Neoliberalism, Canadian Style

Every year since MAiD became legal in Canada, the program’s usage rates have increased. In 2017, the first full year the practice was legal, 2,838 people died by MAiD in Canada. By 2024, that number had risen to 16,000, accounting for a full one in twenty deaths.

At one time, it would have been possible to argue that the rate of MAiD provision, however high, reflects little more than the demand to have control over the end of one’s life when one is suffering from a condition that will soon end one’s life in any case. But two things make this hard to maintain. One is a recent legal change expanding who is eligible for MAiD, and the other is Canada’s persistent neoliberal trajectory, struggling economy, and concurrent cost-of-living and housing crises. The connection between these two factors is especially disturbing.

In its original form, Canadian law only authorized MAiD for patients whose deaths were “reasonably foreseeable.” However, in 2019 plaintiffs challenged the law in that form, winning a decision from the Québec Superior Court that struck down that provision. As a result, MAiD is currently legal in Canada for patients whose suffering is “grievous and irremediable” even if their lives are not immediately threatened by the source of that suffering.

In response, the Canadian government removed the reasonably foreseeable death requirement, allowing, in principle, patients whose only diagnoses are psychiatric to be eligible for MAiD. At present, the only thing preventing this from being legal reality is an explicit and temporary exclusion of patients whose sole underlying condition is psychiatric from MAiD eligibility that gives the federal government until 2027 to legislatively address the issue. The apparent immediate need for this carve-out speaks to the rather obvious way that this legal change could be problematic.

As MAiD laws have become more and more permissive in Canada, social conditions have meanwhile become more difficult. Canada, like much of the rest of the world, has been living through a dismantling of the social safety net since the rise of neoliberalism in the 1980s. Just as the United States and the UK had Ronald Reagan and Margaret Thatcher as their neoliberal avatars, Canada had Prime Minister Brian Mulroney. Since Mulroney’s Progressive Conservatives were in power (1984–1993), every government has tried to outdo its predecessor in its attempts to impose austerity.

This trend continued during the Liberal governments of Jean Chrétien and Paul Martin (1993–2006), despite their campaigning from more left-leaning positions. During this period Canadians saw significant cuts to social programs — especially the transfer payments from the federal government to the provinces and territories that administer health care — in the name of balancing the federal budget. Subsequent governments have largely operated within this neoliberal consensus, with the result being increased economic inequality and degradation of public services. Neoliberalism everywhere disempowered unions and defunded social programs while unshackling capital through deregulation, and Canada was no exception.

Such policies predictably increase inequality and precarity as wages stagnate and wealth concentrates among the elite. At the start of 2025, income inequality in Canada hit a record high, and, as of the first quarter of 2025, those in the top 20 percent of the wealth distribution control almost two-thirds (64.7 percent) of Canadian wealth; whereas the bottom 40 percent of the distribution accounted for only 3.3 percent.

Canada’s present political atmosphere, like the political atmosphere in much of the world, is also not untouched by Trumpism, with the continuing trend of austerity being both a cause and symptom of that shift. As Canadians are increasingly engrossed in conspiratorial social media–fueled outrage, Canadian politicians become more and more brazen. Current Alberta premier Danielle Smith is a font of dangerous and inflammatory misinformation who is constantly flirting with privatizing aspects of Alberta’s health services; Pierre Poilievre, whose national Progressive Conservatives were initially favored to win the most recent federal election, is an extremist Milton Friedman acolyte; and Mark Carney, who leads the federal Liberals and is the current prime minister, is a former banker promising more of the same neoliberal austerity, which could prove to be a gift to future right-wing authoritarians.

Meanwhile, Canada is struggling through an even worse housing and cost-of-living crisis than the United States. Homelessness is a persistent problem. Rents are too high. Homes are unaffordable. The average price of a detached home in Vancouver in 2000 was around CA$350,000. Now it is more than CA$2 million. According to the OECD, Canada has a higher price-to-income ratio for houses (137:1) than the United States, with its famously unaffordable houses (128.5:1); higher than Switzerland, consistently one of the most expensive countries in the world (125.3:1); and well above the OECD (114.9:1) average. As recently as spring 2024, a report from Statistics Canada indicated that 45 percent of Canadians are having trouble meeting day-to-day expenses due to rising costs.

Austerity and Mental Illness

One of the most well-established results in psychiatric epidemiology is that poverty causes mental illness. In fact, pretty much any variable representing someone’s well-being, social position, access to public services, or degree of economic stability, is such that if you dial down its value, a person’s risk of mental illness increases — meaning they are more likely to have mental health difficulties, and those episodes are more likely to be longer lasting and/or more severe. And those causal variables are also themselves causally related. For instance, the more one struggles with economic precarity, the harder it is to maintain access to public services (and vice versa).

Since these factors both independently increase one’s mental health risk (which in turn imperils one’s economic stability and ability to access public services, etc.), mental illness, somatic illness, and socioeconomic precarity can easily create self-reinforcing spirals at both the individual and social levels. Against this background, the Canadian-Trumpist neoliberal era is a terrible context in which to allow mentally ill people to prevail upon a public health system for help killing themselves.

The most common reasons given in support of a MAiD request are an inability to engage in meaningful activities (over 95 percent) or to perform activities of daily living (over 83 percent). Noteworthy, however, is that more than 20 percent cite isolation and loneliness, and in the newly opened track for those whose condition is not terminal, that number rises to 50 percent. Nearly half of MAiD patients in each track worry about feeling like a burden on family, friends, or caregivers.

All of these factors would be ameliorated by living in a more just and equitable society with better public services, and each is exacerbated by runaway inequality and economic insecurity. No doubt, many patients in the original MAiD track, whose deaths were medically foreseeable in any case, would not be dissuaded by any amount of improvement in social conditions. But the question facing Canadian lawmakers now is whether to expand MAiD eligibility for people whose deaths are not reasonably foreseeable — to those who suffer from conditions especially sensitive to the quality of the social environment and that have among their symptoms suicidal ideation and self-harm.

For Genuine Autonomy

It is a truism to say that choices are always relative to a context. This is one of the reasons the notions of freedom and autonomy are notoriously ambiguous. In one sense, one is made freer within a given context when more options are opened up; in another, perhaps deeper sense, one is made freer when one can alter the context itself. Expanding MAiD access enhances choice in the first sense, but without meaningful improvements to the conditions that actually constitute risk for mental illness, justifying it by appeal to freedom and autonomy feels spurious.

This is not some subtle academic distinction — people understand it perfectly well. In 2022, it was reported that at least six Canadian veterans had sought assistance from the Ministry of Veterans Affairs and were offered MAiD instead. One disabled woman, unable to work, who requested MAiD was blunt about the insufficiency of support being her reason for wanting to die, saying, “An increase [in income support] is the only thing that could save my life. I have no other reason to want to apply for assisted suicide, other than I simply cannot afford to keep on living.” Freedom to die is offered with one hand; freedom to improve one’s conditions is taken with the other.

Defenders of expanding MAiD access might argue that even if social conditions are not ideal, that should not be taken as a reason to curtail the freedom to die on one’s own terms for any particular individual who may or may not actually have the power to improve their conditions. Why, they might ask, should any degree of prevailing injustice mean that this person should not be allowed the discretion to die as they see fit?

This is the same chestnut that might be appealed to by someone defending a parent’s choice to homeschool in the face of crumbling public education or allowing access to privatized health services for those who can pay in an otherwise public health care system. All of these situations bear the hallmarks of collective action problems: there is a difficult problem that would require coordination to solve, but until and unless that problem is solved, defection from the efforts to solve it can be individually advantageous.

Notice, however, that in all three cases it is not just that individuals must coordinate but that the systems in question are systems of public provision that ought to serve and benefit everyone. So there is a presumptive responsibility on the part of those who make public policy to improve them rather than hollow them out. When policymakers are undermining the social safety net while simultaneously offering MAiD instead, it is hard not to feel that responsibility has been radically abdicated.

The other problem with this defense of expanding MAiD is that it mistakes an issue of personal morality for a question about the role of the state. There is a certain “Who are you to tell people when they can and cannot end their lives?”quality to the pro-MAiD argument that is intuitively appealing. But we should not view the issue primarily through the lens of personal choice and self-determination. The morality of suicide is one thing, and there is a principled leftist case against laws prohibiting suicide. But we are not asking whether it is morally permissible to kill oneself or even to prevail on another to assist in one’s death. We are asking whether expanding MAiD access while simultaneously exacerbating so many of the factors that drive people to seek MAiD is sound social policy.

The real issue is that, for a great many potential patients in the newly opened MAiD track, the very same society that is worsening their underlying conditions and refusing to offer adequate material support is telling them that they can kill themselves instead. That is unacceptable as an instance of incoherent social policy, but perhaps more fundamentally as a failure of Canadian society to guarantee all its people a minimally decent standard of living.

The Canadian Association of MAiD Assessors and Providers (CAMAP) considers it a “professional duty” for clinicians to inform a patient that they may be eligible for MAiD. Whatever one might want to say about whether this is acceptable for patients only eligible for original-track MAiD — CAMAP claims that a failure to inform could result in a patient uninformed about the law having a death “unacceptable to them” — it seems especially dangerous if Canada expands MAiD eligibility to include the mentally ill. It is difficult to avoid some patients interpreting a clinician’s bringing up MAiD as a suggestion that they make use of MAiD. This is especially true of people who are marginalized, socially isolated, and/or mentally ill. Konia Trouton, former CAMAP President, has said, “We have to make sure that people are aware of their options. Awareness is not the same as coercing them or pushing them in that direction.”

But this view is naive. It assumes that people are immune from psycho-emotional vulnerability and are uninfluenced by power dynamics or by material deprivation. It is precisely this sort of perspective on people that recommends expanding their choices under unjust conditions without, and rather than, remediating the underlying injustices themselves.

Autonomy is a central moral and political value. But we can’t think of autonomy simply as greater freedom of choice. Rather, autonomy is about self-determination — being the author, as it were, of one’s own life. This kind of self-determination is meaningful only when people have the social and material support necessary to live decent, and ideally flourishing, lives. A society that respected autonomy in this deeper sense would do a better job caring for those suffering grievously than offering them a publicly funded death.