Autonomy, Capacity, and the Right to Exit
Replacing suffering-based MAiD eligibility with a single principled standard: decisional capacity.
A Fundamental Reform of MAiD Eligibility
This packet argues that the correct question governing Medical Aid in Dying is not how much a person suffers, but whether they are capable of making an autonomous, informed, and durable decision.
Under current frameworks across North America, access to MAiD turns on clinical judgments about the quality or intensity of suffering — judgments that are both philosophically incoherent and unequal in their application. The reform proposed here replaces these criteria with a rigorous, two-stage decisional capacity standard.
A person who meets that assessment should have access to MAiD regardless of diagnosis, prognosis, or disability status.
The existing eligibility framework is incoherent on its own terms. The right to refuse life-sustaining treatment is near-absolute; the right to actively end one's life is heavily restricted. This asymmetry has no principled foundation once decisional capacity is recognized as the operative criterion in both contexts.
Legally recognized MAiD deaths generate political accountability for institutional failures — inadequate palliative care, mental health resources, and social support — that underlie many requests. The right to exit, properly constructed, is a mechanism for holding systems responsible for keeping life worth living.
Four Structural Commitments
The reform is built on four interlocking propositions, developed in full across the documents in this packet.
Bodily self-determination is not contingent on diagnosis or prognosis. A person with capacity holds sovereignty over decisions of this kind, and the state's monopoly on pharmacological means of exit generates a corresponding duty to provide access.
A rigorous, procedurally demanding assessment — including an extended waiting period and independent psychiatric review — provides substantive protection while remaining principled. The process itself functions as evidence of decisional durability.
Every legally recognized MAiD death is a data point that political systems cannot ignore. Mandatory socioeconomic driver reporting creates accountability for the structural conditions that generate requests, without allowing those conditions to operate as eligibility criteria.
A complete fiscal impact analysis — modeled across low, medium, and high uptake scenarios in Canada and the United States — is presented for transparency. The analysis is accompanied by explicit ethical caveats: fiscal savings must never function as a policy rationale.
Six Briefs, One Companion Essay
Each document is addressed to a distinct audience while sharing a common architecture of argument.
The authoritative reference. Develops the sovereignty model, the two-stage assessment protocol, responses to all principal objections, the structural accountability mechanism, model statutory language, and full fiscal analysis.
Download PDFWritten for elected officials. Presents the policy problem in plain language, the capacity standard, a review of current jurisdictional models, procedural safeguards, and fiscal and political framing.
Download PDFWritten for disability rights advocates and medical ethicists. Proposes the structural accountability mechanism as genuine common ground between reform advocates and those skeptical of expansion.
Download PDFDevelops the full philosophical argument: the sovereignty model grounded in bodily self-determination, the two-stage assessment protocol, and systematic responses to principal objections.
Download PDFAddresses the clinical incoherence of suffering-based criteria, the capacity assessment protocol, the depressive incapacity objection, and practical implementation summary.
Download PDF