In August, the Atlantic published a 10,000-word piece about the ethical quandaries that physicians face in Canada’s Medical Assistance in Dying (MAID) program, prompting disgruntled responses from pro-euthanasia groups. In September, the New York Times published a profile of the Canadian children’s author Robert Munsch, best known for his book Love You Forever. In the interview, the 80-year-old Munsch, dealing with Parkinson’s disease and dementia, says he’s been approved for MAID but has not yet set a time to die. 

The profile starts as you’d expect a profile of a beloved children’s book author to start. The writer Katie Engelhart shares about letters Munsch received from the children who read his books, and how those letters inspired more books, like the 1994 story “Where Is Gah-Ning?” But Engelhart’s beat isn’t children’s literature or Canadian eccentrics. It’s death. That becomes more apparent over the course of the profile. (She’s the author of the 2021 book The Inevitable: Dispatches on the Right to Die.) In Engelhart’s profile, readers learn that Munsch is no longer writing children’s books, that reading is difficult and unenjoyable for him, and that he worries his wife, Ann, will have to care for him when he’s a “lump.” Munsch’s brother, a monk, died from Lou Gehrig’s disease, his life prolonged by what Munsch saw as unnecessary interventions. Munsch wants a different ending, and he told the Times that he hopes MAID can provide it.

Practically no new parent of the last 40 years has avoided receiving a copy of Munsch’s Love You Forever. The picture book’s cover shows a triumphant toddler throwing toilet paper all over a bathroom. The book’s refrain: “I’ll love you forever / I’ll like you for always / As long as I’m living / my baby you’ll be.”

It’s the lullaby that a new mom sings to her baby boy as they rock through the night. She sings it to him when he’s a toddler, a young boy, a teenager, and even a grown man. But at the end of the book, she’s aging and sick. She’s not able to sing anymore. That’s when her son holds her and rocks her, singing the same refrain from all those years ago. 

Honestly, it’s a downer to read to your children at bedtime. Some people find Love You Forever to be profound; others, maudlin. But several people online pointed out a disconnect between Munsch’s message in the book and his plan to die by physician-assisted suicide. 

“It is a touching story of the natural circle of life and of the unconditional love for which we are made,” the Canadian pro-life activist Amanda Achtman wrote. “This is one reason why many Canadians are shocked that the book’s author, of all people, is saying he wants a doctor to end his life by euthanasia.”

Around 5,300 people died by assisted suicide or euthanasia in the U.S. between 1998 and 2020. In Canada, more than 15,000 people died by assisted suicide or euthanasia in 2023 alone. Alexander Raikin, a visiting fellow at the Washington, D.C.-based Ethics and Public Policy who studies end-of-life issues, has been sounding the alarm for years about how assisted suicide laws disparately impact people with disabilities. Raikin grew up in Ontario (coincidentally, where Munsch lives now). He sees Canada as a bellwether for its southern neighbor.

“There are actually a lot of similarities between Canadians and Americans, at least Americans in blue states,” Raikin told The American Conservative in an interview, citing the countries’ aging populations and low fertility rates.  “[Under] Canada’s political system, it’s much easier to implement changes. There are less checks and balances than in the U.S. The current ideas that states like California or New York are interested in implementing, they can look at Canada and that can be a sort of laboratory for policy.”

So what kind of policies are being cooked up in the lab that is Canada? It seems that several U.S. states are following Quebec’s lead in ignoring the law of the land. (The province gave a middle finger to the Canadian federal government in 2024 by announcing it would allow certain advance requests for MAID.) Washington, New Mexico, and others are ignoring state laws and failing to do even the most basic oversight and reporting, Raikin wrote in UnHerd in August. Hundreds of forms related to MAID deaths have just never been filed.

“There’s been a new surge of states choosing not to follow their own assisted suicide laws,” Raikin told TAC. “They believe that assisted suicide is a justified medical treatment that should exist, and because they believe that it is justified and it should exist, they don't want to do anything that would potentially jeopardize it.”

“Washington state’s reasoning [for not releasing an annual report] was because of budgetary concerns, which is an absolute bonkers statement,” he continued. “They’re not worried about prescribing suicide. They’re only worried about the very minimal cost of just writing an annual report. I don’t have the right word for it…. If you want to quote Joe Biden, ‘malarkey.’”

Elsewhere in the U.S., Delaware became the 11th state to legalize medically assisted suicide in May, and advocates of medically assisted suicide think they’re getting closer to a victory in Montana after raising the issue earlier this year. 

As the aforementioned numbers imply, Canada’s MAID program accepts a wide range of patients, and that range is widening. As of March 17, 2027, “persons suffering solely from a mental illness” will be eligible for MAID. Doctors and nurse practitioners who have provided MAID for years are beginning to question the lack of safeguards, as Elaina Plott Calabro reported in The Atlantic, sharing the example of cancer psychiatrist Madeline Li, who regrets providing MAID to a man in his 30s who was diagnosed with cancer and had 65 percent chance of surviving with treatment. “What I’ve learned since is: Eligible doesn’t mean you should provide MAID,” Li told The Atlantic. “You can be eligible because the law is so full of holes, but that doesn’t mean it clinically makes sense.”

The Canadian Association of MAID Assessors and Providers (CAMAP) was not happy with Calabro’s depiction of the MAID program. “Contrary to the implications of the article, MAiD in Canada is governed by rigorous safeguards enshrined in federal law… The rare, edge-case scenarios highlighted in media coverage do not reflect the reality for the vast majority of Canadians who seek MAiD, nor the clinicians who provide it with professionalism and compassion,” CAMAP said in a statement. In the statement, CAMAP also stressed that every person who requests MAID “must undergo a thorough medical assessment by two independent medical clinicians.” But that’s not much of a rigorous safeguard, Raikin said. 

“It could be any two physicians or nurse practitioners [who] believe that you're eligible and in the proper state of mind for MAID,” Raikin told TAC. “We've already had cases like this in Canada, where certain physicians or even an entire province make a determination that a patient does not have an illness that's serious enough to qualify for euthanasia. And yet another physician or nurse practitioner somewhere else in Canada in a different province… determines that contrary to what all these other experts were saying, that no, this patient should qualify for euthanasia, and then they administer euthanasia to that patient.”

Canada’s MAID program was established after a 2015 decision by the country’s Supreme Court in Carter v Canada. As Raikin points out in a September report on Canada’s MAID program, the Supreme Court unanimously removed the prohibition on medically-assisted suicide with the understanding that “risks could be managed through ‘strict limits that are scrupulously monitored and enforced.’” Those “strict limits” were meant to protect the vulnerable, including people with disabilities and people with dementia, from coercion. The percentage of MAID deaths with a neurological condition as a qualifying factor tripled from 2019 to 2023, according to Health Canada data. People with neurological conditions made up almost 15 percent of all MAID deaths in 2023.

“The Canadian Medical Association historically opposed suicide and euthanasia until the Carter decision,” Raikin told TAC. “One of the main reasons for their opposition was because of their concerns over neurologically impaired patients being coerced into dying through assisted suicide.”

As Calabro explores in the Atlantic, memory loss adds another layer of uncertainty to MAID requests. So-called advance requests for MAID are not legal in Canada, but as CAMAP guidance states, “people with dementia are potentially eligible to complete a waiver of final consent” that makes it possible for them to receive MAID at a later date. Reading through CAMAP’s guidance on this issue, one thing stands out: It’s ultimately up to the doctors and nurse practitioners to decide whether a cognitively impaired person who signed a waiver still consents to MAID—whether the patient lives or dies. Who’s to say whether the patient is “happily demented” or not? Whether the patient still has “capacity?” Or whether the patient pulled his or her arm away to resist a lethal injection and live, or merely as a reaction to being touched?

“Canada is effectively entering into a stage where, at the time of death, people who are unable to consent to any medical procedure are being euthanized by their providers with very few safeguards,” Raikin told TAC. “This is someone who is a human being who doesn't understand what is happening, by definition. They are unaware of any prior agreements that they may or may not have entered. They may have fluctuating capacity. They may be, at that current moment, wanting to live. And it is very difficult [to see] how this is not another stage in the dehumanization of people with serious disabilities and illnesses in Canada.”

In her profile of Munsch, Engelhart writes that he “can’t wait too long because, under Canada’s law, he must be able to actively consent on the day of his death.” Munsch told the Times, “I have to pick the moment when I can still ask for [MAID].” When viewed in light of Canadian law, these statements don’t make total sense to Raikin—perhaps Munsch’s dementia has not yet progressed to a “grievous or irremediable” medical condition, he said. But Engelhart’s focus on Munsch’s worries over losing capacity and therefore losing access to MAID comes as groups like Dying With Dignity Canada push for advance MAID requests for people with diagnoses of capacity-impairing grievous and irremediable conditions.

“Without the option of an advance request, people across Canada are forced to make an impossible choice: die earlier than they want to in order to ensure they have capacity to consent,” Dying With Dignity Canada wrote on its website. “Or risk losing capacity and be forced to live in a situation they would find intolerable. The Province of Quebec has become the first jurisdiction in Canada to allow advance requests for those diagnosed with a serious and incurable illness leading to incapacity (e.g., Alzheimer’s), effective October 30, 2024.”

Meanwhile, the Alzheimer Society of Canada issued a statement on September 19 in support of Munsch’s choice, calling it a “poignant” reminder that “raises profound questions about autonomy, dignity, and the importance of advance planning.”

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It’s unclear from Engelhart’s profile whether Munsch currently adheres to any kind of belief system. Munsch, who has battled depression and been open about his struggle with alcohol and drugs, was raised Catholic and at one point thought he would become a priest. He lived with the Jesuits for seven years when he was a young adult. But by the end of his time discerning his path, he realized he no longer had faith. Faith has figured heavily into the MAID debate for years, yet a pro-MAID blog attacked Calabro’s article for elevating nonsecular concerns in a post titled “The Atlantic is Killing Its Reputation.”

“It is… telling that the only ethicist quoted is Étienne Montero, who in addition to being a civil-law professor, also holds a doctorate in theology and seems to have close ties to the Catholic Church,” authors Paul Magennis and Kim Carlson wrote. “His perspective need not be dismissed, but relying solely on this ideologically driven view without balancing it against voices from clinical ethicists or secular experts is misleading. Highlighting a single extreme position while omitting others with more direct relevance to medical ethics leaves the article feeling less like a balanced exploration and more like a predetermined argument.”

Just a few days before Munsch’s profile was published, the Gray Lady ran a very different profile of the famed Estonian composer Arvo Pärt. Pärt turned 90 in September, prompting musicians around the world to honor him with concerts and tributes, even though it was widely understood that he would be too frail to attend them. In the profile, Times writer Joshua Barone traces how Pärt’s journey to a unique composition style coincided with his conversion to Russian Orthodoxy. The composer no longer composes, no longer takes part in public life, and is known to be in cognitive decline, Barone writes. Pärt himself didn’t speak to Barone, but his adult son Michael did, saying his father’s “soul is in a very happy place.” 
“He just is,” Michael Pärt said. “And shouldn’t this be every person’s dream?”