Engineering Morality into the Machine

Incentive design where lives are on the line

Canada’s Medical Assistance in Dying program began as a hedged exception: a release for people already in the terminal stages of suffering, who owned their own deaths and asked to choose the hour. It has since expanded past the shadow of imminent death, and stands to extend to mental illness as the sole condition. I am not here to relitigate that principle. You own your life; the claim that you may end it on your own terms is not the thing I want to contest. What I want to contest is the machinery built to deliver the choice, because that machinery has a bias no one designed and everyone can feel: it is cheaper, faster, and administratively simpler to end a life than to make one worth continuing.

That is not a moral failing of the clinicians inside it. It is a property of the system. A principle, once enshrined, gets mediated through human institutions, and institutions follow incentives the way water follows gravity. If the least-effort path runs toward death, then over time, and without anyone consciously pushing, the traffic will drift down that path. The bureaucratic logic does the work. A patient who dies stops consuming an expensive course of care; a patient relieved of the desire to die consumes years of it. No one has to whisper “one less costly case” for the budget to register the difference. The gradient is quiet, and quiet gradients are the ones that move populations.

So the question is not whether MAID is good or evil. It is whether the incentive field around it can be re-shaped until every actor’s self-interest points at preserving real choice rather than at the exit. That is an engineering problem, and it has an engineering answer.

Re-Wiring the Gradient

The whole of the fix is one idea worked out in detail: make caring at least as rewarded as killing, at every point where an institution feels a cost. Ten mechanisms, and each is aimed at a specific leak.

Start with the money, because the money is the master signal. No ministry or hospital should ever see a budgetary benefit from a death. Score every MAID case as though the patient continued to consume care at the average cost for their condition; erase the accounting wink entirely, and let any site whose case-mix-adjusted rate runs high trip an audit with teeth. Then close the billing asymmetry underneath it. Today there is a code for administering death and often none for the labour of making death no longer wanted. That is perverse on its face. Pay clinicians equally — better, if anything — for intensive palliative optimization, aggressive pain control, the logistics of social support, structured values counseling: bundle it into a funded Relief-First episode of a few weeks that must run before any Track 2 eligibility is finalized.

Much suffering is not medical at all but circumstantial — housing insecurity, thin home care, a missing wheelchair ramp. Where the driver is solvable, solving it comes first. A Counterfactual Care Guarantee makes that a statutory right: the necessary intervention delivered inside fourteen days for urgent cases, thirty for standard, funded from a pool walled off from any hospital’s budget so that the body offering the alternative is never the body that saves money when the alternative is declined.

Then the gate itself needs two keys and an adversary. Track 2 cases should require an independent patient advocate, unaffiliated with the treating institution, to attest that real alternatives were offered and actually made available, that the prognosis is understood, and that the wish is stable over time. For the hard cases, force an adversarial conference — one clinician arguing eligibility, one arguing against it, both filing written reasons — so the decision has to survive a hostile reading before it survives at all. Capacity gets assessed by a specialist in the relevant field, with two concordant consents at least thirty days apart and a same-day re-consent, and if a viable intervention carries even a modest chance of materially reducing the suffering, it must be scheduled before death proceeds.

Coercion, in a setting like this, does not need a raised voice. So no clinician may pitch MAID; they may answer questions, but the suggestion cannot originate with the person holding the prescription pad, and every patient gets a standardized, literacy-tested decision aid that lays out survival-compatible options with real numbers first. Sunlight polices the rest. Publish monthly, risk-adjusted dashboards: the stated reasons for requests sorted into medical versus social, how often a request is withdrawn once support arrives, time-to-support under the Guarantee, case concentration by provider, disparities by disability, income, geography, and Indigenous identity, and survivorship six to twelve months after a decline. What you refuse to measure, you are choosing not to see.

Behind the dashboards, enforcement. Randomized chart audits, video-recorded consent unless refused, license conditions for procedural failure, and a whistleblower channel that reaches patients and families, not just staff. Calibrate the liability so it cuts both ways: safe harbor for the clinician who follows the protocol exactly, and real sanction for the one who conceals an alternative or skips a capacity check, treated not as a paperwork slip but as an abuse of authority. And because none of this can be trusted in advance, any expansion — mental illness above all — carries a sunset clause and hard performance metrics: pilot, monitor independently, and retract automatically if the safeguards fail rather than requiring a fresh act of political will to undo a mistake.

Read the ten together and the shape is plain. Every one of them takes a place where the gradient tilted toward death and tilts it back, until the cheapest, easiest path is care, and the only deaths that make it through the gate are the ones even a hostile advocate could not, in good conscience, block. That is not rhetoric about compassion. It is compassion made structural — the same move you make anywhere the stated goal and the local incentive have come apart. You do not exhort the actors to be better. You change what being self-interested means for them.

The Fallacy on the Other Side

Notice what the MAID protocol is not. It is not a ban. Nowhere does the fix reach for prohibition; every mechanism preserves the choice while re-engineering the pressure around it. That distinction — between shaping the field a decision is made in and forbidding the decision — is exactly what the opposite debate keeps getting wrong.

Consider the recurring verdict that legalizing cannabis or sports betting has “failed.” The claim rests on a buried counterfactual, one that is assumed and never defended: an imagined world in which adults are granted freedom on the condition that they keep exercising it moderately, discreetly, in the low-intensity forms their elders remember. Legalization was supposed to lift the criminal penalty while leaving the culture frozen at some tasteful mean. Reality diverged from the fantasy, and the divergence gets relabeled failure.

The framing is incoherent, and the reason it is incoherent is the whole point of this book’s economics. Legalization is not a promise about outcomes; it is a change in constraints. Removing a legal barrier does not pin culture, technology, and incentive in place. It lets preference, innovation, and competition operate in the open — and markets do not invent demand, they reveal it under reduced friction. High-potency cannabis did not arise because legality corrupted anyone; it arose because a real subset of users already preferred stronger effects and producers in a competitive market optimize along whatever dimension buyers reward. Betting did not manufacture risk-seeking; it dragged an existing appetite out of the offshore dark and into something visible and countable. To call the revealed preference a policy failure is to call natural selection a failure for producing predators. The process did not malfunction. It surfaced a truth its sponsors would rather not have seen.

Which forces the word everyone leans on and no one defines: harm. In these arguments “harm” slides between incompatible meanings — discomfort at visible vice, regret after a bad bet, a vague aggregate unease, distance from middle-class norms of self-control. None of those is harm in any rigorous sense, and the slide is doing the argument’s real work. Emergency-room counts and addiction rates are empirical facts; declaring legalization a failure on the strength of them is a separate normative move that needs a theory of agency to license it, and that theory is exactly what never gets stated.

This volume can state it, because harm has a definition here: harm is the reduction of an agent’s viable futures — a net loss of the capacity to act, adapt, and recover. On that definition, legalization does not harm. It coerces no consumption, mandates no participation, forecloses no alternative; it enlarges the option space and leaves the choosing intact. Permitting an action that some people will use badly is not the same event as constraining an agent’s future. Influence is not coercion. Markets shape preferences, cultures transmit norms, phones amplify temptation — and if influence alone voided consent, then advertising, education, and language itself would be coercive too. Agency includes the right to err, to overindulge, to miscalculate, and to learn from it. A system that forbids the error in order to prevent the regret has already crossed into the thing it claims to oppose.

The Hard Case

I will not pretend every case is easy, because one is not. Sports betting is the strongest challenge to everything I just said, and it deserves to be met on its merits rather than waved past.

Modern betting platforms are not neutral venues for a voluntary risk. They are engineered — ultra-low-latency feedback, variable reinforcement schedules, seamless escalation, implicit leverage, losses that recurse and recovery that is quietly deferred. Those properties can genuinely erode agency over time, not by permitting one bad choice but by draining the financial resilience and decision bandwidth an agent needs to make the next one. And here the harm definition does real work rather than decorative work, because it draws a line the moralist and the libertarian both miss. There is a difference between permitting error and engineering a trap. Allowing an initial bad choice preserves agency; the agent can lose, learn, and walk away. Designing a system so that an initial error predictably cascades into loss of control does not preserve agency — it exploits a cognitive vulnerability to manufacture the very future-narrowing that is harm. The first respects adult moral status. The second is agency-reduction dressed as entertainment.

So the answer is neither the shrug nor the ban. Prohibition fails on its own terms: it does not remove the activity, it displaces it into channels that are less transparent and less constrained, which is agency-destruction with worse instrumentation. The answer is agency-preserving constraint — regulation aimed squarely at the mechanisms that convert a voluntary risk into an involuntary capture. Imposed friction and cooling-off periods, hard loss and leverage caps, legible disclosure of expected value, identity-bound rate limits. None of these tries to optimize the gambler’s outcome or spare him his regret. Each one preserves a recovery path. The rule generalizes cleanly: if a system predictably destroys agency, regulate the system; do not criminalize the chooser. And when the fallout lands on third parties — dependents, defrauded partners — protect them directly, through liability and restitution, rather than pre-emptively revoking a competent adult’s liberty on the theory that spillover might occur.

The alternative slogan, “casinos in our pockets,” is rhetorically strong precisely because it proves too much. The same phone holds the algorithmic feed, the pornography, the trading app, the delivery button, the game that never ends. Single out gambling and you have smuggled in an undefended judgment about which temptations adults may be trusted near. Follow the logic to its end and it stops being about gambling at all; it becomes the claim that adults should not have unmediated access to temptation — that liberty is provisional, extended only while people behave as model citizens and rescinded the moment the results embarrass their betters. A society that treats its adults as permanent risk-management problems has already abandoned agency as a value, whatever it says about freedom in the preamble.

Both halves of this chapter are the same engineering discipline pointed at two failures that look opposite and are not. In Canada the machine drifts toward a death the principle never intended, and the fix is to re-tilt the gradient until caring outcompetes killing. In the legalization debates the reflex is to ban the freedom because the freedom revealed something ugly, when the ugly part is a narrow set of trap-mechanisms that can be regulated in place. Neither answer is exhortation and neither is prohibition. Both are the patient work of arranging incentives and constraints so that the option space stays open and the agency-destroying gradients get flattened. Where lives are on the line, good intentions are not a control system. You have to build the morality into the machine, because the machine is what actually runs.