This one took a bit to write. The first piece is long (1,600+ words), and intense. But it needed to be said. I'll be interested to hear what you think. You can just reply to this email to start a discussion about it.

In this newsletter

1. Medical Aid in Dying and digital accessibility
2. From the podcast: On the importance of digital accessibility
3. alt text, again
4. In case you missed it: Ableism has a massive impact
5. Long Covid changed who needs cognitive accessibility

6. Wrapping up

   Trigger warning: Medical Aid in Dying

You should be concerned about MAiD, if you care about digital accessibility. Yes, they are related.

At first glance, MAiD, or Medical Aid in Dying, seems like it is not a topic directly related to digital accessibility. But it is. Your first reaction is probably, “No, it’s not!”  Most thinking around MAiD seems to be highly emotional, more than logical or rational. I readily admit that my passions run high on this topic.. I'd like you to at least get an understanding of what's going on. You need to fully understand the data and issues around MAiD as someone working in the field of digital accessibility.

What is MAiD?

The term Medical Aid in Dying is a polite euphemism to say euthanasia. It is a doctor intentionally killing a patient, supposedly with the patient’s full, not-at-all coerced consent. A related term you may have heard about is "Physician Assisted Suicide" (PAS): when a doctor gives a patient a medication for the patient to use to kill themselves. The practical difference in the terms is who administers the final act, but the ethical questions are similar.

MAiD, Euthanasia, and PAS in numbers

As of February 2026:

• There are 15 countries worldwide where MAiD, Euthanasia, or PAS is legal.
• There are at least a few other countries with legalization bills under discussion in government.
• There are 14 States or jurisdictions in the USA where it is legal, with 11 more with bills under discussion in state governments.
• There have been an estimated between 350,000 and 400,000 deaths from euthanasia/MAiD/PAS (hard to tell for a number of reasons explained later).
• There have been 1,801 reported MAiD related deaths in Canada in 2016 (first report after legalization) and 16,499 reported MAiD deaths in Canada in 2024 (5.1% of all deaths in the country). That’s a total of more than 76,475 deaths since the program began.

Accurate numbers are hard to get by. No country or jurisdiction seems to keep the same data or even share reports. In some jurisdictions, euthanasia/MAiD/PAS doesn't have to be listed as cause of death.

In Canada, MAiD is now split into two tracks: Track 1 is for people who are facing impending death. Track 2 is for people who aren't supposed to die in the foreseeable future.

Disability and MAiD

As far as I know, Canada is the only country that actually tracks disability as it relates to MAiD. We have anecdotes (should I say horror stories?) coming out the wahoo coming out of Belgium and the Netherlands, and the USA, but no hard numbers outside of Canada. And the Canadian numbers are... scary.

• 32.9% overall of people who died by MAiD self-identified as disabled.
• 5,295 disabled deaths out of 16,104 total deaths by MAiD in 2024.
• 61.5% of deaths were disabled people for Track 2 (people with no foreseeable death).
• It is estimated between 20,000 and 25,000 disabled people died from MAiD in Canada since it's been legal.
• Nearly 50% of Track 2 deaths cited "isolation and loneliness" as a reason for applying for MAiD.

Heck, even the UN Committee on the Rights of People with Disabilities condemned Canada's MAiD law in March 2025, saying it was based on "negative, ableist perceptions of the quality and value of the life of persons with disabilities" and assumed that "'suffering' is intrinsic to disability rather than the fact that inequality and discrimination cause and compound 'suffering' for persons with disabilities."

Horror stories... errr... Anecdotes

• Adult twins euthanized in Belgium. They were deaf, and going blind. Going blind cited as the reason for wanting euthanasia
• Transsexual euthanized in Belgium. Botched surgery cited as the reason for wanting euthanasia
• Woman euthanized in the Netherlands because she was going blind. Being unable to see the dirt to clean it was distressing her enough to warrant euthanasia
• Woman euthanized in Belgium because she was anorexic
• Veterans in Canada offered euthanasia instead of services
• Quebec man dying because new regulations meant he was losing his adapted housing. There was no suitable accessible alternative for his needs.
• A British Columbia man with a history of depression was euthanized, with hearing loss listed as the reason for asking for euthanasia.
• A Canadian woman with fibromyalgia and other complex conditions died from euthanasia. She told assessors she was in unbearable physical pain. After her death, ample evidence, including YouTube videos came out where she said she was actually experiencing mental suffering, not physical. She was living in poverty, had to fundraise for food, was socially isolated, facing eviction, and feared institutionalization.
• Another Canadian woman with Multiple Chemical Sensitivities  died by MAiD after failing to secure accessible, affordable housing.
• A Canadian man with ALS/Lou Gehrig's disease died by MAiD. He could not afford the at-home care needed to keep him at home with his son. Benefits were not covering everything, and he didn't have the $263/day to cover the gap.
• Ontario man with diabetes, starting to lose his sight, and having a history of depression doctor shopped out of his own province for MAiD approval, where he'd been refused, and was approved in British Columbia.

The list goes on, and on, and on...

But! Safeguards!

These laws are passed with the promise of safeguards. Pro-euthanasia advocates say there won't be slippery slopes. Supporters assert that the primary purpose of these laws is simply compassion for people suffering in the last stages of a painful terminal illness.

They lie.

The supposed safeguards are being eroded. Quickly.

Original Canadian eligibility criteria

• Must be 18 years or older.
• Eligible for publicly funded Canadian health care.
• Capable of making health decisions.
• Have a "grievous and irremediable serious and incurable illness, disease, or disability. In an advanced state of irreversible decline. Natural death must be "reasonably foreseeable". Must be enduring intolerable physical of psychological pain.
• Voluntary request (not from external pressure).
• Informed consent after learning about alternatives including palliative care.
• Written request signed by TWO independent witnesses.
• TWO independent physicians/nurse practitioners must assess eligibility.
• Minimum 10-day reflection period between approval and provision.
• Person informed they can withdraw request at any time.
• Must provide express final consent immediately before MAID is administered.
• Mental illness as sole condition excluded.

Current status of safeguards in Canada

• Reasonably foreseeable death: REMOVED.
• 10-Day waiting period: REMOVED.
• Two witnesses: REDUCED TO ONE.
• Final consent requirement: WAIVED.
• Age restriction (18+): PROPOSED FOR REMOVAL.
• Mental illness exclusion: SCHEDULED FOR REMOVAL (March 2027).
• Allowing advanced request: PROPOSED FOR REMOVAL.

What about autonomy?

Pro euthanasia advocates will tell you it's about autonomy and choice.

As I’ve tried to show here, there is no choice. Autonomy without adequate support isn't choice.

It's coercion by circumstance.

What's all this got to do with digital accessibility?

I'll assume that if you're reading this newsletter, you work in tech. Maybe even directly in digital accessibility. Our work is there to ensure websites and applications work for everyone, including, and especially, disabled people.

You'll probably have seen this quote: "Accessibility isn't a checklist". Or "WCAG is the starting point, not the target". These quotes are true. But they don't even begin to paint the picture of how important it is for the web to be accessible.

Look at the context disabled people live in: Unemployed or underemployed. No/low access to accessible housing. No/low access to accessible transportation. No/difficult access to restaurants or entertainment. No/low access to visit family and friend's homes because they aren't accessible. No/difficult access to medical care. Medical providers typically undereducated about disabilities or chronic pain. Benefits being inadequate, and cut into by successive governments.

More context: More and more services are available only online. And what's online is almost never accessible.

When government services move online-only and the website isn't accessible, disabled people lose access to benefits. When job applications are only available through inaccessible portals, disabled people lose employment opportunities.
At the risk of using a sledgehammer to tap a finishing nail, and restating the obvious, the pattern is like this: Facing barriers leads to desperation. Desperation leads to MAiD requests. An ableist system leads to granting MAiD requests.

Our jobs, as digital accessibility experts, aren’t just to help make a website work for disabled people and the greatest number of people possible. Your job as a designer isn't just to create an experience that works for disabled people. Your job as a developer isn't just to make sure you implement designs in an accessible way. Your job as a QA tester isn't just to ensure everyone did their job and the asset is indeed accessible. Your job as the Leader of the organization isn't just to prioritize and appropriately resource the work of everyone else.

No, our job is to make sure that disabled people aren't facing yet another barrier in their day to day lives. Because we face enough barriers as it is. We face so many barriers that it's often tempting to ask for Medical Aid in Dying rather than deal with one more barrier. And (one of) the problem is they are granting these requests.

I can't logic you out of an emotional conclusion about Medical Aid in Dying. But I hope this article is going to give you pause. I haven't linked to further resources;  you can do your own homework and check it all out, because I'm just tired. So very tired of this debate and having to justify my assertions. Tired of running into one barrier after another in my day to day life. Tired of having to justify why we need to make a PDF accessible or add alt text to images, or or

Tying it all back together

It was never just about compassionate death for people in the last phases of a terribly painful terminal disease. I've heard disabled friends say "it's open season on disabled people". I find it hard to disagree with them.

Our responsibilities as people working in tech, building websites and applications,  is to make sure we reduce the friction for our disabled end users as much as possible. I kid you not, you could be saving lives. This shit is life and death. Literally.

From the podcast: On the importance of digital accessibility

I spoke about MAiD and how important digital accessibility is. I couldn't help thinking of something the late Mel Chua said:

Instead of assuming folks are interested, right, it's that extra barrier and then you have to take the extra step of going 'Well, is this worth it? Will they think I'm annoying?' And so if you can just make things accessible by default, and that's probably a recurring theme of folks you've interviewed, I'm guessing. Just make it accessible by default. Assume we're going to show up and we will show up.

You can listen to the whole episode on the podcast website. Or if you prefer, you can read the whole interview with the (human edited) transcript, on the same page.

alt text, again

I was talking about alt text in the last newsletter, and here I am talking about it again.

I was ranting on LinkedIn about how so many accessibility experts and disability rights advocate don't use alt text for images they post on LinkedIn.

Justin Yarbrough, a blind screen reader user, pointed out that ultimately, having an image description in the body of text worked just as well for him as alt text in the image element.

We had a quick discussion - his take is highly pragmatic. It's not standards based though.

I'm a pragmatic kind of guy. But for myself, I'll keep pushing to use actual alt text.

And an image description in the body of the post also makes sense - helps people who can see but have trouble parsing images. Belt and braces.

Just don't use the same text for the image description as you would for the alt text.

I've got it in my to do list to write a "How to", but I've been occupied with writing the 1,600 words behemoth article that opened this newsletter. So alt text for LinkedIn post is gonna have to wait a bit.

Ableism has a massive impact

As I said in a post I wrote a few years ago, I'm not one for political correctness for the sake of political correctness. But words do have power. The words we use have an impact.

Ableism is everywhere. From vocabulary we use that hurt people, even if we didn't mean it to, to euphemisms we use. It piles up. There's only so many times I can hear ableist expressions without shivering.

Because each and every time is a micro aggression. And the sum total of micro aggressions is as harmful as one single instance of a big aggression.

The words we use matter. Let's be careful about the words we use.

You can read the whole post on my archived site. Ableism has a massive impact

Long Covid changed who needs cognitive accessibility

Long COVID created a massive new population of disabled people with cognitive impairments. WCAG finally started addressing this recently.

The numbers are staggering

After the pandemic started, one million additional working-age Americans reported "serious difficulty remembering, concentrating, or making decisions" compared to the previous 15 years, according to Federal Reserve analysis.

Around 70% of long COVID patients experience cognitive dysfunction. Research shows 48% have episodic memory deficits. The New England Journal of Medicine reports even mild COVID causes a 3-point IQ loss in people with resolved symptoms. Those with persistent symptoms show a 6-point loss. Not that I believe in IQ, but as an indication of things getting worse, it's an interesting gauge.

Many experience ongoing problems with memory, attention, processing speed, and executive function.

What this means for digital accessibility

Millions more people now struggle with tasks that were easy before COVID. Remembering passwords. Following multi-step processes. Completing forms with redundant fields. Solving CAPTCHA puzzles.

Your checkout process that worked fine in 2019 might now exclude countless users. Your authentication requiring complex passwords creates barriers. These aren't edge cases. This affects your employees, customers, and users.

WCAG finally addressed cognitive needs

The Web Content Accessibility Guidelines didn't significantly focus on cognitive accessibility until recently. WCAG 2.2, published in October 2023, added nine new success criteria for cognitive disabilities.

These include accessible authentication that doesn't rely on memory tests. Forms that auto-fill previously entered information. Help mechanisms appearing in consistent locations.

The Cognitive and Learning Disabilities Accessibility Task Force worked for years to include these criteria. But this came years after millions developed cognitive impairments from long COVID.

Standards aren't enough

WCAG 2.2's cognitive criteria help. But conforming to standards doesn't guarantee good experiences for people with cognitive impairments.

I've tested a lot technically conformant websites where disabled users still hit barriers. A site can pass every checkpoint and still be unusable for someone with memory or processing difficulties.

Build better experiences now

Don't wait for regulations or standards. Start making your digital products work for people with cognitive impairments today.

Use simple, clear language. Break complex tasks into smaller steps. Provide consistent navigation. Allow users to review information before submitting.

Eliminate unnecessary cognitive load. Remove distractions. Provide clear error messages with solutions. Don't make people remember information from previous steps.

Test with disabled users who have cognitive impairments. Their feedback reveals barriers that audits miss. Users find problems that technically conformant designs didn't prevent.

The path forward

Long COVID changed the disability landscape. More people need cognitive accessibility features now than ever.

Your digital products either work for them or exclude them. Start with WCAG 2.2's cognitive criteria. Then test with real users. Fix the barriers they find.

Millions developed cognitive impairments after getting sick. They need your website to work. Make it happen.

Wrapping up

That's it for now! I hope you enjoyed the newsletter. I'd love to get feedback - What was good? What could be improved? What topic would you like me to talk about? I'm not making any promise, but if a topic you suggest catches my fancy, I'll share my opinion on it.

Just hit reply to this email, or send an email at info@nicolas-steenhout.com. I read every response.