Table 2 Perceived factors leading to the introduction of MAiD

Public advocacy and influence

Participants observed how advocacy efforts by groups of individuals and organizations shaped public opinion and generated public support, which influenced the decision-making processes toward MAiD.

“[There have] been some lobby groups […] that ha[ve] become quite credible and has supported write-in campaigns, lobbying of MPs, and that probably would’ve supported the process [towards MAiD] (P38).”

“There was a fair amount of advocacy from certain individuals and from certain organizations and a little bit from the public as well, and some public service people, like government, to consider the changes in the law so that people would have time to accept death or hastened death (P35).”

Judicial system and notable MAiD legal cases

Participants highlighted how the judicial system played a critical role in interpreting and applying laws, including important court opinions/cases that have influenced the formation of MAiD.

“I don’t think there was [a] strong [MAiD] movement here in Canada, but because there were individuals like Carter who took this case all the way to the Supreme Court […]. We’ve done it backwards compared to other countries, our government had to respond to those court decisions rather than developing a movement over time to kind of get the nuances […] It was individual cases like Rodriguez or Carter that started the process (P3).”

“I guess that’s what Supreme Courts do though and it probably was because the people bringing this case [of MAiD] had become frustrated through the political change. The political change was going to go too slowly for the patients, the people, who wanted to have the hastened end-of-life and the avenue available to do them when your political change is too slow to go to the Court. So, it makes sense that they went to the Court (P32).”

Political ideology and landscape

Participants referred to the shift in ideologies and values within the Canadian political system around the time of MAiD introduction.

“I feel like [the Liberal Party of Canada] need[ed] to make sure that they’re providing what people want, and so they were able to make [MAiD] happen. I think we only got [MAiD] because the Liberals got in, we wouldn’t have had it if the Conservatives stayed in (P36).”

“We’re a liberal society. It’s just the U.S. has a very conservative mindset in the judiciary [related to MAiD], we have a more liberal mindset (P22).”

Policy diffusion

Participants noted how the increasing development and implementation of assisted dying policies in countries outside of Canada shaped its introduction in Canada.

“We were able to look to those other countries to see their experiences [with MAiD]. I think that was able to, in many ways, pave the path forward for MAiD to come here [to Canada] (P25).”

“We also had new evidence, empirical evidence […] [and] then from Oregon and Washington state, the Netherlands, [and the] Benelux countries that demonstrated that there was no slippery slope. They didn’t have that at the time of Rodriguez (P17).”

“Internationally speaking, of course, by the time [Canada] got to our decision [in 2016], there had been several jurisdictions around the world that had already gone ahead with the legalization or decriminalization or some aspect of permitting [MAiD]. So, I feel like there was enough of an understanding of what’s happened in those jurisdictions for the Canadian courts to really get what the implications were of legalizing MAID here and what the potential trajectories could look like (P28).”

Healthcare system emphasis on a patient-centred care approach

Participants described the system-level transformation of the Canadian healthcare system on placing patients at the centre of the care decision-making processes, supporting greater patient autonomy and choice and ensuring their voices are heard and their choices are respected.

“…I think the same individuals who’ve been pushing for things like MAiD are the same ones who push for things like abortion access and ensuring that rights are protected, and various different areas related to human rights in general or human rights specifically related to healthcare, like bodily autonomy (P21).”

“It’s not surprising to me that patients want to take back some of that control around their end-of-life experience. I mean, of course, patients are informed and have their choice around whether they’re doing treatment and what treatment and where they want to be, but it is still very much dictated by our healthcare system as to what options people have and how it’s presented (P27).”

Changes in societal and cultural values

Participants observed how societal changes towards sharing common values and acceptance of human rights within and outside of healthcare, shaped the movement towards MAiD.

“I feel like we got to a point in society where individual choice and human rights are really more acceptable. As a society, we’ve moved past things like no gay marriage and no abortion. And like all these other things that, I think 40 years ago, people felt really differently about, but societal norms have changed (P15).”

“I think a general movement towards understanding that people’s own choices are their own choices. We seem to have moved through legalizing abortion or at least decriminalizing abortion and legalizing same-sex marriage and same-sex adoption and MAiD has come after all of that. Why that particular order? I don’t know, but I think it’s just a move towards realizing that people’s personal decisions are theirs and that there shouldn’t be any barriers to that (P24).”