Sandra Demontigny watched early-onset Alzheimer’s transform her athletic father from a robust patriarch into a battered shell of a man. Once the disease took hold, his untethered energy compelled him to walk into walls and crawl aimlessly along floors. He died aged 53, his face streaked with tears of frustration. When Ms Demontigny was diagnosed with the same, fatal neurodegenerative disease at 39, she vowed that she would not endure her father’s undignified death. Now she can take comfort in knowing she will not.
A new law adopted in the province of Quebec on October 31st allows Ms Demontigny to request what Canadians call medical assistance in dying (MAID) long in advance of her deterioration. It represents a significant expansion of Canada’s federal laws on assisted dying, which require patients to provide consent immediately before they receive a set of lethal injections. In Quebec, patients with an illness that will eventually render them incapable of granting that consent can now make arrangements for MAID months or even years in the future, long before their condition deteriorates. Ms Demontigny, a radiant 45-year-old, says she is immensely relieved that her death will come at a point of her choosing, and feels that it will be more dignified for that.
Slightly over 1,000 Canadians opted for a doctor-assisted death in 2016, the first year in which it was permitted. By 2023 that number had risen to 15,343, 4.7% of the 326,571 deaths in Canada that year. No country that permits assisted dying has seen faster growth in the practice. (The Netherlands has allowed assisted dying for more than two decades, and it accounts for a higher share of deaths there than in any other country, 5.4% as of 2023.)
A popular practice
Nowhere in Canada has adopted MAID faster than the French-speaking province of Quebec. The share of deaths in the province that were doctor-assisted reached 7.2% in 2023. Michel Bureau, who heads a commission on end-of-life care that reports to the provincial legislature, says there is little doubt that the province carries out the highest number of doctor-assisted deaths in the world relative to its population. He says that Quebeckers now see MAID as a fundamental part of their medical system. Surveys suggest that three-quarters of Canadians support MAID. In Quebec that number is 86%. Dr Bureau says the number of people in Quebec choosing MAID will keep rising, now that consent may be given in advance.
That pleases Georges L’Espérance, a retired neurosurgeon who runs the Quebec Association for the Right to Die with Dignity. He says he has helped hundreds of people end their lives, and has noticed a rise in requests for his services since the law was changed in October. His relationships with patients seeking MAID tend to be very different from those shared with patients awaiting brain surgery. He usually met people going under the knife for a single consultation before surgery. Applying for MAID is a multi-step process that requires repeated meetings with patients and can run over several years.
Dr L’Espérance says MAID patients know there is no hope their lives can be improved, but that “people are smiling 15 minutes before they know they are going to die. They talk, share a glass of wine, and tell their family members how much they are loved.” He stays with family members for at least an hour after patients die. He answers all their questions. Often they embrace him. “I never had that experience as a surgeon,” he says.
Opponents of MAID’s expansion in Canada say that too few of the doctors recommend traditional palliative care as an alternative. Dr L’Espérance and others point to statistics suggesting that 78% of those who opt for MAID have tried palliative care first. Opponents also worry that some patients choose MAID because Canada’s strained, publicly funded health-care system has failed them.
A report published in October by the coroner from Canada’s most populous province, Ontario, stated that 116 people who were given MAID in 2023 (2.5% of the 4,644 in total) were struggling with disabilities, but not dying. One man in his late 40s who suffered from severe ulcers, multiple mental illnesses and chronic suicidal thoughts ended his life with the help of a doctor. The report found that people who opted for MAID tended disproportionately to have lived in areas with poor access to housing and labour markets, though it notes that this could simply be because old and disabled people tend to live in those areas. The coroner also found that people opting for MAID lived disproportionately in white neighbourhoods.
Live and let die
The federal government has deferred until 2027 a decision on allowing mentally ill patients to apply for MAID. But although it could have challenged Quebec’s expansion of the practice, it has chosen not to. Canada’s health minister, Mark Holland, cited the torment his grandmother endured in her final years with Alzheimer’s in his decision to allow Quebec to go ahead.
Ms Demontigny has been speaking to her husband and their three children about the kind of life she wants to live before she dies. Those conversations have been a gift to a woman who feared an agonising death: “I am so relieved. I’m a naturally joyful person. I can find beauty in what others might find ugly.” ■