Canada's Euthanasia Regime - Interview with Dr Ramona Coelho

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Ramona Coelho

An excellent interview of Dr Ramona Coelho by Jonathon Van Maren was published in the European Conservative on April 24, 2024. 

As stated by Van Maren, Dr Coelho is a family physician in London, Ontario, with a practice largely serving marginalized patients, she has testified before Parliament, laid out the dangers of legal euthanasia on TV and in print, and presciently warned policymakers of many of the scenarios we now see unfolding. Dr Coelho is a leading voice opposing Canada's euthanasia regime.

Van Maren begins the article by bringing up two of the most recent Canadian euthanasia stories and commenting on the issue of euthanasia for mental illness alone:

For the past several years, the euthanasia horror stories unfolding in Canada have captured the attention of the press on both sides of the Atlantic. I have detailed many of them in my reporting; as I write this, a desperate father is battling in court to prevent his healthy 27-year-old autistic daughter from dying by doctor-administered lethal injection; another Canadian has been approved for euthanasia after developing bedsores while waiting for necessary healthcare that is increasingly difficult to obtain.

At the end of January, the Trudeau government delayed, for the second time, their plan to expand euthanasia eligibility to Canadians struggling solely with mental illness. Initially, a strong majority of Canadians supported legal euthanasia in limited circumstances. The events of the past several years have begun to erode that support, and the Conservative Party is campaigning on a promise to pass legislation banning euthanasia for mental illness. It is an incredibly pressing issue: if suicide-by-doctor were to be made available to the mentally ill, Canada’s ever-rising euthanasia death rate would spike overnight.

Dr Coelho defines what the term MAiD means:

Medical Assistance in Dying (MAiD) is the Canadian term that refers to both euthanasia and assisted suicide, although up to this point 99.9% of cases have been euthanasia (physician administered lethal cocktail to induce death, usually by IV) so I think it’s accurate and clearer to refer to this as euthanasia. However, it is possible that there might be more cases of assisted suicide (patient self-administers the lethal cocktail of drugs) in coming years as both are permitted. I will refer to it as MAiD just for ease and as some very few cases do involve assisted suicide.

Van Maren then asks Dr Coelho to comment on euthanasia for mental illness:

MAiD really never should have been an option for those with mental illness. Canadians face major barriers to access mental health care and numerous Canadian psychiatrists have voiced serious reservations about this expansion. We do not even understand how clinically to distinguish between the overwhelming majority of those with mental illness, who recover with suicide prevention and services, and those very few who might not. Such an expansion would allow healthcare practitioners arbitrarily to decide who deserves suicide prevention and who is deemed eligible for MAiD, potentially placing many Canadians’ lives at risk.

The legislation permitting MAiD for mental illness should have been permanently abandoned. But despite recommendations from its most recent parliamentary committee and most Canadian provinces asking that the legislation be indefinitely paused, the government has chosen simply to delay its implementation once again, this time until 2027. Politically, the delay in implementation of this legislation, rather than stopping it altogether, seems imprudent for the current government, as it may become a significant election issue. I would say Canadians are increasingly recognizing the risks of expanding MAiD to include individuals whose sole medical condition is mental illness.

Dr Coelho then comments on possible further expansions of MAiD in Canada:

And besides this, we still have the 2023 parliamentary recommendations to include MAiD for “mature” children and advance directives for euthanasia next. MAiD was initially introduced as an exceptional procedure to be used only for those near death with intolerable suffering, but once society embraces the intentional ending of one’s life as a treatment for suffering, it becomes practically impossible to contain, with Canada being a case in point.

Dr Coelho then comments on the concerns with medical safety:

In February 2024, the Canadian Human Rights Commission expressed ongoing concern over reports indicating that individuals with disabilities opt for MAiD due to a lack of essential support services. The CHRC is joined by UN human rights experts, Canadian disability groups, Indigenous advocates, social justice groups, and numerous medical and legal professionals in these concerns.

I was interviewed for a documentary featuring the tragic MAiD death of Rosina Kamis, who, citing poverty and loneliness, chose MAiD due to insufficient support. Some Canadian bioethicists argue that MAiD under “unjust social circumstances” is a form of “harm reduction.” However, this is not a free autonomous choice, but death driven by desperation and structural inequalities.

Messages promoting suicide and easier access to lethal means heighten suicide risks. MAiD exacerbates these dangers, endangering vulnerable individuals by increasing the likelihood of being induced into a premature death. Additionally, healthcare providers’ often inaccurately rate the quality of life of individuals with disabilities as poor, which may lead to their biases leading to suggesting or approvals of MAiD, particularly when patients are experiencing transient low points in their lives.

Dr Coelho then comments on the model practise standard:

Health Canada’s “Model Practice Standard for Medical Assistance in Dying” suggests informing patients about MAiD if the practitioner suspects it aligns with patient values and preferences. In contrast, other jurisdictions discourage or prohibit raising death as a treatment option due to concerns about undue patient pressure. The model practice standard’s stance on “conscientious objection” supports “effective referral” of patients. This means that, if a physician is concerned that MAiD is not a patient’s best option, they must still refer the patient to ensure access to MAiD, instead of pausing or stopping the process.

Examples of these unsafe policies are evident in MAiD training videos. In one, an instructor recognizes that patients may choose MAiD for unmet psycho-social needs, suggesting referral for MAiD completion if discomfort arises. Another instructor in a separate video advises continuing the MAiD process even if a practitioner believes a patient doesn’t qualify for MAiD, suggesting doctor shopping is acceptable.

Certain regions in Canada have the highest MAiD death rates globally. By 2022, nearly 45,000 MAiD deaths occurred across Canada since its legalization—almost 13,000 in 2022 alone, with estimates for 2023 approaching 16,000. Canada’s MAiD regime has chosen to prioritize accessibility over patient safety.

Dr Coelho then comments on her experience with the disability community:

Realizing my political naivety while advocating for legislative change has been a profoundly sad and eye-opening experience. Despite the government’s repeated assurances of listening to the concerns of persons with disabilities and their advocates, the reality witnessed during parliamentary hearings has been disheartening, as their voices are frequently disregarded or dismissed.

Throughout these hearings, committee members have consistently challenged the credibility of accounts detailing abuses within the Medical Assistance in Dying (MAiD) system. They assert an unwavering trust in MAiD assessors, portraying them as professionals deserving of complete faith and trust to get it right every time. However, this confidence is inconsistently applied, as committee members often interrupt and question the integrity of medical and legal experts expressing caution or offering alternative perspectives.

Furthermore, the presence of physicians who are now part of the government on MAiD parliamentary committees has not resulted in the expected depth of medical expertise or unbiased guidance. Instead, their contributions have often been marked by bias, with loaded questions designed to limit responses and paint concerned witnesses as advocating for prolonged suffering. This portrayal is starkly at odds with the reality faced by patients who endure lengthy waits for treatment. This waiting for care and being neglected by our society and health care system wears people down and can lead to choosing MAiD as the only accessible option.

Dr Coelho then comments on the euthanasia lobby:

Behind the scenes, powerful lobby groups in Canada wield significant influence in shaping the debate surrounding the expansion of MAiD. These groups, backed by substantial funding for government relations, dictate the trajectory of discussions, often overshadowing the voices of the underfunded and marginalized disability community. Despite the government’s claims of inclusivity, the reality is that this debate has been primarily driven by powerful interests, rather than the voices of those directly affected.

In essence, the legislative process surrounding MAiD in Canada has exposed systemic flaws and power imbalances, highlighting the urgent need for genuine inclusivity and meaningful dialogue that centers on the experiences and concerns of the real stakeholders, the disability community, which is most directly impacted by these policies.

Coelho is then asked about what must be done to reduce MAiD:

Thomas Insel’s book Healing drives home the critical role community life, support networks, and purpose have in dictating mental health outcomes, thereby highlighting the need for proactive measures. Firstly, the government must fulfill its duty to ensure everyone gets timely care, counseling, and the community resources they need. It’s unfortunate that we’re offering death as an option without properly supporting people who are struggling. At the same time, establishing a national suicide prevention framework is imperative to mitigate the risk factors that could contribute to MAiD decisions.

Palliative care centers have to be prioritized, offering a range of services including pain management, emotional support, end-of-life planning, and counseling individuals facing terminal illness, alongside robust access to disability and mental health services. This entails a concerted effort to build expertise, expand medical care systems, and ensure widespread accessibility.

Investment in community systems is essential too, fostering relationships and a sense of purpose and belonging. By organizing regular community gatherings, support groups, and educational workshops, communities can forge stronger bonds, mitigating feelings of isolation and despair. On the ground level, everyone can be involved in making sure neighbours and family members feel they are needed and cared for.

Furthermore, Canada’s commitment to the UN Convention on the Rights of Persons with Disabilities must be upheld, ensuring the provision of essential services and support for those with disabilities and chronic illnesses. The government has to address the systemic lack of social, economic, and health supports in order to alleviate the suffering that may otherwise drive individuals towards MAiD. We know that suffering from social and economic deprivation actually increases overall suffering from disability as it becomes conflated.

In essence, reducing the number of victims under Canada’s MAiD regime requires a comprehensive approach. Only through concerted efforts across these fronts can Canada ensure the dignity and well-being of its citizens, particularly those facing vulnerability and suffering. We need to make people feel they can live with dignity.

Dr Coelho is then asked what a future government must do:

Sadly, many Canadians remain unaware of the risks of our MAiD regime. As I mentioned, once a society embraces ending life as a solution to suffering, containing this procedure becomes nearly impossible. Tragically, the victims of this system are dead and can be forgotten, silenced, unable to recount the injustices that may have influenced their “choosing” death.

Therefore, to start, completely repealing Bill C-7 is imperative. Anything less is unacceptable to the disability community and greatly perpetuates the risks that death is driven by unjust circumstances.

There is also an urgent need to redefine the terms used in legislation, particularly ambiguous terms like reasonably foreseeable natural death (RFND). Through broad interpretations, individuals with potentially years of life ahead of them are prematurely ending their lives through the RFND track—a practice that was intended only for those in the final stages of life. Moreover, we have people who are simply stating they will refuse care to make themselves sick enough to qualify for RFND; MAiD should only be available to those with a disease prognosis of six months or less, not to individuals deliberately inducing sickness to qualify.

It is necessary to stem the influence of powerful lobby groups and expansionist medical advocacy organizations like the Canadian Association of MAiD Assessors and Providers (CAMAP). CAMAP received 3.3 million Canadian dollars in funding from Health Canada to educate MAiD assessors and providers and has many problematic guidance policies. A balanced independent panel of experts, as urged by the Canadian Human Rights Commissioner, should be convened to review the MAiD regime. This panel should guide legislative amendments, Health Canada policies, and provincial regulatory bodies to increase patient safety.

Many existing policies clearly require revision, including raising MAiD unsolicited, enforced mandatory referrals, and the worrisome trend of integrating MAiD into all care facilities. Ideally, a civil board comprising a multidisciplinary team should evaluate each case before approval to mitigate choices to die that are driven by structural inequalities. We also need better, publicly available, data collection all around.

This is not merely a matter of individual autonomy; it is a public safety concern that is affecting marginalized and disabled individuals. When discussing autonomy, we must consider relational autonomy—what we owe to each other and society as a whole. MAiD is a public policy, so we must consider the well-being of all—not just those seeking to end their lives on their own terms.

Previous articles by or articles concerning Dr Ramona Coelho (Article links).