A fact-checked debate about euthanasia in Canada

Summary

The video script presents a fact-checked debate on euthanasia in Canada, focusing on the country's Medical Assistance in Dying (MAID) laws. Two experts, Dr. Stefanie Green and John Maher, discuss the expansion of MAID to include non-terminal and mental health conditions, contrasting viewpoints on its necessity and potential risks. They address concerns about social influences, the adequacy of palliative care, and the impact on mental health treatment, while emphasizing the importance of patient autonomy and societal support.

Takeaways

• 🩺 Canada legalized euthanasia, known as Medical Assistance in Dying (MAID), in 2016.
• 📈 The number of assisted deaths in Canada has risen to over 10,000 people in 2021, more than any other country where assisted dying is legal.
• 📜 In 2021, eligibility for MAID expanded to include people who are not nearing the end of their lives and will soon include those with serious mental conditions.
• ⚖️ The legalization of assisted dying in Canada resulted from constitutional court challenges, not voter initiatives or government decisions.
• 🗣️ There are conflicting viewpoints on MAID in Canada, with concerns about its impact on vulnerable populations and the adequacy of safeguards.
• 🏥 Over 80% of people who receive MAID in Canada are receiving palliative or hospice care at the time of their death.
• 🔍 Canada's assisted dying laws lack some safeguards found in other countries, such as the requirement to try all reasonable treatments.
• 📊 National polls consistently show Canadian public support for assisted dying, including among religious people and those with disabilities.
• 🧠 There is no consensus among Canadian psychiatrists on when a psychiatric illness is incurable, complicating the application of the new law.
• 💬 Experts debate the ethical and social implications of MAID, particularly regarding people making choices due to social reasons like poverty and loneliness.

Q & A

What is the term used for euthanasia in Canada and when was it legalized?

In Canada, euthanasia is referred to as 'medical assistance in dying' or MAID for short. It was legalized in 2016.

How has the number of assisted deaths changed in Canada since the legalization of MAID?

Since the legalization of MAID in 2016, the number of assisted deaths in Canada has risen to over 10,000 people in 2021, making it more than any other country where assisted dying is legal.

What was the significant change in Canada's MAID eligibility criteria in 2021?

In 2021, Canada expanded the eligibility for MAID to include people who are not nearing the end of their lives, which was a significant change from the previous criteria.

Starting from which year will Canada include people suffering solely from serious mental conditions in its MAID eligibility criteria?

Starting from next year, which would be 2023 based on the transcript's timeline, Canada will include people suffering solely from serious mental conditions in its MAID eligibility criteria.

What is the debate format in this transcript about euthanasia in Canada?

The debate format involves each expert picking three facts that their opponent must concede are true, followed by a fact exchange and four additional rounds for further clarification of positions.

How does the legalization of assisted dying in Canada differ from other countries?

The legalization of assisted dying in Canada is a rights-based issue, resulting from constitutional court challenges, rather than voter initiated ballots or government decisions, which can change with shifting political winds.

What is Dr. Stefanie Green's perspective on providing assisted dying in Canada?

Dr. Stefanie Green, a provider of assisted dying in British Columbia, Canada, finds it profoundly meaningful to be involved at the end of a patient's life and to facilitate their final wishes.

What are the concerns raised by John Maher regarding Canada's assisted dying laws?

John Maher, a psychiatrist, is concerned about the lack of safeguards in Canada's assisted dying laws, such as no requirement for trying all reasonable treatments, no review process, and the potential for social reasons like poverty and isolation to influence the decision for assisted dying.

How does the debate discuss the issue of palliative care in relation to MAID in Canada?

The debate mentions that over 80% of people who receive MAID in Canada are receiving palliative or hospice care at the time of their death, and there has been an increase in funding for palliative care research and the number of people dying with palliative care at home since MAID was legalized.

What are the key illnesses that underlie the majority of MAID requests in Canada?

The majority of MAID requests in Canada come from patients with a cancer diagnosis, followed by end-stage organ failures and neurologic conditions, which are in the 10% to 15% range.

What is the societal concern expressed by John Maher regarding the expansion of MAID eligibility to include mental illness?

John Maher expresses concern that the expansion of MAID eligibility to include mental illness could have a discriminatory impact and that there is no consensus among Canadian psychiatrists on when a psychiatric illness is incurable, which is a requirement for MAID under the law coming into effect in 2024.

Outlines

00:00

⚖️ Conflicting Views on Euthanasia in Canada

This paragraph explores the contrasting opinions of two doctors on euthanasia in Canada. It highlights the country's approach to assisted dying, known as MAID, which became legal in 2016 and has seen a significant increase in assisted deaths. The discussion includes the expansion of MAID eligibility to those with serious mental conditions and emphasizes the factual debate format where experts agree on certain facts before further discussion.

05:01

📝 Legal and Ethical Perspectives on MAID

This paragraph delves into the legal and ethical aspects of MAID in Canada, emphasizing that it is a rights-based issue resulting from court challenges rather than voter initiatives or government decisions. It discusses the case of Jean Truchon, who opted for assisted dying due to loneliness exacerbated by the pandemic, raising concerns about people choosing MAID for social reasons like poverty and isolation.

10:05

🏥 Patient-Centered Care and Assisted Dying

Dr. Stefanie Green shares her experiences as a provider of assisted dying in British Columbia, emphasizing patient-centered care. The paragraph outlines the prevalence of MAID in Canada, the types of conditions qualifying for it, and the lack of safeguards compared to other countries. It stresses the rigorous process and eligibility criteria in place for MAID in Canada.

15:07

🤝 Mental Health and MAID: A Psychiatrist's Perspective

Dr. John Maher, a psychiatrist, expresses concerns about MAID for patients with mental illness. He highlights the importance of helping patients live fulfilling lives despite their conditions and criticizes the inadequacies in palliative care and support services. The paragraph debates the ethical implications of providing MAID while people await treatments that could alleviate their suffering.

📊 Data and Public Opinion on Assisted Dying

This paragraph examines public opinion and data related to MAID in Canada, noting that the majority of Canadians support assisted dying. It contrasts views on MAID for mental illness and highlights concerns from disability and indigenous organizations about the discriminatory impact of the legislation. It underscores the need for more research on the socioeconomic reasons behind MAID requests.

🧠 Uncertainties and Personal Experiences in MAID

The final paragraph explores the uncertainties surrounding MAID, particularly in cases involving mental illness. Dr. Maher and Dr. Green discuss the need for better understanding and research on the reasons behind MAID requests. They share personal experiences and emphasize the importance of compassionate care and support to reduce suffering, concluding with the overall adequacy and positive impact of Canada's assisted dying approach.

Keywords

💡Euthanasia

Euthanasia refers to the act of intentionally ending a life to relieve pain and suffering. In the video, it is a central theme with a debate on its ethical and legal implications, especially in Canada where it has been legalized under specific conditions.

💡Medical Assistance in Dying (MAID)

MAID is a term used in Canada to describe the practice of euthanasia when performed by a medical professional at the request of a patient. The script discusses the expansion of MAID eligibility and the debate surrounding its application.

💡Assisted Dying

Assisted dying is a broader term that encompasses euthanasia and physician-assisted suicide, where a patient is provided with the means to end their life. The video script highlights the increase in assisted deaths in Canada post-legalization.

💡Palliative Care

Palliative care is specialized medical care focused on providing relief from the symptoms and stress of serious illnesses. The script mentions concerns that some individuals might opt for MAID due to inadequate access to palliative care.

💡Terminal Illness

A terminal illness is a disease that is expected to result in death, with no chance of recovery. The script discusses the initial criteria for MAID being limited to those with terminal illnesses but later expanded to include non-terminal conditions.

💡Non-Terminal Illness

Non-terminal illnesses are conditions that are not expected to result in death. The video script notes the controversial expansion of MAID to include individuals with non-terminal illnesses, such as serious mental conditions.

💡Patient-Centered Care

Patient-centered care is an approach to medical treatment that prioritizes the patient's wishes, needs, and values. Dr. Stefanie Green in the script emphasizes the importance of this approach in providing assisted dying services.

💡Constitutional Court Challenges

These are legal actions taken to challenge the constitutionality of laws or policies. The script explains that the legalization of assisted dying in Canada was a result of such challenges brought by individuals with both terminal and non-terminal illnesses.

💡Voter Initiated Ballots

Voter initiated ballots refer to the process where voters can propose new laws or changes to existing laws through a ballot measure. The script contrasts this method with how assisted dying was legalized in Canada, not through voter initiatives but through court decisions.

💡Social Inequities

Social inequities refer to unfair and unequal treatment or conditions in society. The video script raises concerns that social factors like poverty and isolation might influence an individual's decision to request MAID.

💡Mental Health

Mental health refers to the state of an individual's emotional, psychological, and social well-being. The script discusses the controversial aspect of including mental health conditions as a criterion for MAID in Canada.

💡Capacity

In the context of the script, capacity refers to an individual's ability to make informed and voluntary decisions about their healthcare, including the choice of MAID. It is a critical aspect of eligibility for assisted dying.

💡Propriety of Action

Propriety of action refers to the correctness or appropriateness of an action according to the law or ethical standards. The script mentions that no one has been charged with misappropriate action in the context of MAID in Canada, indicating the law is being followed correctly.

Highlights

Euthanasia became legal in Canada in 2016, termed 'medical assistance in dying' (MAID).

The number of assisted deaths in Canada has risen to over 10,000 people in 2021, the highest by raw number in any country where assisted dying is legal.

In 2021, eligibility for MAID expanded to include individuals not nearing the end of their lives.

Starting from the next year, MAID eligibility will also include people suffering solely from serious mental conditions.

The debate format involves each expert presenting three facts that their opponent must concede are true, followed by a fact exchange and additional clarification rounds.

In Canada, assisted dying is a rights-based issue, resulting from constitutional court challenges rather than voter initiatives or government decisions.

Jean Truchon, a plaintiff with cerebral palsy, cited loneliness from the pandemic as a factor in his choice for assisted death, raising concerns about social reasons influencing such decisions.

There are 15 countries allowing some form of medically assisted dying, with varying eligibility criteria and procedural safeguards.

Canada's assisted dying laws lack certain safeguards present in other countries, such as a requirement that all reasonable treatments have been tried.

Over 80% of people receiving MAID in Canada are also receiving palliative or hospice care at the time of their death.

The data on palliative care and MAID does not reflect the quality of palliative care received, indicating a potential gap in understanding patient experiences.

The majority of people accessing MAID in Canada have cancer diagnoses, followed by end-stage organ failures and neurologic conditions.

Wait times for MAID in Canada are shorter than for many specialized services, suggesting a more accessible process for those seeking it.

National polls show consistent public support for assisted dying in Canada, including among the religious and those with disabilities.

There is a discrepancy in polls regarding Canadian public support for MAID for mental illness, indicating a need for further public understanding and discussion.

Canadian psychiatrists lack consensus on the incurability of psychiatric illnesses, which is a requirement for MAID eligibility under the law coming into effect in 2024.

The debate highlights the importance of considering both the medical and social aspects of assisted dying, including the impact of wait times for treatment and care.

Personal experiences from both debaters underscore the profound impact of MAID on patients and the healthcare system, with stories of relief and transformation for those seeking MAID.

The debate concludes with a call for more research on the reasons behind MAID requests, the impact of socioeconomic factors, and the effectiveness of current safeguards.

Transcripts

I have a bunch of patients who are waiting for it, right?

They've been approved—

They've not been approved.

They're waiting and hoping to be approved.

These two doctors have conflicting viewpoints

on euthanasia in their country.

I think Canada's approach to assisted dying has been successful.

I am very concerned about medical assistance

in dying laws in Canada.

Euthanasia became legal in Canada in 2016.

They call it “medical assistance in dying” or MAID for short.

Since then, the number of assisted deaths in Canada

has risen to over 10,000 people in 2021.

That's more people by raw number than any other country

where assisted dying is legal.

In 2021, eligibility for MAID expanded to include people

who are not nearing the end of their lives.

And starting next year...

that will include people suffering solely

from serious mental conditions, too.

Our participants are here to engage in a new kind of debate.

Yeah, that's where you and I would disagree.

I know.

Where instead of fighting over unvetted talking points...

we ask each expert to pick three facts

that their opponent would have to concede are true.

Dr. Maher, do you agree that these facts are true?

I do.

Dr. Green, do you agree that these facts are true?

Yes, I do.

They'll present their facts and they'll each get a chance

to respond with a footnote.

And after the fact exchange...

we'll also have four additional rounds

to further clarify their positions.

This is a fact-checked debate about euthanasia...

in Canada.

Here we go.

In Canada

assisted dying is a rights-based issue...

resulting from constitutional court challenges.

The legalization of assisted dying did not come about due to

voter initiated ballots, as happened in some US states...

or because the government thought it was a good idea.

Both of which can change with shifting political winds.

Importantly, these court cases were brought and won

by people with both terminal

and non-terminal illnesses.

It is true that court cases...

gave people who didn't have terminal illness...

the right to have assisted deaths.

But one of the plaintiffs in that key case...

Jean Truchon, who had cerebral palsy...

when he was considering getting assisted death

what he said was that it was the loneliness...

that was brought on by the pandemic...

that was leading him to make that choice.

So I'm really concerned about what that means

for people in Canada...

who will make choices to die.

Not for medical reasons alone, or maybe not even primarily

because of medical reasons

but because of social reasons: poverty...

isolation, loneliness.

That worries me a great deal.

Jean Truchon ultimately led his challenge

to the new law for assisted dying...

because he was about to lose function in his remaining limb.

That was his initial incentive.

Ultimately, this comes down to a question of rights.

And who, if anyone, controls our lives.

My name is Dr. Stefanie Green

and I'm a provider of assisted dying in British Columbia, Canada.

I've always been taught about the importance

of patient-centered care.

And I have found it to be profoundly meaningful

to be involved at this time in their life...

and to provide and facilitate their final wishes.

There are 15 countries that allow

some form of medically assisted dying...

Including ten US states and Washington, DC...

that allow people with a six month prognosis...

to self-administer a prescribed drug.

Canada is one of eight countries

that allows assisted dying for people

without a terminal diagnosis.

Next year, it will join most of these countries

in extending eligibility to people

whose only condition is a mental illness.

In these countries, cases involving

primarily psychiatric conditions are rare.

In Belgium and the Netherlands...

they made up about 1% of all cases.

Canada's assisted dying laws

lack the safeguards that other countries have.

There is no requirement

that all reasonable treatments

at least have been tried by the patient.

The doctors are able to initiate the conversation.

There is no review process.

There's nobody looking to see

whether people in Canada licensed to do this...

have in fact followed the law and followed the rules.

Canada rejected paternalism in medicine quite a few decades ago.

The Supreme Court decision states that a patient...

is not required to undertake medical treatments...

that are unacceptable to the individual.

We have long accepted that patients can refuse medical treatment.

Even if the result of that refusal is death.

There's actually a very rigorous process in place

for this assisted dying model.

There's a number of eligibility criteria, but once they are met

there are on top of that, a number of procedural safeguards.

Of course, we're in complete agreement

that paternalism is not a good thing

and every Canadian is free to make their own choices.

But when we're talking about assisted death

we're talking about choices made at a point in time

when a person is profoundly vulnerable.

My name is John Maher.

I'm a psychiatrist with a community mental health team

in Ontario, Canada.

My goal is to help my patients

live their lives the way they want...

and to do all we can to ensure that mental illness...

and all that follows from that doesn't keep them

from living full, rich lives.

There was an initial concern

that people would request assisted dying...

because they couldn't access palliative care.

But the data has put that fear to rest.

Over 80% of the people who receive MAID in Canada...

are receiving palliative or hospice care at the time of their death.

For those few who are not...

88% of them have access to such care.

Compare that to the wider Canadian population

and all causes of death

when statistics suggest

that only a minority of people are receiving

palliative care before they die.

The data that you're referencing...

comes from the forms that are filled out by the MAID providers...

and it tells us nothing,

nothing at all, about the quality of the palliative care.

We also know from the data you're citing that 21% of people who...

who received MAID had palliative care for less than two weeks.

While it's true, we don't have an objective marker...

for the quality of palliative care received.

What we do know from lots of data...

is that since MAID was legalized in Canada...

we have a significant increase

in the funding for research for palliative care and an increase

in the number of people receiving and dying with palliative care at home.

The vast majority of people who access MAID in Canada

are patients with a cancer diagnosis.

The next most common underlying

illness are end-stage organ failures.

So end-stage heart disease

end-stage lung disease, end-stage liver disease...

and neurologic conditions, they’re around the 10% to 15% range.

The wait times for MAID in Canada

are shorter than the wait times

to get a lot of specialized services.

That might be pain clinics, psychiatric care...

long-term care homes, veterans’ benefits...

supportive housing, community-based care.

That's not right.

My job as a MAID provider

requires me by law to ensure

that my patients have been offered the resources and services

that could potentially reduce their suffering.

I agree we need to reduce wait times

but at some point when potentially helpful resources...

are not reasonably available

we can no longer hold individuals hostage to society's failings.

It seems to me that the greatest failing

we're talking about here is a society

that's willing to help its citizens die...

rather than provide the services...

that we know help, that we know work...

that we know reduce suffering.

Killing people while they're on wait lists...

is profoundly immoral.

National polls consistently show

that the Canadian public supports assisted dying.

This includes people who self-identify

as religious and people with disabilities.

These polls were conducted before our law changed

to allow assisted dying,

in the first five years of legalized practice...

and in every year since the amendment that extended eligibility

outside the end of life context.

Two polls that asked Canadians

about their views on MAID for mental illness

came back with very different results.

One poll showed over 60% of Canadians in favor.

Another poll, one in particular looking at MAID for mental illness

showed that only 31% of Canadians support it.

I don't think Canadians have a full understanding...

of what is happening.

But those organizations that are focused on what's happening...

and drawing attention to it

namely the 137 disability organizations in Canada...

the national indigenous organizations...

the mental health organizations, the United Nations...

everyone who is looking at this and understanding

what is going on is gravely concerned...

about the discriminatory impact of this legislation.

Canadians have been talking about and debating

assisted dying since the 90s.

There are multiple reports, multiple committees...

multiple news stories, multiple court cases...

to suggest that Canadians are unaware of what the issue is

is not exactly fair to the Canadian public.

There is no consensus

among Canadian psychiatrists

on when any particular psychiatric illness is incurable.

And under the law that comes into effect in 2024 in Canada

a psychiatric illness must be incurable

and a person must be in a state of irreversible decline.

But we can't say who that is.

Consensus in health care is rarely required.

There is no consensus amongst doctors...

about whether they can accurately predict

a prognosis of six months.

Yet it's an eligibility requirement for assisted dying

in several countries, including the United States.

However, in Canada, for MAID to proceed...

two independent clinicians must be of the opinion...

that the patient's condition is incurable.

When someone has a terminal illness...

say cancer, we have a pretty good idea...

of how long they might live.

May not be precise, but we have a good idea.

In mental illness, we have no idea.

People get better after five years, after ten years.

These are very, very different conditions...

very different circumstances.

Now, we'll move on to the additional rounds.

Questions.

Personal experiences.

Debunk.

Uncertainties.

Stefanie, can you ask John a question

that helps clarify his position?

John, do you believe every person

with a mental health disorder can be treated successfully?

Because if not and they have capacity...

should they not be allowed to access the same legal health care

available to everyone else?

We both know the majority of people living with mental illness...

have full capacity.

They can make their own treatment decisions.

To answer your question, can we treat everyone?

I don't think that's the right question.

The question is, can we reduce suffering?

Can we help people cope with suffering?

There are certainly going to be people

whose illness will not get better, their physical illness.

But can we mitigate their experience of their symptoms?

Can we bring support...

care, compassion, and love to them in a way

that makes their life for them worthwhile?

I'm not talking about denying anyone...

the option of choosing MAID.

To be frank, everyone can already choose suicide.

What we're working to do is to ensure

that every person is treated with respect, dignity...

provided with care and support...

that we know can help reduce suffering.

Okay, John, would you like to ask Stefanie a question?

Only one in three Canadians

have access to mental health care who need it.

Only one in five children.

We know from disability organizations across the country...

that disability supports are completely inadequate...

to live a meaningful life.

People are suffering...

in ways that we can do something about.

I'm asking you...

would you support providing MAID to someone...

while they're waiting for treatment or care...

that could help them?

But it's down the road a bit.

I would happily stand with you

and call for our government to do better than what it's doing.

I think it's a separate issue.

There can come a time, on a case-by-case basis...

Every situation is individual, every situation is unique

and every case needs to be assessed in a unique way.

There may be a time when a certain treatment

is available, too far away,

much too expensive, inaccessible to the patient.

In this case, we have to seriously consider

not holding them hostage to society's failing

and to consider offering MAID if it's truly what they need.

A tough situation.

I grant you that.

John, can you tell us something from your personal experience

that has strengthened your conviction on this issue?

As a psychiatrist...

who works with a community mental health team...

supporting people with the most serious mental illnesses...

We are becoming overwhelmed...

by what MAID has introduced...

into our clinical worlds.

I have patients who are already saying...

“I'm going to stop treatment.”

“I'm not going to keep trying.”

“I can die.”

Our efforts to help them stick with the very challenging

and sometimes long-term treatment required to heal and recover

is being undermined.

We're not just doing suicide prevention anymore.

We're doing MAID prevention.

I'm going to tell you about a gentleman I’ll call Ray

who was 62 years old with metastatic lung cancer.

And Ray had been asking for MAID for quite some time.

And as he and I worked through the rigorous eligibility criteria...

at some point, I was able to sit in front of him

and tell him he was eligible for this care.

And when I sat there and did that, I saw in him...

a physical transformation, which I've learned actually happens...

almost every time.

I saw his shoulders relax.

I think I saw him smile for the first time since I'd met him...

and it was immediately followed by an expression of gratitude

for the mere possibility.

He decided to proceed with MAID

and we held it not long after, in the rooftop garden

of the facility in which he was living.

And as is required by law

I was seeking his final consent

before I administered the medication.

He was surrounded by his friends...

and as he gave me that consent

he reached out and grabbed my hand.

He looked at me and he said,

“I know this is going to sound odd, Dr. Green

but I think you saved my life.”

And it reminds me all the time...

that for the people who actually need and want this care

it is tremendously important.

Stefanie, what is one piece of specific misinformation...

that you've heard about MAID that you'd like to correct?

Recently, a number of eye catching headlines

have appeared in the news about Canadians requesting

assisted dying due to the threat of homelessness...

or the fact that they're living in poverty.

And while it's true that anyone can ask

for an assessment of eligibility for MAID...

and those unacceptable social inequities

might be contributing towards suffering.

The law is actually perfectly clear and Canadians cannot access

MAID based on those factors alone.

John, would you like to clarify a piece of misinformation?

Some MAID providers have argued that MAID...

for non-terminal conditions...

is not suicide.

For decades, suicide has been defined

as taking steps to arrange your own death.

Some have said that what makes MAID different than suicide...

is that it's well thought out.

It's not impulsive.

But in fact, in one US survey of over 1.4 million Americans

80% of people reported

that they thoughtfully planned their suicide...

Which means that we have to consider

where it fits into all of our suicide prevention efforts...

and whether it undermines those very directly.

And now for a round called Uncertainties.

John, what is something we don't know

about this issue that we need more research on?

Canada currently collects data...

on the illnesses—

the physical illnesses that lead to requests for MAID.

What we don't have is data...

that considers the socioeconomic reasons people might request it.

And how significant an impact...

that might have on the request

and perhaps whether it drives it completely.

We don't know whether poverty, homelessness...

being on a waitlist for treatment...

being refused disability benefits...

we don't know why...

people are choosing MAID and we should.

On this point, John, I think we're almost in agreement.

Canada has recently expanded the type of data it's...

gathering on patients who request and receive MAID.

And I'd be curious to see if it mirrors what we know

from international jurisdictions.

Everywhere where this data is collected elsewhere...

we know that it is the socially advantaged...

who are accessing assisted dying

not the socially disadvantaged.

So I'll be curious to see if that plays out

in the Canadian context, which is what I expect to be frank.

That said, I think we do have a good idea

of how people describe their own suffering...

and therefore why they're requesting MAID.

Primarily, it's for people who can no longer do the things

that bring meaning to their lives...

who no longer are able

to do what we call the activities of daily living...

who've lost a sense of dignity or independence.

And I think if we could find research

that would help us better understand...

what leads to that type of suffering...

potentially there's a way we can learn to treat it.

I'm concerned about this law...

having, I'll acknowledge, the unintended...

but profoundly disturbing consequence...

of having people feel like they're a burden

and that they should choose death over life.

That they should no longer demand

of their government, of their fellow citizens...

that care and support be provided.

Having spent time

with many suffering individuals, I can tell you...

that Canadians are extremely grateful for this option.

In a testament to the quality of care being provided...

not a single person has been charged with misappropriate action.

I think Canada's approach to assisted dying

is more than adequate.

It is solid.

It is good, and for some, it may be a model...

for considering care in their own region.