Public-opinion polling in recent years has shown a growing general consensus among Canadians in support of MAiD (Medical Assistance in Dying), or doctor-assisted suicide. A January 2020 Angus Reid Institute poll 1 1 “Social Values in Canada: Consensus on Assisted Dying & LGBTQ2 Rights, Division over Abortion Rights, Diversity,” Angus Reid Institute, January 24, 2020, http://angusreid.org/social-values-canada/. found four in five (80%) Canadians indicating it should be easier to make their own end-of-life decisions, compared to nearly three-quarters (73%) in 2016.

However, new polling conducted by the Angus Reid Group for think tank Cardus indicates that this support is not as unequivocal as it appears at first glance. While 77% indicate that access to MAiD is a basic human right, a closer look shows that Canadian opinion can be categorized by at least three distinct groupings.

Perspectives on MAiD are polarized, with a group of 33 percent being “Enthusiastic Supporters” of MAiD on the one side, while a smaller group of 19 percent of Canadians on the other side is “Opposed” to MAiD. The largest group, however, is the 48 percent of “Cautious Supporters,” who indicate support for the concept and legal rights of Canadians to access MAiD but express serious concerns about how MAiD might harm aging and vulnerable Canadians as well as the Canadian health-care system.

Almost half of Canadians have very decided views on MAiD, with 33 percent “Enthusiastic Supporters” in favour and 19 percent “Opposed,” demonstrating consistent and relatively intractable views on most of the questions polled.

Forty-eight percent of Canadians who “cautiously support” MAiD have important reservations and give considerable weight to concerns about the impact of MAiD on society. Many of their views reflect those of a large and broad segment of all Canadians:

• 69 percent of all Canadians say policy-makers should give considerable weight to the concern that expanding MAiD may lead to people with mental-health issues like depression choosing death rather than dealing with the underlying causes of their condition.
• 68 percent of those polled say leaders should pay attention to important concerns raised by a UN report critical of the lack of safeguards 2 2 Catalina Devandas-Aguilar, “End of Mission Statement by the United Nations Special Rapporteur on the Rights of Persons with Disabilities,” United Nations Human Rights Office of the Commissioner, April 12, 2019, https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=24481&LangID=E.  in Canada to protect people with disabilities and to ensure access to alternatives to MAiD.
• 65 percent want policy-makers, the courts, and politicians to give significant weight to the concern that MAiD could increase pressure on people with disabilities or the elderly to choose death to avoid being a burden on others.
• 62 percent of Canadians want policy-makers, the courts, and their leaders to give significant weight to concern that the health-care system will  begin to ignore long-term care and chronic disease in the elderly as MAiD becomes more available and routine.

Attitudes in Quebec vary significantly from the rest of Canada given that 50 percent in the province are enthusiastic supporters of expanding MAiD and only 9 percent are opposed. Generally Quebecers respond 10 to 15 percentage points more in favour of MAiD and are less bothered by the concerns that are evident in the rest of the country.

Visible minorities and those born outside of Canada tend to be more negative toward MAiD, expressing greater concern about its consequences for society and the health-care system.

End-of-life issues are complex and involve personal moral and spiritual perspectives as well as legal, social, and medical considerations. The context for this survey is the introduction of Bill C-7, federal legislation that would expand access to doctor-assisted suicide, or what is commonly referred to as Medical Assistance in Dying (MAiD). In response to a Supreme Court of Canada decision in 2015, commonly referred to as “the Carter decision,”   3 3 Carter v. Canada, [2015] 1 SCR 331, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do. legislation was passed, and came into effect in June 2016, that sought “to respect personal autonomy for those seeking access to MAiD, while at the same time protecting vulnerable people and the equality rights of all Canadians.” 4 4 Carter v. Canada.

Canadians give weight to several concerns when asked for their views about expanding MAiD. In fact, 65 percent of Canadians give “a great deal” or “a lot” of weight to the concern that the elderly and those with disabilities will feel more pressure to choose death in order to avoid being a burden on others.

This is a higher-priority consideration in Quebec (where MAiD has been in effect longer than elsewhere in Canada), at 76 percent, and lower in Ontario, at 59 percent. It is especially high among women in Quebec (83%).

Nearly seven out of ten (68 percent) believe significant weight should be given to concerns raised by a UN report last year that was critical of Canada’s safeguards for people with disabilities, including the implementation of measures to ensure that they are provided alternatives to assisted dying.

At the same time, 69 percent of Canadians expressed that policy-makers should give considerable weight to the possibility that people with mental-health issues like depression will choose death, rather than dealing with the underlying causes of their condition. Furthermore, 56 percent of Enthusiastic Supporters felt that these concerns should be given “a great deal” or “a lot” of weight, as did 73 percent of “Cautious Supporters” and 81 percent of those opposed to MAiD.

Seventy percent of Canadians give considerable weight to the consideration that broadened access to MAiD will result in much less suffering in society. In Quebec, this number is 83 percent; in the rest of Canada, it is 65 percent. Ninety-one percent of Enthusiastic Supporters felt this way compared with only 21 percent of those opposed to MAiD.

These concerns and caveats in Canadians’ support for MAiD extend beyond worry about MAiD’s impact on others to its effect on the health-care system and the quality of end-of-life care available to all Canadians.

More than six in ten Canadians (62%) attach a lot of importance to the possibility that the public health-care system will begin to ignore long-term care and chronic disease in elderly people as MAiD becomes more available. This ranges from a high of 64 percent in Alberta to a low of 50 percent in Manitoba. Women (65%) are more likely to share this concern than men (59%), Those born outside of Canada (71%) and visible minorities (70%) also give more weight to these concerns.

The Parliamentary Budget Officer has reported that the expansion of MAiD in Bill C-7 is expected to have a net reduction in health-care costs in the range of $150 million per year. 5 5 “Cost Estimate for Bill C-7 ‘Medical Assistance in Dying,’” Office of the Parliamentary Budget Officer, October 20, 2020, https://www.pbo-dpb.gc.ca/web/default/files/Documents/Reports/RP-2021-025-M/RP-2021-025-M_en.pdf.  In response to the question of what sort of weight this should be given, 43 percent of respondents indicated “a great deal” or “considerable,” while most Canadians (57%) would attach little or no weight to possible financial savings.

Nevertheless, when polled, one-quarter (26%) of Canadians say that if their own family doctor recommended MAiD to a very sick loved one it could erode their trust in their doctor’s commitment to other care alternatives. In fact, 54 percent of Canadians give “quite a lot” or a “great deal” of weight to the concern that the confidence of patients in doctors could be compromised, given that patients look to doctors “to heal, comfort, and fight for them.” Sixty-three percent of visible minorities share this concern.

Forty percent of Canadians are concerned that providing MAiD could conflict with a doctor’s duty of care and the Hippocratic Oath.

Seventy percent of Canadians say that policy-makers should give quite a lot or a great deal of consideration to whether more investments and wider access to MAiD will mean less investment by the government in traditional palliative care for the dying. Meanwhile, 57 percent of Canadians are at least somewhat concerned that the expansion of MAiD will result in a loss of knowledge in the medical profession about providing traditional end-of-life care for extremely ill patients. Likewise, 59 percent are concerned that expanded MAiD may result in doctors losing interest in providing traditional care for extremely sick patients. And 60 percent are at least somewhat concerned that medical schools will give priority to training doctors for MAiD at the expense of training in traditional palliative care. Those born outside of Canada are twice as likely to be “very concerned” as those born in Canada.

The federal government found that 70 percent of Canadians who want to receive traditional palliative care to die naturally at home are not able to get it. Nevertheless, when polled, one-quarter (24%) of Canadians (without knowing it was a government statistic) indicated that they found this estimate too high, and another one-in-ten opted for “way too high”.

Sixty-eight percent of Canadians indicate that they would prioritize expanding resources to meet more of the demand for traditional palliative care services, whereas 32 percent (the majority of whom are Enthusiastic Supporters) would prioritize expanding MAiD as an option for more Canadians to consider.

The question of conscience protection for MAiD affects not only individuals but also health facilities that have been started by religious, ethnic, or community organizations that have conscientious objections to MAiD. Often such facilities have been founded by Christian, Jewish, Muslim, or Sikh organizations that provide significant amounts of capital to build and operate such structures, even though they may be partially publicly funded.

Fifty-five percent of Canadians reported that religious hospitals should be free to refuse to participate in MAiD on moral grounds, moving patients who want an assisted suicide to another facility. Of the 45 percent who say that religious hospitals should be forced to provide MAiD, 68 percent are in the enthusiastic-supporter category and 63 percent say hospitals should be required to provide MAiD, even if that results in a significant loss of beds in the system. As a proportion of all Canadians, that works out to 28 percent taking this hard line.

On a similar question regarding religious nursing homes and hospices, 57 percent agree that “nursing homes or hospices with moral objections should be able to say no and patients requesting assisted dying would be moved to other locations” compared with 43 percent who indicated that such facilities should be required by law to allow MAiD in their facilities.

One-third of Canadians (33%)“enthusiastically support” making MAiD available to Canadians and expanding access. This group believes expanding access to MAiD will result in much less suffering in society. When asked about their own deaths, more than half (56 percent) of this group report that they would choose MAiD for themselves. When asked about the frequency and desirability of MAiD, Enthusiastic Supporters are more likely to overestimate the number of Canadians whom they expect will choose MAiD at the end of life, compared with other respondents. They believe doctors who administer MAiD are acting in accord with a physician’s duty to care. Members of this group are the most likely to insist that health facilities lose their funding if they do not provide MAiD, even if that would result in a loss of hospital beds available for end-of-life care.

Enthusiastic Supporters are more likely to reside in Quebec (making up a full 50% of the Quebec sample). Twenty-seven percent of those residing in the rest of Canada, however, identify as Enthusiastic Supporters of making MAiD more available. Members of this group nationwide are more likely to identify as non-religious or spiritually uncertain than those opposed to MAiD. Enthusiastic Supporters are less likely to be immigrants to Canada or visible minorities.

Just under half (48%) of Canadians are cautious supporters. They generally believe MAiD should be an option at the end of life and that the choice is a personal decision a patient should be able to make with his or her doctor. However, when asked about the details and implications of MAiD in practice, and how much weight should be given to concerns about it, this group expresses multiple concerns. They support MAiD with certain caveats and believe significant attention should be given to particular concerns, including the impact of MAiD on the vulnerable, the elderly, and those with disabilities, as well as the quality of end-of-life care provided by doctors and the health-care system as the practice becomes more routine.

Nineteen percent of Canadians are generally or strongly opposed to MAiD and doctor-assisted suicide. This is the group of Canadians most likely to choose palliative care if available or to prefer a natural death at the end of life. More than other Canadians, they believe that administering MAiD or doctor-assisted suicide goes completely against a physician’s duty to care. They report having serious concerns about the impact of MAiD on the vulnerable, the elderly, those with disabilities, and on end-of-life care in the health-care system. Those Canadians who make up the opposed group are the most likely to express concern that MAiD “may end up going further than it really should.”

The number of those who identify as opposed is significantly higher In Alberta, at 32 percent, compared with the national average of 19 percent, and only 9 percent in Quebec. The opposed are more likely to be religiously committed or to say that they are privately faithful. The opposed are also more likely to be visible minorities or immigrants to Canada.

There is a striking contrast between respondents in Quebec and other provinces regarding attitudes toward MAiD. As noted above, 50 percent of Quebecers report feeling enthusiastic about expanding access to MAiD, compared with 27 percent in the rest of Canada.

This profound divide colours the two solitudes’ perspectives on the range of issues associated from implications for health-care delivery to personal preference: When asked to choose between MAiD and traditional palliative care or natural death at the end of life, 40 percent of respondents in Quebec choose MAiD over the latter, compared with 25 percent in the rest of Canada. In Quebec, 41 percent identify as Cautious Supporters of expanding access to MAiD and only 9 percent identify as Opposed.

The story of Canadian attitudes toward MAiD is a complex one. It is clear that general support for MAiD has increased since it has become legal, but for most Canadians, many caveats accompany their support.

Of the one in three Canadians who enthusiastically support MAiD, their collective estimate is that almost half or more Canadians will ultimately choose it when their time comes; and 56 percent expect that they themselves will choose it. They consistently answer the range of questions in a manner that promotes the dedication of increased resources toward MAiD as part of the health-care system. But they are a minority.

While the group that opposes MAiD and consistently answers in the opposite manner is smaller, at one in five, it is still significant. But what this report shows is that in the binary telling of the story of Canadian public opinion, the nuance and genuine concern that approximately half of Canadians are feeling gets lost. They believe policy-makers need to ensure that resources and priorities are given to protect the vulnerable, that the health-care system remains prioritized on providing support for the majority of Canadians who are not expected to seek MAiD, and that the debate is pursued with the care that such a sensitive matter deserves.