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Cited by 37Palliative Care and End-of-Life IssuesPalliative and Oncologic CareEthics and bioethics in healthcare

Association of socioeconomic status with medical assistance in dying: a case-control analysis

Open access
Redelmeier, Donald A, Ng, Kelvin, Thiruchelvam, Deva, Shafir, Eldar·2021·BMJ Open
DOI 10.1136/bmjopen-2020-043547PMC PMC8154947
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Abstract

OBJECTIVES: Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN: Population-based case-control study of adults who died. SETTING: Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS: Patients receiving palliative care under universal insurance with no user fees. EXPOSURE: Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE: Whether the patient received medical assistance in dying. RESULTS: A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS: Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

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  • A 2021 study of older adults (>65 years) who died under palliative care between June 1, 2016 and June 1, 2019 (50,096 of whom 920 received MAiD) concluded that medical assistance in dying was significantly less frequent for palliative care patients who had low rather than high socioeconomic status.

    “A 2021 study of older adults (>65 years) who died under palliative care between June 1, 2016 and June 1, 2019 (50,096 of whom 920 received MAiD) concluded that ‘medical assistance in dying was significantly less frequent for palliative care patients who had low rather than high socioeconomic status are less likely to receive medical assistance in dying under universal health insurance.’30”

    From Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada (2021) · cites this paper as [30]

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Research works printed but not linked: 5

  1. [22]Hoffman KM, Trawalter S. Assumptions about life hardship and pain perception. Group Processes & Intergroup Relations 2016; 19: 493– 508.
  2. [23]Cheek NN, Shafir E. The thick skin bias in judgments about people in poverty. Behavioural Public Policy 2020; 4: 1– 26.
  3. [93]Hoffman KH, Trawalter S. Assumptions about life hardship and pain perception. Group Processes & Intergroup Relations 2016; 19: 493– 508.
  4. [99]Mani A, Mullainathan S, Shafir E, et al. Poverty impedes cognitive function. Science 2013; 341: 976– 80. 23990553
  5. [112]Bor J, Cohen GH, Galea S. Population health in an era of rising income inequality: USA, 1980–2015. The Lancet 2017; 389: 1475– 90. 10.1016/S0140-6736(17)30571-8 28402829 · DOI

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Authors
Redelmeier, D. A., Ng, K., Thiruchelvam, D., & Shafir, E.
Affiliations
  • University of Toronto (CA)
  • Institute for Clinical Evaluative Sciences (CA)
  • Princeton University (US)
Corresponding author
Redelmeier, Donald A
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2021-05
Volume
11
Issue
5
Pages
e043547
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2020-043547
PMC
PMC8154947
OpenAlex
W3164343313
Cited by
37
References
95
Citations by year
2026: 6 · 2025: 5 · 2024: 11 · 2023: 8 · 2022: 6 · 2021: 1
FWCI
5.62
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Open (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Sunnybrook Research Institute (#001)
  • Alfred P. Sloan Foundation (#2014-6-16)
  • Canadian Institutes of Health Research (#436011)
  • Canada Research Chairs (#950-231316)
  • National Science Foundation (#SES-1426642)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
Keywords
medical assistance in dying, socioeconomic status, access to end-of-life care, palliative care, health disparities, universal health insurance, low-income patients, physician decision-making, Ontario
MeSH terms
Adult, Humans, Medical Assistance, Ontario, Palliative Care, Social Class, Case-Control Studies

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