Does Canada's euthanasia law enable healthcare serial killing.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Christopher Lyon

Professor Christopher Lyon, who teaches at the University of York in the UK, researches and concludes that Canada's (MAiD) euthanasia law enables healthcare serial killers (HSK).

Lyon's research was published by HEC Forum on August 2, 2024 under the title: Canada's Medical Assistance in Dying System can Enable Healthcare Serial Killing. 

(Read the research article with references (Link).

Healthcare serial killers (HSK) is not a new phenomenon. Lyon writes about several well known HSK's, and examines what enable them to remain undetected for long periods of time while killing their patients.

Lyon outlines his article by stating:

Criminal HSK appears globally. Offenders may kill fewer than ten to hundreds of people. They are often challenging to detect and stop due to job-related access to means of killing, responsibility for record-keeping, trusted role, professional insularity and protectionism, poor oversight, and victims whose deaths are less likely to attract suspicion due to age, illness, or existing likelihood of dying. Ambiguous or divergent legal and medical concepts and practices can make prosecuting HSK challenging.

He continues:

Medical Assistance in Dying (MAiD), the expression frequently used to describe legal euthanasia or assisted suicide (EAS) in Canada and elsewhere, is currently available in several countries and under consideration in others. Beginning in 2016 with “no model…without standards, without guidance, without training”, Canada’s MAiD system is criticized as the most permissive or least safeguarded in the world, raising the question of whether it could protect patients who fit the clinical profile of adult victims of HSK from a killer working as a MAiD provider. Indeed, like the systemic issues that enable criminal HSK, concerns are frequently flagged that the risks stemming from the Canadian MAID programme’s ambiguous criteria, noncompliance with law and regulation, applications in mental illness, impact on clinical staff, and inconsistent oversight. Accordingly, assessing the Canadian system through the HSK lens is helpful in illuminating gaps in the safeguards and opportunities to prevent abuses by such an offender. This task is critical, as forms of MAiD are available or under consideration in many countries, and Canadian courts seem likely to maintain some form of its constitutional permissibility.

Lyon begins by outlining Canada's law.

The Criminal Code defines MAiD as a “non-culpable” form of homicide that is “not an offence,” whereas “culpable homicide is murder, manslaughter, and infanticide.” Similar to other countries, clinicians engaged in legal MAiD must assess candidates and terminate their lives within the legislated eligibility criteria. Track 1 MAiD, legal since 2016, is for people whose “natural deaths are reasonably foreseeable”. Since 2021, track 2 has been available for those with a “reasonably foreseeable natural death” after a 90-day “assessment period”.

Currently, to be assessed for legal MAiD, a person must be at least 18 years of age and capable of “making decisions with respect to their health” and independently assessed by two nurse practitioners or medical doctors to “have a serious and incurable illness, disease or disability,” to be in “an advanced state of irreversible decline in capability,” and that those issues produce “enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable” (Criminal Code, 1985, sec. 241). The applicant must also be informed of means to relieve their suffering. Still, such means do not have to be provided or attempted before death is available, a feature unique to Canadian MAiD.

Lyon explaines the changes to the law in 2021 that created a two track law whereby people who are deemed to be terminally ill can have a same day death and people who are deemed to not be terminally ill, but approved for euthanasia, must wait 90 days. Lyon explains:

Track 1 eligibility is broad. It ranges from a clinically assessed terminal or worsening of a patient's diagnosed illness, disease, or disability that makes their death subjectively “reasonably foreseeable” to, at least as advised by the Canadian Association of MAiD Assessors and Providers (CAMAP), a remediable intention or action to attempt suicide through refusals of care, sustenance (i.e., voluntarily stopping eating or drinking, or VSED) or other unspecified measures that would cause or hasten death if left unremedied. Some published witness accounts and parliamentary committee testimony suggest the track 2 assessment period can be shortened this way. Comments in CAMAP’s 2018 conference report and a journal also assert that a MAiD clinician is unlikely to be prosecuted for mentioning to an ineligible person forms of suicidal self-harm to hasten death or make them eligible for MAiD, implying that clinicians have an informal power to engineer eligibility. At least one jurisdiction permits (or permitted) family members, not criminally exempted clinicians, to administer the lethal injections. Québec’s MAiD commission annually identifies multiple cases of criminal and provincial law-breaking in MAiD deaths, amid other cases in prisons, Ontario and British Columbia. However, there are no known instances of regulatory sanctions, prosecution, pending or attempted, of these transgressions, which include approvals and deaths of patients who lacked capacity or did not meet other eligibility criteria. A lawyer in an unsuccessful recent case challenging a MAiD approval pointed out that in their province “AHS [Alberta Health Services] operates a MAID system with no legislation, no appeal process and no means of review”.

Lyon examines the role of Dying with Dignity, Canada's leading euthanasia lobby group. He continues by describing how healthcare serial killers (HSK's) carried out their murders without being detected and the research related to preventing HSK's. For the purpose of brevity Lyon examines HSK's Elizabeth Wettlaufer, Harold Shipman, Charles Cullen, Lucy Letby, Gosport War Memorial Hospital and the Liverpool Care Pathway. 

Lyon compares the workings of Canada's euthanasia law in relation to known cases of HSK's:

Because MAiD typically involves clinicians who sequentially assess and euthanize two or more patients, it can be accurately described as non culpable serial homicide, a legal form of HSK, if Criminal Code eligibility criteria and safeguards are met. If clinicians do not adhere to these safeguards and criteria, they commit culpable serial homicide.

Whether MAID’s regime may facilitate criminal HSK hinges on concerns about the adequacy of safeguards emerging from academics, clinicians, MAiD practitioners and colleagues, journalists, and family members of MAiD recipients. Despite these issues, risks of culpable homicide do not explicitly feature in today’s MAID discourse, beyond limited prospective arguments it might “veil…homicides occurring within the health system—whether consensual or not”. Some features of Canada’s MAID system that might support this position are described next, organized by clinician and structural issues.

Lyon first comments on the broad criminal exemptions for MAiD providers.

The potential problem of HSK in MAiD begins with the unprecedented Criminal Code exemptions from homicide and suicide offences (Criminal Code, 1985), effectively legalizing a form of HSK through a loophole missing from other HSK instances, in addition to the pre-existing difficulty in prosecuting known cases. In this light, MAiD may have rendered prosecutions of clinicians even more difficult or lenient, perhaps evidenced by the lack of charges so far in any of the cases identified as questionable or legally non-compliant MAiD in the news and official reporting.

Lyon then comments on the self-reporting system and concerns with compliance and the lack of law enforcement.

Unlike other MAiD jurisdictions, Canada uniquely lacks an oversight system to independently review MAiD requests, consistent post-death reporting, and a waiting period between approval and death. Despite known referrals, no police investigations or charges are yet known in these cases of federal criminal and provincial law violations. It is also dubious that healthcare systems could readily spot and stop culpable homicides in MAiD by relying on self-reported legal compliance, filtering possible criminal activity through local oversight or regulatory colleges before (electively) involving police, or operating without a supervisory unit at least as empowered as Québec’s MAiD commission.

Lyon comments on the power of the clinician to define and apply MAiD.

Some legal scholars argue that clinicians who mistakenly believe they are enforcing a positive right with the unrequested presentation of MAiD may edge into coercion or legal precarity if they do so for people “seeking not MAID but rather help for suicidality or other forms of care”, a concern reflected in some local guidance. However, CAMAP’s documents and an associated legal academic asserts that prosecutors would be uninterested in clinicians who tell ineligible patients about suicidal actions that might qualify for MAiD and advise medical staff to mention the option of death by MAiD to anyone potentially eligible.

These sentiments recall the warnings of euphemisms and individual biases in Gosport and LCP and the risks from confusing medical with speculative legal and personal views, allowing clinicians to perceive and shape MAiD and assessments and communication in ways that may favour a death outcome.

Lyon comments on the financial incentives for euthanasia providers. He outlines the fact that euthanasia providers are not only paid to kill but many of them are now have a role on the CAMAP, how some of the killers are now collecting money as speakers and at least two of them have published books.

Lyon comments on the fact that many of the providers view their role as a "mission" or an "obligation". Lyon writes:

Approaching prospective MAiD recipients from a sense of personal duty or desire for social change may confuse a clinical eligibility assessment with a political mission. An account of a provider “counselling” a prospective patient with psychosis to fly to their clinic for MAiD, where an unknown but somehow qualifying physical illness might be found and annual reports of numerous deaths that broke federal and provincial laws, including people without a required serious incurable illness or fluctuating eligibility, in addition to expansionism, raises the question of whether a mission view can incentivize transgressing laws and safeguards.

Lyon then comments on sadism and pleasure:

Sadism may be associated with non-sexual pleasure derived from opportunities for cruelty toward others and killing or harming sentient creatures. Though not always sadistic or sexual, pleasure is also a frequent occurrence of SK, may be addictive and is a feature of clinical personality disorders. This is important because elation and a sense of liberation from ending suffering are common in HSK. MAiD providers likewise describe positive feelings for gratification from killing, including feeling “hyped up on adrenaline,” “very good,” “gratification,” and “satisfaction” or as,

“Loving;” “a solitary practice;” “intimate contact;” “heartwarming,” “the most important medicine I do;” “satisfying medicine;” and “rewarding.”…“an ultimate act of compassion; “an honor;” “incredible gift;” “liberating;” “unlike anything I’ve ever…” and “extraordinary work”…“the right thing in the right circumstance.”

In Australia, one provider mentions “a pressing need for sex” after a death.

MAiD (as a suicide or homicide) provides opportunities for sadists to cause death to the patient and perhaps cause indirect harm if the provider is aware of a patient using it to emotionally harm people that they dislike (e.g., ex-partners, by scheduling death on their birthdays or weddings). Providers sometimes appear hostile toward witnesses or family members.

Lyon comments on pathological altruism and mercy-heroism:

Noted elsewhere is the “mercy-hero” variation of HSK, which also results from a distorted sense of self and compassion without the power and control features of sadism. Providers who describe MAiD as “care,” “loving,” “compassion,” or “alleviating suffering,” or as a form of compassion derived from “suffering in someone else and the desire to change that to help them” may align with this possibly pathologically altruistic type of killing.

Lyon discusses the lack of clinician vetting, structural issues in Canada's law, bureaucratic obstacles, imprecise and poorly designed concepts, hastening death, assessor shopping, pairing and soliciting, deficient data and ambiguous reporting, unmonitored, unassessed or undermined capacity to consent to death.

Ellen Wiebe

Lyon examines two leading Canadian euthanasia providers, Dr Ellen Wiebe and Dr Stephanie Green. Lyon courageously states about Wiebe:

Wiebe’s public history of MAiD has themes of HSK in that it is custodial, mission-driven, and utilitarian, with possibly sadistic elements in her apparent enjoyment of patient deaths and dismissing, disparaging, subverting, or overcoming patients, loved ones, regulators, organizations, and law that she disagrees with or who resists her efforts. Like HSK, she has a track record of multiple serious formal complaints involving patient deaths against her that, while dismissed, still merited high-level regulatory review.

Lyon states about Green:

Green’s approach to MAiD shares themes with custodial, utilitarian, and sadistic or mercy-hero HSK descriptions as she financially and emotionally benefits from her homicides, makes self-promotional claims about her status and skill, suggests she is helping, yet also justifies and distances herself from her actions.

Lyon then offers proposals for tightening up  Canada's euthanasia law in a way that would prevent the concern with health care serial killers. I will not comment on these proposals but I will go to his conclusions:

While provocative, this paper is limited to critically assessing the MAiD system as an opportunity structure for culpable HSK to highlight gaps in the current safeguards. It does not assess that criminally culpable homicide (murder, manslaughter, etc.) is happening, only that it could, and that Canada’s MAiD regime may serve as a protectorate that allows serially homicidal personalities to “safely” or legally kill. How society and medicine reconcile with that possibility or other issues of the morality, ethics, or clinical and social benefits or harms of MAiD are beyond consideration here. Additionally, the examples cited in this paper are drawn entirely from publicly available sources. It is unknown what confidential or internal information may be available to confirm or mitigate these concerns—yet it is already easy to identify fundamental problems with the safeguards. This paper also addresses the possibility of malfeasance on the supply, rather than demand, side of MAiD. Further criminological or sociological research might, for example, examine MAiD through a “victim-offender overlap” lens and the influence of promotional marketing by DWDC and others. Other parallels may appear between MAiD assessment and provision and the idea of HSK as a confidence trick, especially where a provider frames MAiD (death) in attractive language to patients and their caregivers. Related work could also explore the possibility, perhaps implicit in some recent reporting, that MAiD requestors may manipulate law and safeguards or individual providers, akin to “suicide-by-police”.

Canada’s recent history involves unprosecuted admissions of illegal assisted suicide or homicide by clinicians who deemed the law unfair. Now legally protected under MAID, clinicians may sequentially take many lives by euthanasia, committing serial non-culpable homicide. It is reasonable to consider that without adequate oversight, some medical practitioners may be drawn to commit MAiD homicides for personal benefit and rationales that diverge from MAiD’s legal, bioethical, and medical justifications, with some suggestion that this could be occurring. Examining the current MAiD system’s ability to enable or conceal serial murder is a valuable way to assess its ability to prevent this occurrence. Such an analysis shows that poor vetting, ambiguous concepts, inconsistent oversight and standards, assessor shopping, and concentrated clinician power and prejudices combine to describe a system bereft of measures to prevent and detect criminally culpable or antisocially motivated individuals operating as MAiD assessors and providers. Remedying these issues will better protect patients and systems from such abuses, which may still have to contend with law-abiding clinicians participating in MAiD for the same benefits and motives as their criminal counterparts—reminding us again of the many warnings of the lethal dangers of bias and poor oversight in EAS.

Christopher Lyon became concerned with Canada's euthanasia law after his father died by euthanasia in questionable circumstances in Victoria BC. Lyon was recently interviewed by Sharon Kirkey for an article that was published in the National Post on July 6, 2024:

Others like Christopher Lyon, a Canadian social scientist at the University of York in the U.K. have remarked that pleasure from euthanasia is deeply disquieting, “because death is usually a deeply painful or difficult moment for the patients and their loved ones.”

Lyon’s 77-year-old father died by MAID in a Victoria hospital room in 2021, over the family’s objections. (Wiebe was not the provider.) His father had bouts of depression and suicidal thinking, but was approved for MAID nonetheless. Lyon wonders what draws some providers to MAID “and what happens to a person when killing becomes a daily or weekly event.”

“Some providers have counts in the hundreds — this isn’t normal, for any occupation,” he said. “Even members of the military at war do not typically kill that frequently. I think that’s a question that we’ve not really ever asked.”

Christopher Lyon has the strength of character to write the reality about Canada's euthanasia law, that the law is not designed to prevent health care serial killers from becoming legal euthanasia providers.