So, I have never, ever seen the stats you share here on healthcare in Canada or heard reference to MAID. Thank you for shining a huge spotlight on this issue while the US is again getting dragged towards socialized medicine by the Democrats.
For any non-Canadians who think that Mark Atwood is nutty here; no. As a Canadian, his analysis is very plausible, and he's identified what a lot of us were terrified of when a very authoritarian federal government put this policy into place: the cost-reduction feedback loop.
Canada is, sadly, a pro-Death culture. It's not quite at Moloch levels. We're not yet a modern Cathage, or the Aztecs. Perhaps we're at Incan levels. It's not merely MAID; I believe we're the only country in the world to have no law prohibiting abortion whatsoever.
You might think that a government that prohibits almost all private medicine would, if it did start tossing positive* rights into its laws, enshrine the right to a doctor. Or timely medical treatment. You would be wrong. Instead, pro-Death rights become enshrined.
*positive rights are entitlements, compelling others to provide certain goods or services for the recipient, at the cost of enforced labour of others; negative rights are the more traditional form of rights, such as the right to freedom of thought.
I would be interested in a survey that compared attitudes toward MAID between those who have had to be at the side of family who have died after months or years of dementia/pain, and those who have not.
Like being there for pregnancy and childbirth, it changes you.
Witnessing a bad death changes what you want. It doesn't change what a 50 year incentive structure does to a healthcare system at population scale. These are different questions.
The original MAID framework (reasonably foreseeable death within a year) addresses exactly the situation you're describing. Nobody defending that boundary is dismissing what you saw. The essay isn't about that case.
It's about the expansion to conditions that aren't terminal, aren't physical, and aren't foreseeable. The person who watched a parent die of late-stage cancer has an experience that's orthogonal to evaluating whether a 34-year-old with treatment-resistant depression should qualify. Proximity to one kind of suffering doesn't calibrate judgment about the other.
The structural loop the essay describes doesn't require anyone to make a bad decision. It just requires each actor to follow the incentives in front of them (including patients who are offered a fast, free, dignified exit from a system that has already failed them). That's not the same moral universe as a terminal cancer patient choosing their timing.
Yes, the cases that concern you were also highlighted in a recent National Post story about MAID, that we are seeing “mission creep” away from the clear terminal cases.
My reply concerns the basic driver behind MAID: that those uncontroversial cases are very numerous, and politicians may be applying a kind of Blackwood’s Rule to tolerating it Going Too Far. Like “Better one die that shouldn’t, as long as ten die that should”.
It’s just a damn minefield for tweaking any incentives and rules, because so many will be so protective of MAID. If you’ve seen somebody dying in pain, you’ll be protective of MAID out of fear you’ll have the rug jerked out when you need it.
You should consider open sourcing this model, it allows people to understand the consequences and incentives that are created when you move from "foreseeable death within a year" to other conditions.
As the pool of physicians and NPs is limited, they will no longer perform MAID but just sign off on orders. The scope of practice for nurses would expand to include the MAID assessment and the procedure. Should the number of nurses be insufficient, they can supervise nurse assistants or med techs who perform the assessment and administer an oral version of MAID.
Family/caregivers will be able to request MAID.
All age restrictions will be removed from MAID. Any health condition qualifies for same-day MAID, clinical documentation no longer required.
MAID tourism would be lucrative and is advertised on billboards throughout the US and Mexico. Canada MAID has direct mailers and AI robocalls to all US seniors along with full-page ads in AARP: The Magazine as well as AAA Explorer.
Per AI, MAID in BC currently costs $1500-$2600 from assessment through ‘the end’ procedure. Not sure of the offset with system saving $ in the long run, but the short term cost ie 50k death/year around $75 -135 million would be more expensive than forever months of wait time.
I'm so glad a friend passed this along. I haven't known your work, but now I do. I was trained decades ago in the kind of structural thinking you describe, starting with an early workshop by Peter Senge.
I come to this conversation as a cancer survivor who stumbled into the headlines and became a longtime advocate for patient empowerment and, more recently, patient autonomy. While speaking at hundreds of medical conferences I of course heard thousands of presentations by others, both insiders and patients, in dozens of countries. So your essay here (brilliantly written with solid logic) lands into both my structural thinking and what I've heard from others about their countries.
Many of my events were in Canada, but I can't say I know a shred of the specifics you describe. But as I reflect on our experience in the US (double your costs, and poorer outcomes), one new observation is clanging in my head:
_________
There's a *universal* truth that so many things are now medically possible that *no system could possibly be created* to deliver all possible services to all who could use them.
There Will Always Be Increasing Shortages. (And it’s not just the US or Canada.)
_________
(I happen to be experiencing one right now, so it's fresh in my mind.)
I'm sure you've heard the casual remarks by Musk-like people asking why on earth society should spend so much money keeping people alive when new technology means there will be less and less need for contributions from us human meat-bags. It astounds me that Harari wrote about that a *decade* ago (in Homo Deus), long before LLMs started taking jobs away.
Obviously as a human meat-bag I have an opinion that I want to be kept alive. But how much cost could I justify, and who do I assert should fund it?
(To be clear, I'm not taking a position here - I'm pointing to the very problematic questions!)
And finally - my most-activated patient colleagues take all of this as good reasons for us to learn to be as self-sufficient *and autonomous* as we can, in pursuit of whatever medical needs we can resolve ourselves. For a lot of us that means learning to use LLMs productively, with critical thinking. (I've been doing that a lot.)
Why would increased "participation" in MAID reduce funding for healthcare? (I can see it might reduce funding pressure.) Presumably (conjecturally) those who opt for MAID are on the lower end of economic contribution to government funds, so while yes they take pressure off the system, the ratio of funds to need should increase, and I would think an equilibrium would be reached. Is this effectively what your system models?
My apologies I've only read a quarter of the essay, just wanted to jot these thoughts down before others supplant them. Lazy, I know .
The political economy of healthcare funding is driven by constituency pressure, not actuarial optimization. Here's the loop:
The funding isn't set by need ratios. It's set by political pressure. When a patient dies by MAID instead of waiting 40 weeks for treatment, they disappear from the wait list statistics. They stop calling their MP. They stop showing up in emergency rooms generating bad press. They stop being a visible, vocal constituency for healthcare investment. The ratio of funds-to-need might technically improve, but the political signal that drives funding decisions gets quieter, not louder. Dead constituents don't vote.
The equilibrium you imagine would require the funding decisions to track the actuarial reality of need. They don't. They track the political cost of visible suffering. MAID converts visible suffering (long waits, inadequate care, public deterioration) into invisible death (a documented "choice" in a clinic). Invisible death produces no political pressure. Reduced political pressure produces reduced funding. The ratchet clicks.
The second assumption (MAID recipients are "lower end of economic contribution") is probably wrong in the near term but becomes more right over time. The current eligible population skews toward people with serious illness and disability. But as eligibility expands to mental illness, frailty, and eventually "completed life," the eligible population starts including working-age people with treatable conditions who are unhoused, isolated, or undertreated. These are precisely the people generating the most healthcare system contact and the most fiscal pressure. Their deaths produce larger per-capita savings.
The equilibrium question is the right frame beware applying it to the wrong variable. The equilibrium in this system isn't "funds match need." It's "political pressure matches tolerance for visible suffering." MAID moves suffering off-screen. The equilibrium point in that model is much lower than one would expect.
Ok, I think my question still stands, though it's really only a factor determining where equilibrium is achieved.
The other conversation is whether Canada will really be an outlet. If I'm not mistaken, Australia has assisted suicide, and I suspect most Western nations will follow suit. If they still exist.
So, I have never, ever seen the stats you share here on healthcare in Canada or heard reference to MAID. Thank you for shining a huge spotlight on this issue while the US is again getting dragged towards socialized medicine by the Democrats.
For any non-Canadians who think that Mark Atwood is nutty here; no. As a Canadian, his analysis is very plausible, and he's identified what a lot of us were terrified of when a very authoritarian federal government put this policy into place: the cost-reduction feedback loop.
Canada is, sadly, a pro-Death culture. It's not quite at Moloch levels. We're not yet a modern Cathage, or the Aztecs. Perhaps we're at Incan levels. It's not merely MAID; I believe we're the only country in the world to have no law prohibiting abortion whatsoever.
You might think that a government that prohibits almost all private medicine would, if it did start tossing positive* rights into its laws, enshrine the right to a doctor. Or timely medical treatment. You would be wrong. Instead, pro-Death rights become enshrined.
*positive rights are entitlements, compelling others to provide certain goods or services for the recipient, at the cost of enforced labour of others; negative rights are the more traditional form of rights, such as the right to freedom of thought.
I would be interested in a survey that compared attitudes toward MAID between those who have had to be at the side of family who have died after months or years of dementia/pain, and those who have not.
Like being there for pregnancy and childbirth, it changes you.
Witnessing a bad death changes what you want. It doesn't change what a 50 year incentive structure does to a healthcare system at population scale. These are different questions.
The original MAID framework (reasonably foreseeable death within a year) addresses exactly the situation you're describing. Nobody defending that boundary is dismissing what you saw. The essay isn't about that case.
It's about the expansion to conditions that aren't terminal, aren't physical, and aren't foreseeable. The person who watched a parent die of late-stage cancer has an experience that's orthogonal to evaluating whether a 34-year-old with treatment-resistant depression should qualify. Proximity to one kind of suffering doesn't calibrate judgment about the other.
The structural loop the essay describes doesn't require anyone to make a bad decision. It just requires each actor to follow the incentives in front of them (including patients who are offered a fast, free, dignified exit from a system that has already failed them). That's not the same moral universe as a terminal cancer patient choosing their timing.
Yes, the cases that concern you were also highlighted in a recent National Post story about MAID, that we are seeing “mission creep” away from the clear terminal cases.
My reply concerns the basic driver behind MAID: that those uncontroversial cases are very numerous, and politicians may be applying a kind of Blackwood’s Rule to tolerating it Going Too Far. Like “Better one die that shouldn’t, as long as ten die that should”.
It’s just a damn minefield for tweaking any incentives and rules, because so many will be so protective of MAID. If you’ve seen somebody dying in pain, you’ll be protective of MAID out of fear you’ll have the rug jerked out when you need it.
And that itself is one of the incentive gradients driving it to its horrible terminal.
You should consider open sourcing this model, it allows people to understand the consequences and incentives that are created when you move from "foreseeable death within a year" to other conditions.
Tinkering with variables.
As the pool of physicians and NPs is limited, they will no longer perform MAID but just sign off on orders. The scope of practice for nurses would expand to include the MAID assessment and the procedure. Should the number of nurses be insufficient, they can supervise nurse assistants or med techs who perform the assessment and administer an oral version of MAID.
Family/caregivers will be able to request MAID.
All age restrictions will be removed from MAID. Any health condition qualifies for same-day MAID, clinical documentation no longer required.
MAID tourism would be lucrative and is advertised on billboards throughout the US and Mexico. Canada MAID has direct mailers and AI robocalls to all US seniors along with full-page ads in AARP: The Magazine as well as AAA Explorer.
Per AI, MAID in BC currently costs $1500-$2600 from assessment through ‘the end’ procedure. Not sure of the offset with system saving $ in the long run, but the short term cost ie 50k death/year around $75 -135 million would be more expensive than forever months of wait time.
I'm so glad a friend passed this along. I haven't known your work, but now I do. I was trained decades ago in the kind of structural thinking you describe, starting with an early workshop by Peter Senge.
I come to this conversation as a cancer survivor who stumbled into the headlines and became a longtime advocate for patient empowerment and, more recently, patient autonomy. While speaking at hundreds of medical conferences I of course heard thousands of presentations by others, both insiders and patients, in dozens of countries. So your essay here (brilliantly written with solid logic) lands into both my structural thinking and what I've heard from others about their countries.
Many of my events were in Canada, but I can't say I know a shred of the specifics you describe. But as I reflect on our experience in the US (double your costs, and poorer outcomes), one new observation is clanging in my head:
_________
There's a *universal* truth that so many things are now medically possible that *no system could possibly be created* to deliver all possible services to all who could use them.
There Will Always Be Increasing Shortages. (And it’s not just the US or Canada.)
_________
(I happen to be experiencing one right now, so it's fresh in my mind.)
I'm sure you've heard the casual remarks by Musk-like people asking why on earth society should spend so much money keeping people alive when new technology means there will be less and less need for contributions from us human meat-bags. It astounds me that Harari wrote about that a *decade* ago (in Homo Deus), long before LLMs started taking jobs away.
Obviously as a human meat-bag I have an opinion that I want to be kept alive. But how much cost could I justify, and who do I assert should fund it?
(To be clear, I'm not taking a position here - I'm pointing to the very problematic questions!)
And finally - my most-activated patient colleagues take all of this as good reasons for us to learn to be as self-sufficient *and autonomous* as we can, in pursuit of whatever medical needs we can resolve ourselves. For a lot of us that means learning to use LLMs productively, with critical thinking. (I've been doing that a lot.)
And yes to prevention, as you say.
I wonder what the demographics by "race" are? Is this simply a means to eliminate whites? Will the immigrants and their children agree to MAID?
Why would increased "participation" in MAID reduce funding for healthcare? (I can see it might reduce funding pressure.) Presumably (conjecturally) those who opt for MAID are on the lower end of economic contribution to government funds, so while yes they take pressure off the system, the ratio of funds to need should increase, and I would think an equilibrium would be reached. Is this effectively what your system models?
My apologies I've only read a quarter of the essay, just wanted to jot these thoughts down before others supplant them. Lazy, I know .
The political economy of healthcare funding is driven by constituency pressure, not actuarial optimization. Here's the loop:
The funding isn't set by need ratios. It's set by political pressure. When a patient dies by MAID instead of waiting 40 weeks for treatment, they disappear from the wait list statistics. They stop calling their MP. They stop showing up in emergency rooms generating bad press. They stop being a visible, vocal constituency for healthcare investment. The ratio of funds-to-need might technically improve, but the political signal that drives funding decisions gets quieter, not louder. Dead constituents don't vote.
The equilibrium you imagine would require the funding decisions to track the actuarial reality of need. They don't. They track the political cost of visible suffering. MAID converts visible suffering (long waits, inadequate care, public deterioration) into invisible death (a documented "choice" in a clinic). Invisible death produces no political pressure. Reduced political pressure produces reduced funding. The ratchet clicks.
The second assumption (MAID recipients are "lower end of economic contribution") is probably wrong in the near term but becomes more right over time. The current eligible population skews toward people with serious illness and disability. But as eligibility expands to mental illness, frailty, and eventually "completed life," the eligible population starts including working-age people with treatable conditions who are unhoused, isolated, or undertreated. These are precisely the people generating the most healthcare system contact and the most fiscal pressure. Their deaths produce larger per-capita savings.
The equilibrium question is the right frame beware applying it to the wrong variable. The equilibrium in this system isn't "funds match need." It's "political pressure matches tolerance for visible suffering." MAID moves suffering off-screen. The equilibrium point in that model is much lower than one would expect.
Ok, I think my question still stands, though it's really only a factor determining where equilibrium is achieved.
The other conversation is whether Canada will really be an outlet. If I'm not mistaken, Australia has assisted suicide, and I suspect most Western nations will follow suit. If they still exist.
It does, but its still gated on "reasonably foreseeable death within a year". We will see which way everyone else breaks.
*outlier