Critics: Death Stats in Canada, Some U.S. States Hide Euthanasia, Assisted Suicide Numbers

As a result of the framework for counting MAID deaths, a Canadian person who avails himself or herself of assisted suicide because of a cancer diagnosis is listed as officially dying of cancer and not of the lethal drugs they were prescribed and ingested.

Prescription pills.
Prescription pills. (photo: Video_Creative / Shutterstock)

The method used by the Canadian government and several U.S. states to record assisted suicide deaths leads to incomplete statistics and less accountability, anti-euthanasia advocates said this week. 

The issue was thrown into sharp relief late last month when, in a Nov. 28 X post, the official account for Statistics Canada — Canada’s national statistical agency — responded to a query from a user about why euthanasia and assisted suicide deaths were not listed among the top 10 official causes of death in the agency’s 2022 statistics, despite accounting for more than 13,000 deaths that year. (In Canada, euthanasia and assisted suicide are commonly referred to as medical aid in dying, or MAID.)

“MAID deaths are coded to the underlying condition for which MAID was requested,” the agency account wrote, saying it uses World Health Organization (WHO) guidelines to code the deaths. As of November, the WHO guidelines do not include a coding standard for assisted suicide and euthanasia. 

“In the case of a disability or mental health condition, deaths are coded to the underlying disability or mental health issue that MAID was granted for,” the agency continued, answering a question from a user about how assisted suicide deaths for people suffering from non-terminal mental illness will be coded when Canada expands the practice to the mentally ill in 2024.

In the database, the underlying cause of death is defined as the disease or injury that initiated the train of morbid events leading directly to death. As such, MAID deaths are coded to the underlying condition for which MAID was requested.
For more info:

— Statistics Canada (@StatCan_eng) November 28, 2023

Deaths are coded using the World Health Organization’s International Classification of Diseases and Related Health Problems (ICD). In the cause of a disability, deaths are coded to the underlying disability or mental health issue that MAID was granted for.

— Statistics Canada (@StatCan_eng) November 28, 2023

As a result of this framework for counting MAID deaths, a Canadian person who avails himself or herself of assisted suicide because of a cancer diagnosis is listed as officially dying of cancer and not of the lethal drugs they were prescribed and ingested.

The agency’s response drew consternation and confusion from some social media users, in part because the counting mechanism means that MAID does not appear in a top 10 list of causes of death in Canada that Statistics Canada shared, despite comprising the sixth leading cause of death according to separate government statistics. Those statistics show that there were 13,241 “MAID provisions” reported in Canada in 2022 — accounting for 4.1% of all deaths in Canada. 

Assisted suicide is not the same as euthanasia, although the two phrases are often used interchangeably. Assisted suicide is the act of making the means of suicide — such as a lethal dose of medication — available to the patient, who subsequently acts on his or her own. Euthanasia, in contrast, refers to the practice of a medical professional or other person directly acting to end the life of a patient, a practice that remains illegal across the entire U.S. despite nearly a quarter of U.S. states legalizing assisted suicide. 

Alex Schadenberg, executive director of the Euthanasia Prevention Coalition, an international organization with headquarters in Ontario, told CNA that in practice, assisted suicide deaths are counted the same way in each of the 10 U.S. states that offer it. On a patient’s death certificate, assisted suicide is not listed as the cause of death but rather the medical condition that the patient was suffering with. 

All but two states — Oregon and Vermont — explicitly require by law that assisted suicide deaths be counted this way. In Oregon, the state “recommends” recording deaths this way on the patient’s death certificate in order to “balance the confidentiality of patients and their families, while ensuring that we have complete information for statistical purposes” by, according to the Oregon Health Authority website, later doing a follow-up report to find out how the patient actually died. 

Schadenberg said his organization has for years highlighted the importance of death certificate accuracy, especially when it pertains to euthanasia and assisted suicide.

“It’s important, as a culture, that we know how someone died... It’s important to know that assisted suicide and euthanasia is the sixth cause of death in Canada [in 2022], and probably in 2023 it’ll be the fifth cause of death in Canada. It’s very important to know that,” Schadenberg told CNA. 

Canada legalized assisted suicide and euthanasia in 2016 and originally included an eligibility criterion that there be a “reasonable foreseeability of natural death.” After that portion of the law was struck down by the country’s Supreme Court, the current law allows any consenting adult with “a serious and incurable illness, disease, or disability” in an “advanced state of irreversible decline in capability” to request assisted suicide. 

Schadenberg noted that counting assisted suicide deaths using the WHO standard — in addition to obfuscating the person’s true cause of death — inflates the death rates from certain diseases, such as cancer, if more and more people are choosing to end their own lives prematurely after being diagnosed and cancer is subsequently listed as their cause of death. That throws off the data when doctors later attempt to determine a prognosis for future patients if the data show so many people apparently dying of cancer prematurely, he noted. 

This reporting procedure causes further difficulty because, in the U.S., the doctor prescribing the lethal medication is rarely present at the point of the patient’s death, Schadenberg pointed out. The patient takes the drug on his or her own, usually at home. 

Therefore, Schadenberg asserted, in states where assisted suicide is legal such as Oregon, the state often has no way to prove that a patient died from assisted suicide. The Oregon Department of Health has no authority nor budget given to them under law to investigate these cases. As a result, he said, assisted suicide is “mixed in” with all other causes of death. 

“Transparency has been intentionally removed from the equation,” Schadenberg commented. 

Schadenberg said he believes the decision to count MAID deaths this way is part of an effort to “normalize the concept of killing someone.”

This counting method leads to further problems in both the U.S. and Canada, including a skewing of overall suicide statistics, another advocate said. 

Wesley J. Smith, a lawyer and a senior fellow at the U.S.-based Discovery Institute, told CNA that because of the way assisted suicides are counted in the states, the countrywide total number of suicides reported each year is likely an undercount — which is significant, given the fact that deaths by suicide grew to “the highest number ever recorded in U.S. history” in 2022. 

“When states turn in their suicide statistics to the federal government, they don’t include assisted suicides as suicides,” Smith explained, noting that the states are reliant on doctors self-reporting how the patient died. 

As a result, he said, the Centers for Disease Control and Prevention almost certainly does not have a full, complete picture of how many people have committed suicide in the U.S. Echoing Schadenberg, Smith said he believes this counting practice is part of an effort by some pro-assisted suicide activists to redefine the practice as “not suicide,” and thus as more culturally acceptable.

He said because assisted suicide is a state issue in the U.S., the only way to undo this method of counting deaths is through the passing of state legislation, which he said is “incredibly unlikely.” That said, Smith said he believes disability rights activists in the U.S. have thus far managed to keep the worst practices of Canada’s MAID system from arriving in the States. 

‘Morally unacceptable’

Amid an expansion of the practice in 2021 that included the removal of several safeguards, the Canadian government said it would wait two years to extend assisted suicide and euthanasia to mentally ill citizens to study how it could be “safely” provided. The government earlier this year extended that delay by another year, meaning Canadians suffering from mental illnesses will be able to apply for assisted suicide by mid-March 2024. Numerous groups in Canada have expressed concern about the change. 

Instead of assisted suicide or euthanasia the Catholic Church supports palliative care, which means accompanying patients toward the end of their lives with methods such as pain management and emotional and spiritual support, while not accelerating the process of death. 

The Catholic bishops of Canada reiterated Nov. 28 that Catholic medical institutions cannot offer medical aid in dying (MAID) and promoted instead the expansion of palliative care practices. 

“Euthanasia and assisted suicide (MAID) have always been, and will always be, morally unacceptable because they are affronts to human dignity and violations of natural and divine law. Catholic health care affirms that every person, made in the image of God (cf. Gn 1:26), has intrinsic value, regardless of ability or health,” the bishops wrote.

“For these reasons, we, the members of the Canadian Conference of Catholic Bishops, unanimously and unequivocally oppose the performance of either euthanasia or assisted suicide (MAID) within health organizations with a Catholic identity. We oppose any efforts by governments or others to compel such facilities to perform MAID in violation of Catholic teachings. Anything to the contrary would deeply betray the identity of these institutions as Catholic and would not be in keeping with the Church’s moral teachings on the sanctity of life and the dignity of the human person.”

Addressing the push to offer MAID to the mentally ill in Canada, the bishops urged the country to better invest in mental health care services. 

“With the threat of MAID becoming available to Canadians whose sole medical condition is mental illness, we cannot emphasize enough how important it is for public health care to invest more in mental health resources,” the bishops wrote. 

“This investment is urgently needed not only because of the present mental health crisis in which needs far exceed resources, but because discouragement and despair can also result from this very scarcity of reachable, reliable, and robust support.”

When patients choose an option that cannot be offered within a Catholic health care institution, the bishops said, they are “assured of a safe and timely discharge and transfer of care.” The bishops noted that the Canadian Conference of Catholic Bishops (CCCB) developed an online toolkit consisting of four modules that can be used by individuals, groups, parishes, health care facilities, and other institutions as a source of learning on the issue.

The bishops concluded by reaffirming Catholics’ commitment, “as Christians, to accompany the sick with care and love until natural death.”

“We continue to pray for the sick, for all caregivers, and for lawmakers whose role it is to help shape a society that does not harm or endanger the lives of its citizens,” they concluded.

All Canadian provinces except Manitoba and the Yukon experienced a steady year-over-year growth in assisted suicides in 2022, with a country-wide growth rate of 31.2% over 2021, government statistics show.