Katie Engelhart on Medically Assisted Dying in the U.S. vs. Canada

The Canadian Pulitzer Prize–winning journalist Katie Engelhart wrote The Inevitable: Dispatches on the Right to Die. In this conversation with Reason‘s Kevin Alexander, Engelhart discusses why people choose assisted death, compares U.S. and Canadian health care systems and assisted-dying laws, and addresses debates about disability rights and media coverage of medically assisted dying.

Q: Why did you choose to structure your book around these different stories?

A: I wanted to bring readers on this journey of increasing discomfort. I opened the book with a legal, medical assisted death that I watched in California of an 89-year-old man. His doctor predicted that he had two or three weeks left. This man decided he wanted to die by medically assisted death. His three adult children, who lived in three different states, had flown in for it. They were all literally embracing him at the time of his death. The alternative would have been for him to wait the two or three weeks. His kids may or may not have been there. He would probably have felt increasing pain. Drugs would have helped that, but also had a side effect of sedation. He would’ve stopped eating and drinking. His death certificate would have said prostate cancer, but he probably would have died of kidney failure. That felt like a noncontroversial case.

But then there were other stories. We meet people who are physically sick but aren’t imminently dying. We meet [people] with cognitive disorders but otherwise relatively healthy bodies. And we’re confronted with the question of whether there should be eligibility criteria at all.

Q: What are the major differences between medical aid in dying [MAID] laws in the U.S. vs. Canada?

A: Oregon passed its death with dignity law in the ’90s. According to the Oregon criteria, a person who was eligible had to be medically competent to make the choice, but also two doctors in Oregon had to agree that a patient, if left alone, would die within six months. In every place where assisted dying is legal in the United States, you’ve got that six-month criterion.

In Canada, there was a requirement that a person’s death had to be imminent. Over the years, the law has expanded. A court decided it was unconstitutional to have even that vague requirement that someone’s natural death be imminent, because it discriminated against people with disabilities who were potentially suffering, who wanted to end their lives, but who weren’t dying in any imminent sense. Now, patients with potentially decades of life ahead of them can qualify.

Q: What do you say to the argument that the existence of these laws devalues the lives of disabled people?

A: A person has to ask for medical aid in dying. That person has to go through a laborious process of filling out paperwork, being interviewed by numerous doctors. That process itself is meant to prevent a person from slipping into this because she feels like her life is devalued.

Now, medical aid in dying exists within the American health care system, and that makes it especially complicated. In other countries where assisted dying is legal, there is public health care. So for instance, in Canada if someone chooses a medically assisted death, we know that person has been eligible for free health care. In the United States, there is always the possibility that someone will choose assisted dying, in part, because they don’t have access to good-quality medical care.

Q: How much truth is there to the recent scare stories out of Canada?

A: You’ve got a lot of headlines like “This Person Is Thinking About Applying for MAID Because He’s Poor,” and that person is many degrees away from being qualified. Also, poor people are deserving of health care choices, too. So I think there’s been quite a lot of sensationalizing. On the other hand, when you open up the option of assisted dying to people who are not dying, things get complicated.

Serious medical decisions are always motivated by a host of factors. It’s inevitable that MAID decisions will be messy in places like Canada. In the U.S., it’s a lot more straightforward because a person has to be close to their natural death.

This interview has been condensed and edited for style and clarity.