a request arising “in the context of social isolation and perceived lack of supports”; another identified “socio-economic factors” as part of the surrounding circumstances.⁶
These are not incidental details. They go to the heart of the moral question. A system that offers death in the presence of remediable social suffering risks transforming what is presented as a choice into a constrained response to abandonment. Autonomy, in such conditions, becomes a thinner concept than the law presumes. It is formally intact, yet materially shaped by the absence of viable alternatives.
This concern has been articulated with increasing force by disability advocates. Inclusion Canada warned Parliament that the expansion of MAiD risks creating “a two-tiered system of supports,” in which persons without disabilities receive suicide prevention while persons with disabilities may be steered toward assisted death.⁷ The organisation’s submission is not rhetorical but analytical: it identifies a structural asymmetry in how vulnerability is treated across populations. The United Nations Committee on the Rights of Persons with Disabilities has echoed this concern, cautioning that Canada’s framework may expose persons with disabilities to pressure where “social determinants of health are insufficiently addressed,” thereby undermining genuine consent.⁸
At this point, the internal logic of the system becomes visible. If autonomy is the governing principle, and suffering the qualifying condition, then exclusions become increasingly difficult to defend.
This is precisely the question now being considered by the Special Joint Committee on Medical Assistance in Dying. In its review of the regime, the Committee examined whether MAiD should be extended to “mature minors”—children deemed capable of informed medical consent.⁹ While not yet law, the Committee’s report acknowledges the question as live policy, not theoretical speculation. Once the framework is defined in terms of capacity and suffering, the exclusion of minors appears less as a moral principle than as a contingent limitation.
The same dynamic is evident in the ongoing debate over mental illness as a sole underlying condition. The planned expansion—repeatedly delayed but never definitively abandoned—has exposed the difficulty of applying the concept of “irremediability” to psychiatric conditions, where prognosis is uncertain and recovery remains possible.¹⁰ The hesitation of policymakers reflects an awareness that the conceptual tools developed for terminal illness do not translate cleanly into this domain. Yet the pressure to include such cases persists, because the governing principles point in that direction.
Perhaps the most striking illustration of boundary movement emerged in the testimony of Louis Roy before the parliamentary committee. Addressing the question of neonatal cases, he stated:
“In certain cases, for example severe malformations in a newborn… it would be appropriate to consider extending medical assistance in dying to children under one year of age.”¹¹
This statement is not law. It is more revealing than law. It demonstrates that within the professional and policy discourse, the extension of euthanasia to infants—once beyond the horizon of consideration—has entered the field of serious argument. The significance lies not in immediate adoption but in the shifting of what is thinkable.
Comparative experience confirms that such shifts are not isolated. In Belgium, euthanasia—initially restricted to adults—was extended in 2014 to minors of any age under strict conditions, including parental consent and medical certification.¹² In Netherlands, paediatric euthanasia has likewise expanded, with policy developments extending consideration to increasingly younger cohorts.¹³ These developments were not present at the inception of those regimes. They emerged over time, through incremental adjustments justified by the same principles now operative in Canada.
Within Canada, there are signs of resistance. Under Premier Danielle Smith, Alberta has sought to introduce additional safeguards, particularly in relation to minors and mental illness, reflecting concern that the federal framework is outpacing both clinical certainty and public consensus.¹⁴ These measures do not reverse the trajectory, but they indicate a growing recognition that the trajectory exists.
At the centre of the debate lies a deeper philosophical transformation that policy language often obscures. Classical medical ethics, rooted in the Hippocratic tradition, drew a clear boundary: the physician does not intentionally end life. Modern bioethics, prioritising autonomy, has redrawn that boundary in defined cases. The redefinition appears limited in scope. It is not limited in implication. Once dignity is understood primarily as the capacity for autonomous choice, conditions that impair independence—disability, dependence, suffering—can come to be interpreted as diminishing that dignity. The conclusion follows, not by coercion but by inference: where dignity is diminished, the option of death may be regarded as proportionate.
This is the conceptual pivot on which expansion turns.
A society does not need to compel death in order to normalise it. It need only construct a framework in which death becomes a reasonable response to conditions that remain otherwise unaddressed. The danger is not that every decision is wrong. It is that the system gradually reclassifies which lives are considered reasonably livable.
The Canadian MAiD regime now stands at a point where its founding rationale and its present operation are in visible tension. It continues to be defended as an exceptional response to extreme cases, even as its scope, application, and underlying logic extend beyond those limits. The language of safeguards remains; the boundaries they were intended to secure have shifted.
The question that remains is not procedural but foundational.
Is assisted death to be understood as a last resort for those who are dying, or as a general response to suffering wherever it is found? The framework cannot sustain both interpretations indefinitely. To choose the latter is to accept that the limits of the system will be determined not by fixed principles, but by the evolving definition of suffering itself.
Canada has not yet reached the end of this development. But the direction is now clear, and the underlying logic is increasingly difficult to deny.
The issue is no longer whether MAiD exists, nor even how widely it is used. It is whether a society that defines care, in certain cases, as the provision of death can maintain a stable account of why some lives must be protected while others may be ended.
That question, once raised, does not easily admit of a final answer.
¹ Carter v. Canada (Attorney General), 2015 SCC 5.
² Government of Canada, Bill C-14: An Act to Amend the Criminal Code (Medical Assistance in Dying), S.C. 2016, c. 3.
³ Government of Canada, Bill C-7: An Act to Amend the Criminal Code (Medical Assistance in Dying), S.C. 2021, c. 2.
⁴ Health Canada, Fourth Annual Report on Medical Assistance in Dying in Canada 2023 (Ottawa: Health Canada, 2024), 10–12.
⁵ Ontario Office of the Chief Coroner, Medical Assistance in Dying Death Review Committee Annual Report 2024 (Toronto: Ministry of the Solicitor General, 2025), 18–22.
⁶ Ibid.
⁷ Inclusion Canada, “Submission to the Special Joint Committee on Medical Assistance in Dying,” 2023.
⁸ United Nations Committee on the Rights of Persons with Disabilities, Concluding Observations on Canada, 2025.
⁹ Special Joint Committee on Medical Assistance in Dying, Medical Assistance in Dying in Canada: Choices for Canadians (Ottawa: Parliament of Canada, 2023).
¹⁰ Government of Canada, “Medical Assistance in Dying and Mental Illness,” Department of Justice backgrounder, 2024.
¹¹ Louis Roy, testimony before the Special Joint Committee on Medical Assistance in Dying, Parliament of Canada, January 2023.
¹² Government of Belgium, Act on Euthanasia (2002; amended 2014).
¹³ Government of the Netherlands, Termination of Life on Request and Assisted Suicide (Review Procedures) Act (2002; subsequent paediatric policy developments).
¹⁴ Government of Alberta, “Protecting Vulnerable Albertans Seeking Medical Assistance in Dying,” policy statement, 2026.
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