Canada: How Death Care is pushing out Health Care

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Alexander Raikin has written another excellent exposé on Canada's euthanasia regime published in the National Review on September 14, 2023 entitled: How Death Care pushed out Health Care. 

Raikin's previous article: No other options: An exposé on euthanasia in Canada, published by the New Atlantis on December 16, 2022, provides important insights into Canada's euthanasia law.

Raikin focuses on proceedings from the Canadian Association of MAiD Assessors and Providers (CAMAP), training seminars and interviews with patients and doctors concerning death 'care'. 

CAMAP is an independent organization funded by Canada's federal government to train doctors and nurse practitioners on how to euthanize (kill) patients (MAiD).

A panel at the CAMAP training seminar explained how "strict" the law is:

On the same day that a patient enters into an optional written agreement with only one of his or her two MAID assessors — even if it is unsigned, without any witnesses, and with no family members having been informed — the clinician can administer the lethal injection without asking for the final consent of the patient.

Quoting from a CAMAP training seminar, Raikin writes:

"Next question is from Debbie," the moderator of a discussion on medical decision-making capacity said to her fellow physicians. “How would folks interpret someone who has lost capacity with a waiver in place and is now delirious, shouting, pulling their arm away as one tries to insert the IV to provide MAID?”

The question is important because the patient is clearly unable to consent and is showing signs of resisting. 

The Moderator, Dr Ellen Wiebe, possibly Canada's most prolific euthanasia doctor, responds to the question by stating:

“I’m guessing I would bring in one of their other providers, you know, palliative care or, or whatever, and get them sedated. But what would you say?”

First to speak is Jim MacLean, who claims that he has performed more than 75 “provisions” since MAID expanded to include non-dying patients. “I don’t think I have any great thoughts on this one.” Wiebe laughed. “Everyone’s different. I mean, you try to deal with the situation. Calm the room down. See what you can achieve through conversation and calmness.”

Chantal Perrot is the co-chairman of a clinician advisory council for Canada’s largest pro-MAID lobby group. She described herself to a parliamentary committee as someone who has “cared for hundreds of patients . . . as they navigated the MAID process.” Responding to Wiebe, she said, “That’s a question. If they’re sedated, then have we sedated them into being accepting of MAID? You know, that’s a whole other question.”

Kevin Reel, a senior ethicist at Sunnybrook Hospital in Toronto and former president of the Canadian Bioethics Society, answers in part with another question: “If what we’re doing by trying to honour the waiver is reducing distress for the patient and also for maybe even the family around them, would it be acceptable to do something similarly covert to keep them from reacting in that way?”

Reel continues, “That might be a way around it, but — ” before being interrupted by MacLean, whose new answer takes the question from the hypothetical to the actual and clarifies what he meant by “conversation and calmness”: “One waiver I did use, the patient was a little agitated. So we did give her some subcutaneous hydromorphone” — an opiate ordinarily used for acute-pain control instead of sedation — “before I did the MAID, did the provision. So we did, we did use it in that situation and it was very helpful.”

“Good,” the moderator says, before moving on to the next question. 

No one on the panel or audience objects.

Raikin explains:

The asterisk in the law is that the agreement is in place only as long as the patient “does not demonstrate, by words, sounds or gestures, refusal,” or “resistance to its administration.” If this demonstration is “involuntary” and “made in response to contact,” the death of the patient may still proceed. But consent is a spectrum, and patients with delirium can flicker between having capacity and not; patients can also change their minds about dying at the hands of their physician or nurse.

The recording from an October 2021 training session documents the use of sedation to obtain consent. 

Raikin explains the importance of the use of sedation to obtain consent for death:

At the core of death care is the presumption that safeguards work and that consent, the most important safeguard, prevents death care from slipping into rampant homicide or suicide contagion. Instead, it is turning into the end of medicine.

Raikin provides examples of the use of sedation to gain consent for death:

In Belgium last year, after a lethal injection failed to kill a 36-year-old woman with terminal cancer, the presiding physician smothered her with a pillow. In New Zealand and Canada, suicidal patients seeking medical care for suicide prevention were prompted to consider assisted suicide instead.

In the Netherlands, a similar story of a physician sedating her patient into accepting euthanasia led to the first criminal trial of a euthanasia physician. She was acquitted. The judges said, “We believe that given the deeply demented condition of the patient the doctor did not need to verify her wish for euthanasia,” even though the patient repeatedly attempted to fight off her physician.

I have written previously about how a failed suicide attempt in Canada was completed through euthanasia, despite concerns of illegality by physicians involved with CAMAP, an organization that has held internal seminars on patients requesting euthanasia because of poverty, lack of medical care, homelessness, and credit-card debt.

Raikin quotes Michel Bureau, head of the Commission sur les soins de fin de vie (Commission on end-of-life care), the independent monitoring agency for MAID in Quebec who told the Canadian Press news agency this summer:

“We’re now no longer dealing with an exceptional treatment, but a treatment that is very frequent.”

In every jurisdiction that has legalized assisted suicide, the number of deaths have ballooned and "safeguards" have been rescinded. Raikin writes:

In California, the number of assisted suicides last year increased by more than 63 percent. In Canada, the number of deaths by euthanasia is on track to increase more than 13-fold in just the first seven years of the practice’s legalization. Belgium has seen a more than twelvefold increase since 2003. In Switzerland, which legalized assisted suicide in 1941, the number of such suicides has doubled every five years since 1999.

Raikin gives examples of deaths that are outside of the law:

A sibling found out that his brother’s MAID paperwork in British Columbia listed only “hearing loss” as his qualifying condition. In the Netherlands, dozens of patients qualified for euthanasia only because of autism. In Canada, “advanced age” helps qualify patients to die, even though Quebec cautions that to rely on it as the sole criterion is illegal. Young patients have died through euthanasia in Belgium for a range of reasons, including a botched sex change, sexual exploitation by a psychiatrist, unresolved post-traumatic stress disorder after a terrorist attack, and again, this time in twins, hearing loss.

Last year the Swiss Medical Association saw a need to issue a statement reminding physicians, for the first time, that “assisted suicide for healthy persons is not medically and ethically justifiable.” The agency responsible for monitoring assisted suicides in Quebec issued a similar reminder over the summer.

Raikin quotes bioethicist Leon Kass, who warns that if the value of a human being is considered subjective, invariably the right to die metamorphoses into the duty to die.

Raikin explains the planning and goals of CAMAP:

In 2018, at CAMAP’s annual conference, the leading death-care practitioners gamed out their plan. It was nothing short of prescient. Many speakers, such as the CEO of Dying with Dignity, stressed that MAID is a “political issue” and that it would require “the political will to speak out against Catholic institutions around MAID.” Moreover, as some panelists insisted, it was important for practitioners to “recognize the harm to vulnerable populations that comes with the assertion of freedom of religion.”

 In comparison, MAID was “sacred.” One speaker implored non-MAID clinicians “to keep the spirit of MAID intact.”

Just two years into Canada’s euthanasia experiment, physicians were busy laying plans for how to expand euthanasia to children, especially Indigenous children, since they “are considered wise because they are closest to the ancestors.”

Raikin explains how CAMAP promotes euthanasia for poverty:

Senior CAMAP leadership has repeatedly denied that patients are receiving euthanasia primarily because of poverty. Yet in 2018, it devoted an entire panel to “providing MAID to vulnerable, Indigenous, homeless, and frail elderly populations.” Panelists described how they could “help to empower vulnerable populations” by helping “patients fight for options that would allow them to have access to MAID” — in other words, to help find “what supports” patients might need to die instead of to live.

“I have a First Nation patient who meets all the criteria for MAID, but much of their suffering is due to a life lived in poverty,” one panelist said. “If I could change their social determinants of health, their situation might improve.” Even a hypothetical example of a patient with “fixed delusions that are causing him severe suffering” was deemed potentially eligible because “it doesn’t matter what he wants [MAID] for.”

Stefanie Green, the leader of  CAMAP, advocated that opposition by hospices to euthanasia will be overcome. Raikin quotes Green as stating:

“Over time, perhaps ten years from now, I think this conversation will happen again. If we push it now too hard and too fast, I think that will put more wedges in.”

CAMAP’s strategy has already succeeded. In 2017, Vancouver Island had a Catholic hospital and four hospice beds. Now as a consequence of a public campaign by death-care advocates, there are no remaining “MAID-free” spaces on the island.

In 2021, Vancouver Island had the highest euthanasia rate in Canada. 

Raikin discusses the cases of several Catholic hospitals that have been taken over by the Australian government in order to provide access to death services. 

Raikin writes of the doctors who object to euthanasia and are being forced out of medicine:

Helen Lord, one of the nine palliative specialists in Tasmania, retired once                "death care" began.

“I know I actually can’t kill someone, I can’t do it.  

“I said I’m not going to have any part of this. It’s not medicine. It’s just not what we do. . . . Half of the people who came into [my] palliative care were scared that they were going to be euthanized.”

When Lord spoke out against euthanasia she was accused of being a right-wing Evangelical, which she is not. Lord does believe that "life is precious" and "time is precious."

Félix Pageau, a geriatrician practicing in Quebec, testified to a national parliamentary committee in Ottawa that in his opinion as a physician, based on research, Canada was not ready to expand MAID to advanced dementia. For this, he said, a colleague in his home hospital “filed a complaint to the Collège des médecins” saying he “lied” to the committee. The Collège decided to “open an inquiry, even though they don’t have jurisdiction over testimony at the federal [level] or in the Parliament.” The investigation became an ordeal — and an expensive one, since Pageau needed to hire a lawyer. Pageau in his parliamentary testimony was exercising his free-speech rights. Eventually, the Collège ruled that it did not have jurisdiction, but the point was made.

Raikin continues:

Another physician, a former director of a palliative clinic in Canada, told me, “I had to leave a job that I loved” because “the MAID situation” made it “just too difficult to practice medicine here.” After she spoke up publicly to urge that MAID and palliative care be separate, she was constantly harassed; her email was flooded with dozens of gory images. Another palliative-care physician told me that he started his own small clinic rather than stay at the hospital where he practiced. “Physicians that go against the narrative are sanctioned,” he said. “They’re marginalized. It’s hard. It’s risky.”

Dr David D’Souza and Dr Mark D'Souza are physicians in Ontario:

“I think already there’s a lot of abuse going on, and I’m seeing it in my own practice,” including when families pressure loved ones to die so that estates or insurance payouts become available sooner. “It’s making me think twice about whether I should be continuing in geriatric care.” His brother, Mark, also a physician, left palliative care entirely. “We’re literally doing harm even though it’s under the guise of compassion,” Mark said.

Raikin states: 

The effect of legalizing death care is not just the hostile takeover of medicine. It hurts those who are the most vulnerable, those who want not to die but to be helped to live.

Gabrielle Peters, a disabled writer and policy analyst in Canada, told Raikin that it is essential that there are MAiD free places in Canadian healthcare. Raikin interviewed Rachel, who lives with chronic pain, PTSD and depression.

Rachel, a woman with a condition that causes chronic pain, told me about the difficulties of the past year. “Every day was really hard to stay alive,” she told me. “I really felt like I was dead.” She also suffers from major depression and has a history of PTSD from childhood abuse. “If I said that I wanted to die or that I couldn’t hack it anymore” when she spoke with health-care practitioners before MAID was legalized, “I was met with, ‘Here’s some coping skills and let’s talk about it,’ and various forms of therapy and resources being brought to bear.”

Once her condition qualified for MAID, in 2021, she began to notice a trend. “I would call the crisis line, the suicide crisis line. Many of these mental-health professionals, their advice would be to go look up Dying with Dignity’s website.” She tried to get help for thoughts of suicide, and instead she was being offered advice for how to die from assisted suicide.

“I have been afraid, you know, over this last couple of years to go to just my local hospital, because I was afraid that if any doctor either brought up MAID themselves or met my kind of ambivalent desire for MAID, all I needed was a push and I would be dead right now.”

Rachel found help at the Centre for Addiction and Mental Health (CAMH), Canada’s largest mental-health teaching hospital, located in Toronto. 

Raikin writes:

Its policy is that no CAMH clinicians can provide MAID on site. She felt that she had found a MAID-free space that could treat her illnesses. (CAMH is yet to release a statement on whether its MAID policy will change when, in six months, MAID will be expanded to include mental illnesses.)

Rachel decided to risk everything. With her meager savings from her disability benefits, she purchased a one-way, long-distance bus ticket, not knowing whether she would be admitted to the hospital or instead end up homeless.
“I literally just presented myself at the CAMH ER,” she said. “Part of the reason I felt safe to go to CAMH is just because I knew that they do not endorse MAID for mental illness. They’re pretty strict on that.” In a sense, Rachel lucked out. Despite the usual long wait times at Canadian emergency rooms, especially for psychiatric illnesses, her poor condition meant that her case was triaged to the front of the queue. She soon discovered how MAID was viewed by doctors at the center. “On the psych ward at CAMH, my psychiatrist was terrified — terrified,” Rachel said, carefully enunciating every syllable, “that I would talk about MAID on the floor with the other patients. She was terrified of suicide contagion.”

Over the span of weeks, Rachel began to recover. She was finally put on a new form of pain control; her depression improved. But the most important change at CAMH was that, finally, she felt listened to. “Sometimes, all you need is someone to come alongside you. And just help you cope through the everyday,” she said. “Whether it’s a doctor or just the person who is walking alongside me while I’m in a lot of pain. It may not change how much pain I actually have. But it sure makes a big difference to how much I suffer from that pain.”

Rachel is now happily back home. “I have no intention of using MAID. I have 100 percent turned away from it. Only because I had health care. All I needed was health care and pain care.”

Raikin recounts his previous article about Rosina Kamis, who died by euthanasia and her friend James, who has a similar medical situation:

In the first story that I wrote about death care, “No Other Options,” published in the New Atlantis, I wrote about Rosina Kamis, a 41-year-old Toronto woman with fibromyalgia. She chose to die from MAID in part because of her inability to access proper medical care. Before she died, she entrusted her friend James, a former neighbor, to represent her as her power of medical attorney; since her physicians weren’t listening to her, she wanted to see if someone else who has fibromyalgia, as James does, could get her the medical care that she needed. Despite his efforts, James couldn’t help her — and now, after her death, he can’t get the help that he needs. He messaged me months after our first conversation to tell me that he now sees his own future in what happened to Rosina.

James told me that he is living with the specter of an imminent administered death, like Rosina’s. He could decide to stop fighting for the care he needs, too. It seems inevitable. “I’m going to take it one day. That’s how it feels to me. I don’t like that, but to me, the way things are going, this society is really sending us disabled people a message,” James said. “We got that message even before MAID. But now it’s codified into law and there’s these processes and resources to expedite it.”

“I have diagnosed mental-health conditions and I can’t get treatment. I need therapy. My doctor asked me the other day, What do I need? I need therapy. I need a long-term relationship with someone. And she told me, she said, That’s impossible.” Instead, he was sent YouTube videos on how to do stretches. He chuckles.

“I need actual health care,” James said. Eventually, he tells me, he’ll get death care instead.

CAMAP, which sells itself as the experts on MAiD in Canada, received $3.3 million from the Canadian government to develop a curriculum for MAiD clinicians.

Thank you Alexander Raikin for your research and your continued advocacy for health care not death 'care'.