MAiD Part 2: The Consent Fiction
When Documenting a Process Stopped Being the Same as Verifying It
Introduction: The Gap Between Paper and Practice
Part 1 established the data case: approval rates rising as eligibility expands, enforcement absent despite documented violations, care inaccessible while death moves in thirteen days. The numbers are not in dispute. What remains to be examined is the mechanism that allows them to coexist with a system that still officially describes itself as carefully safeguarded.
The mechanism is this: at some point in the evolution of Canada’s MAiD framework, the documentation of consent replaced the verification of it. The paperwork that records a patient’s capacity, voluntariness, and informed understanding began functioning as proof of those things — rather than as a record of an independent process that genuinely established them.
This is the consent fiction. It is not a conspiracy. It is what happens when a system scales faster than the infrastructure designed to keep it honest, and when the institutions responsible for oversight quietly decide that access is more important than accountability.
Carter v. Canada promised that consent would be meaningful, not inferred. Part 2 is about the distance between that promise and the present.
1. What Meaningful Consent Actually Requires
Informed consent in medicine is not a signature. It is a process — one that requires the patient to understand their condition, the available alternatives, the likely outcomes of each, and the freedom to choose without coercion. In the context of an irreversible decision, that process demands time, independent assessment, and a genuine engagement with the question of whether alternatives have been exhausted.
Carter specifically required that MAiD consent be free from external pressure, that patients be fully informed of alternatives including palliative care, and that capacity be rigorously assessed by independent practitioners. The two-assessor requirement, the reflection periods, and the 90-day minimum for Track 2 cases were all designed to ensure that what gets documented as consent is consent in substance, not just in form.
The Macdonald-Laurier Institute’s 2025 MAiD Death Review identified a precise formulation of where this has broken down: safeguards are being treated as procedural hurdles, not substantive protections. Assessors are making capacity decisions in informational voids — formally recording “unknown” for whether applicants have access to disability supports or home care — and approving patients without those gaps being resolved.
That is not a consent process. That is a consent form.
2. The Assessor Problem
The consent fiction is partly structural and partly cultural. Structurally, it is produced by a system in which the same professional community that trains MAiD assessors, advocates for MAiD access, and provides MAiD services is also the community responsible for identifying when consent is inadequate. The fox is not merely guarding the henhouse — it designed the henhouse and wrote the guarding standards.
The Canadian Association of MAiD Assessors and Providers (CAMAP) receives federal funding from Health Canada. Its training programs shape how assessors interpret eligibility, how they weigh refusal of treatment, and how they understand their professional role. The cultural message embedded in that training — documented in conference materials and professional publications — emphasizes barrier reduction and patient-centered access. These are not inherently wrong values. But they are the wrong primary values for the person whose job is to determine whether a patient’s request should be declined.
The Ontario MAiD Death Review Committee captured the problem directly in its 2025 reporting:
The report raises concerns that people are being approved even when it is unclear why they refused all treatments. MAiD legislation requires more than a respect for autonomy, it also mandates the application of clinical expertise to ensure that reasonable care options are considered.
— Ontario MAiD Death Review Committee, via Canadian Affairs (August 2025)
That warning describes a systemic inversion. The assessor’s role is not to respect the patient’s refusal of alternatives and proceed. It is to understand why alternatives were refused — and to determine whether that refusal reflects genuine informed autonomy or whether it reflects depression, social pressure, inadequate information, or the simple unavailability of care. When that distinction stops being made rigorously, the consent being documented is the patient’s stated preference, not their free and informed choice.
3. Speed as a Consent Problem
Thirteen days. That is the average time between a MAiD request and death in Canada as of 2024. For context, the 90-day minimum assessment period for Track 2 — non-terminal — cases exists precisely because Parliament recognized that non-terminal suffering requires extended evaluation. The 13-day average reflects primarily Track 1 cases, where death is deemed reasonably foreseeable.
But the speed problem is not only about averages. It is about what the speed signals. A process that moves from request to death in under two weeks — and in some documented cases, on the same day or the next — is not a process built around the patient’s need for reflection. It is a process built around the system’s administrative efficiency.
Genuine informed consent for an irreversible decision requires time — not because bureaucracy demands it, but because human beings need it. The research on suicidal ideation is unambiguous: the desire to die is frequently not stable. It fluctuates with pain levels, social support, access to treatment, and mood. A patient who requests MAiD on Monday may, with adequate palliative intervention, feel differently by the following month. A system that processes the request in thirteen days forecloses that possibility not through malice but through speed.
The Health Canada consultation on advance requests — requests made before a person loses capacity, to be acted upon later — reveals how far the system is willing to extend this logic. The October 2025 summary noted:
The principle of advance requests was generally supported. Concern about how advance requests could be implemented safely in practice.
— Health Canada, What We Heard: National Conversation on Advance Requests for MAiD (October 2025)
That sentence is a structural admission. Policymakers broadly support a mechanism they cannot yet explain how to implement safely. The pattern — expand eligibility, resolve the safety questions later — is by now familiar. It is the same pattern that produced the current consent problems. Applying it to advance requests, where the patient cannot revoke consent at the moment of provision, is not an evolution of the framework. It is its logical endpoint.
4. Autonomy Without Alternatives Is Not Autonomy
The philosophical defence of MAiD rests on autonomy — the right of a competent person to make decisions about their own life and death. It is a serious argument and it deserves a serious answer, not dismissal.
The serious answer is this: autonomy is only meaningful when the person exercising it has genuine alternatives available. A choice made in a vacuum of options is not an expression of freedom. It is a resignation to circumstances.
Consider the conditions in which many Track 2 MAiD requests are made. The patient cannot access adequate disability supports — documented in over 1,000 cases between 2019 and 2023. The patient cannot access timely palliative care — only 15 percent of Canadians in smaller communities have access to such services at all. The patient is waiting months or years for mental health treatment in a system where the average healthcare wait time has reached 30 weeks. The patient feels like a burden — a cognitive state that half of all MAiD recipients in 2023 reported, and which clinical literature identifies as a distortion that responds to treatment, not a terminal diagnosis.
In those conditions, MAiD arrives in thirteen days. The system that cannot provide care within a year can provide death within a fortnight.
Dr. Ramona Coelho, testifying before Parliament, described this as “a cliff, not a slope.” The warning is precise. A slope implies gradual descent with opportunities to stop. A cliff implies a threshold — and the moment a patient enters a system where MAiD is available faster than alternatives, they are already at the edge. The consent that follows is real in a narrow procedural sense. It is not free in any meaningful human sense.
This is what the expansion of Track 2 has produced: a regime in which the word “autonomy” is used to describe decisions made by people who have been failed by every other part of the system, and whose suffering — real, legitimate, deserving of response — is being addressed by removing them rather than supporting them.
5. The Advance Request Horizon
The consent problem becomes categorically more serious when applied to advance requests — the mechanism Quebec has already legislated and which federal consultation is now actively exploring.
An advance request allows a person to authorize MAiD to be provided at a future point when they may no longer have the capacity to consent or to revoke. In practice, this means a person with a dementia diagnosis could authorize their death to occur when their condition reaches a specified stage — and that authorization would be acted upon by a physician assessing a patient who can no longer confirm, modify, or withdraw the request.
The consent fiction in the current system is at least operating on patients who are present and responsive. The advance request framework removes even that constraint. The “consent” being acted upon is the preserved preference of a person who may no longer exist in any continuous psychological sense — whose values, fears, and understanding of their own condition may have changed entirely in the intervening years.
In 2023, 241 people with dementia died by MAiD in Canada. In 106 of those cases, dementia was the sole diagnosis. These deaths occurred under the current framework, which still nominally requires contemporaneous consent. The advance request expansion would remove that requirement. It would extend the consent fiction to its furthest logical limit: a living person being put to death on the authority of a document signed by an earlier version of themselves, in a system that has already demonstrated it treats documentation as verification.
Quebec has passed the legislation. Federal consultation has begun. The question is not whether this is coming. The question is whether the consent infrastructure will be rebuilt before it arrives — or whether the system will simply extend its existing logic into new territory, as it has done at every previous expansion.
Conclusion: What Consent Requires That the System Is Not Providing
The consent fiction is not a failure of individual assessors. Most physicians working in this space are trying to do right by their patients. It is a systemic failure — produced by a framework that scales access faster than it builds accountability, that trains its gatekeepers through the same institutions that advocate for the service, and that has consistently chosen to expand eligibility before resolving the safety questions that expansion creates.
Meaningful consent to MAiD requires four things that the current system does not reliably provide: time sufficient for genuine reflection, access to real alternatives so that the choice is not made in a vacuum, independent assessment untainted by the cultural assumptions of a provider community, and a willingness to say no when the criteria are not met.
The approval rate — 78 percent and rising — tells us the fourth condition is not being met. The 13-day average tells us the first is not being met. The 1,000-plus cases of patients dying while waiting for disability supports tell us the second is not being met. And the documented reluctance of oversight bodies to challenge providers tells us the third is under pressure.
What Canada has built is a system that produces consent paperwork reliably. What it has not built is a system that produces consent.
Part 3 examines the institutional architecture that made this possible — the network of funding, training, and administrative practice that expanded MAiD without a single politician having to defend a vote.
Editor’s Notes — Sources and Standards
Primary sources for Part 2:
Macdonald-Laurier Institute, MAiD Death Review Committee Series (2025)
Ontario MAiD Death Review Committee Reports (2024–2025), via Canadian Affairs (August 2025)
Health Canada, What We Heard: National Conversation on Advance Requests for MAiD (October 2025)
Health Canada, Fifth Annual Report on Medical Assistance in Dying, 2023 (December 2024)
Health Canada, Sixth Annual Report on Medical Assistance in Dying, 2024 (2025)
Cardus, In Contrast to Carter (September 2025)
Canadian Institute for Health Information, Access to Palliative Care in Canada (2023)
Quebec Commission sur les soins de fin de vie, Annual Reports (2023–2024)
Fraser Institute, Waiting Your Turn: Wait Times for Health Care in Canada (2024)
The advance request data for Quebec draws from the provincial legislation passed in October 2024 and federal consultation documentation. The dementia figures (241 deaths; 106 sole-condition) are from Health Canada’s 2023 annual report. Dr. Ramona Coelho’s parliamentary testimony is part of the public record of the Special Joint Committee on Medical Assistance in Dying.
Part 3 exposes the machinery running behind it — the networks, incentives, and quiet coordination that keep MAiD expanding while oversight collapses.
Proceed to Part 3.
