Disparities in public awareness, practitioner availability, and institutional support contribute to differential rates of MAiD utilization: a natural experiment comparing California and Canada

Abstract

ABSTRACT Even though California and Canada both legalised medical aid in dying (MAiD) in 2016 and have similarly sized populations, only 853 medically assisted deaths occurred in California versus 13,241 in Canada in 2022, the most recently reported year. Ten testable hypotheses were proposed to explain this 15-fold differential in MAiD utilisation. A demographically representative online survey of adults 60 and older in both jurisdictions (N = 556) revealed no differences in moral acceptance of MAiD or willingness to use it. However, only 25% of Californian participants were aware that MAiD was legally available versus 67% of Canadian participants. Evidence in the public domain revealed that there were 6.0 times more MAiD practitioners per capita in Canada than in California, and there was far greater support for MAiD by Canadian healthcare institutions. The evidence did not support hypotheses presuming more restrictive laws in California or greater access to palliative care/hospice. While other reasons may contribute to the difference in MAiD utilisation, limited public awareness, fewer MAiD practitioners per capita, and sparse support by healthcare institutions may significantly reduce California residents’ ability to exercise their autonomy when making end of life choices.