The Economics of Euthanasia
Engineering Out the Abuse Incentive From Canada's MAID
Canada’s Medical Assistance in Dying (MAID) program is a proving ground for the boundaries of state-sanctioned autonomy. It began as a carefully hedged exception for those in the terminal stages of suffering. Now it has expanded to include cases far from the shadow of imminent death, and—unless halted—will extend to mental illness alone. The principle behind MAID is clear: you own your life, and you may end it on your own terms. The problem is that the machinery delivering this choice is riddled with incentives that make killing easier than caring.
This is not paranoia; it’s basic incentive theory. If death is cheaper, faster, or more convenient than life, the system will, over time, lean toward death—often without anyone needing to consciously push it. The bureaucratic logic does the work. To make MAID genuinely about autonomy rather than convenience, you have to rewire those incentives until every actor’s self-interest aligns with preserving real choice.
1. Erase the Budgetary Signal
No hospital or ministry should ever see a financial benefit from a MAID case. Budgets must be calculated as if the patient continued to consume care at average cost. That eliminates the subtle budgetary wink that says, “Well, that’s one less expensive patient.” Outlier MAID rates, once adjusted for case mix, should trigger an audit with teeth.
2. Pay for Life-Preserving Interventions
Right now, MAID has a billing code. The work of relieving suffering so that death is no longer desired often does not. That’s perverse. Pay clinicians equally—better, even—for:
Intensive palliative care optimization
Aggressive pain interventions
Social and logistical support coordination
Structured values-clarification counseling
Wrap these in a “Relief-First Episode” code: 2–6 weeks of funded, targeted support before any Track 2 eligibility is finalized.
3. Guarantee the Alternatives
When suffering is driven by solvable problems—housing insecurity, inadequate home care, lack of adaptive equipment—these must be addressed first. Mandate a Counterfactual Care Guarantee: a statutory right to the necessary interventions within 14 days (urgent) or 30 days (standard). Fund this from a pool completely separate from hospital budgets.
4. Two Keys to the Gate
Track 2 cases should require an Independent Patient Advocate unaffiliated with the treating institution to attest that alternatives were offered and made available, the patient understands the prognosis, and the decision is stable over time. For complex cases, force an adversarial case conference: one clinician argues for eligibility, one against, with both filing written reasons.
5. End Soft Coercion
No clinician should “pitch” MAID. They can answer questions, but they cannot initiate the suggestion except in rare, clearly defined situations. Provide all patients with standardized, literacy-tested decision aids presenting survival-compatible options before MAID, with absolute risk data and realistic timelines.
6. Specialist Capacity Checks
Capacity assessment should be done by a specialist in the relevant field—psychiatry for mental illness, neurology for neurodegeneration, palliative for symptom-driven cases. Require two concordant consents at least 30 days apart, plus a same-day re-consent. If a viable intervention exists with a 20–30% chance of materially reducing suffering within 90 days, it must be offered and scheduled before MAID proceeds.
7. Metrics That Matter
Publish monthly, risk-adjusted dashboards tracking:
Primary reasons for requests (medical vs. social)
How often requests are withdrawn after support arrives
Time-to-support under the Counterfactual Care Guarantee
MAID case concentration by provider/site
Disparities by disability, income, geography, Indigenous identity
Survivorship outcomes 6–12 months post-decline
8. Audit and Accountability
Randomized chart audits, license conditions for procedural failures, and video-recorded consent (unless refused) should be standard. Establish an independent whistleblower channel for patients, families, and clinicians to report coercion or violations.
9. Calibrate Liability
Offer safe harbor to clinicians who follow the protocol precisely. Punish those who bypass it—concealing alternatives, skipping capacity checks—as abusers of authority.
10. Expansion Only with Reversibility
Any expansion—especially mental illness as sole condition—must carry a sunset clause and hard performance metrics. Pilot first, monitor independently, retract automatically if safeguards fail.
The Verdict
This isn’t about being “for” or “against” MAID. It’s about understanding that every moral principle you enshrine gets mediated through human institutions, and institutions follow incentives like water follows gravity. If the cheapest, easiest path is toward death, that is the path you will get—no matter the rhetoric about compassion.
The answer is not to ban MAID, nor to trust the system’s good intentions. It is to weaponize incentive design so thoroughly that killing becomes harder than caring, and the only deaths that pass through are those that even a hostile advocate could not in good conscience block.
That’s not just policy. That’s engineering morality into the machine.