Ontario: At least 428 non-compliant euthanasia deaths.

The reason the public has been left in the dark about Canadian euthanasia providers’ noncompliance with the law is simple: the authorities have decided there is nothing to see.

Alex Schadenberg
Executive Director,
Euthanasia Prevention Coalition

A research essay by Alexander Raikin that was published by the New Atlantis on November 11, 2024 uncovers that there have been at least 428 non-compliant euthanasia deaths in the province of Ontario. In his research essay Raikin sets out the tone of his conclusions in his opening paragraph by stating:

For years, there have been clear signals that euthanasia providers in Canada may be breaking the law and getting away with it. That is the finding of the officials who are responsible for monitoring euthanasia deaths to ensure compliance in the province of Ontario. Newly uncovered reports reveal that these authorities have thus far counted over 400 apparent violations — and have kept this information from the public and not pursued a single criminal charge, even against repeat violators and “blatant” offenders.

Firstly, I would like to thank Alexander Raikin for the incredible research and continued research into Canada's euthanasia law. Raikin's essay is long but thorough. I can assure you that Raikin is only uncovering the tip of the iceberg.

Raikin outlines his research by establishing the parameters of the law. He explains that Canada's euthanasia law is regulated by criminal law and through provincial and federal regulations. Non-compliance with the law may lead to convictions and jail sentences.

Raikin has conducted in-depth research into the compliance with the euthanasia law in Ontario and uncovered that non-compliance with the law. Raikin reports:

From 2018 to 2024, in presentations held behind closed doors and in reports that were nominally public but garnered little attention, Huyer has shown that his office has identified hundreds of “issues with compliance” with the criminal law and regulatory policies. In 2023, his office raised these concerns for a quarter of all euthanasia providers in Ontario.

Most of the information in these documents, which were shared with The New Atlantis by three physicians who had access to them on condition of anonymity, is being newly made public or reported on for the first time in this article. Raikin writes:

After more than four hundred identified issues with compliance, ranging from broken safeguards to patients who were euthanized who may not have been capable of consent, Huyer’s office has failed to alert the public or take any steps to prosecute offenders. Whether or not these hundreds of “issues” are in fact violations of criminal law is unclear precisely because none of them have been referred to law enforcement for investigation. Instead, Huyer’s office has deemed virtually all of them as requiring nothing more than an “informal conversation” with the practitioner or an “educational” or “notice” email. Even in one egregious case, in which the practitioner was found to have violated multiple legal requirements, and which Huyer himself described as “just horrible,” his office reported the case only to a regulatory body instead of the police.

Non-compliance with the law existed from the law's inception. Raikin explains:

In June 2017, a year after euthanasia was legalized in Canada, Dirk Huyer and two co-authors published a paper in the journal Academic Forensic Pathology that examined the first one hundred euthanasia deaths in Ontario based on reports to his office by euthanasia providers. The paper shows early warning signs that providers were not complying with the federal criminal regulations for MAID.

Raikin quotes from the paper:

“The MAID regulations require clinicians to notify the pharmacist of the purpose of the MAID medications before they are dispensed,” the paper notes. “However, some physicians listed that they did not abide by these regulations.” Only 61 percent did. Federal legislation at the time also required a 10-day waiting period between the request for euthanasia and the administered death to ensure that patients really did wish to die, a safeguard that could be waived only if the patient was approved and on the verge either of losing capacity to consent or of imminent natural death. Yet according to the paper, euthanasia providers recorded expediting deaths for reasons including not only loss of capacity or imminent death but “persistent requests” and “inconvenient timing of the death in relation to other familial life events.”

Huyer admits in 2018 that these issues with non-compliance never went away. Raikin writes:

In an October 2018 memo to all Ontario health care practitioners, Huyer announced that his office would implement a new system “to respond to concerns that arise about potential compliance issues.” That is because “some case reviews have demonstrated compliance concerns with both the Criminal Code and regulatory body policy expectations, some of which have recurred over time.”

In the new system, each compliance issue gets assigned a “level” of severity, with 1 being the least severe and 5 the most severe, along with an action the Coroner’s Office will take to address it, from an informal conversation (Level 1) to a report to the police (Level 5).

In a video uncovered by Raikin, Huyer tells a group of Nurse Practitioners that a pattern of non-compliance continues. Raikin writes:

At a private monthly webinar of Ontario nurse practitioners in December 2018, available as an unlisted video on YouTube where it has been viewed only a few dozen times, Huyer further explains...

...there is a “very small handful” of practitioners who “are not responding to our educational input and are maintaining the same practice repetitively. And so we see a pattern of noncompliance, we see a pattern of not following legislation, a pattern of not following regulation, and frankly we can’t just continue to do education to those folks if they’re directly repeating stuff that we’ve brought to their attention.”

In the video Huyer outlines one of the cases:

One is a blatant situation that’s published through the College of Physicians and Surgeons of just being completely unprepared and bringing wrong medications. They brought scopolamine and Ativan. Those were the drugs that the clinician brought to the home to administer MAID. And it was just horrible. It was horrible. The family, and I’m talking about what’s public, so this isn’t anything non-public, the family and the deceased person suffered tremendously.

Huyer explains that he reported this case to the College of Physicians and Surgeons who investigated the case and they concluded that the College:

“was of the view that Dr. Tjan” — the euthanasia provider in this case — “continued to underestimate the magnitude of providing medically-assisted death and the responsibility attached.”

Raikin states that Dr. Eugenie Tjan remains a licensed physician in Ontario and she continues to practise palliative care and euthanasia.

Raikin points out that if this case did not trigger a criminal investigation, no wonder the compliance concerns that Huyer’s office identifies have received so little public attention. Meanwhile, out of sight, the number of concerns continued to rise.

When Raikin asked Huyer by email about why no cases have been referred to law enforcement, Huyer replied that:

..the responses “are case specific and we look at each case wholistically.” If his office believes that “the MAiD process was overall appropriate” and “the issue was isolated,” then “we do not notify other organizations, e.g., regulatory bodies or law enforcement.”

Huyer gave a presentation in September 2020 titled: “Monitoring and Oversight of Medical Assistance in Dying in Ontario.” Raikin reports:

Dr. Huyer gave a presentation on “Monitoring and Oversight of Medical Assistance in Dying Ontario” at a symposium of the Canadian Association of MAID Assessors and Providers. According to slides The New Atlantis has obtained of this presentation, Huyer’s office identified 76 “issues with compliance” since it had implemented the level system in late 2018, roughly a two-year span. All of these compliance concerns were assigned one of the first three levels of severity, triggering at most a “notice email” to the practitioner.

Based on the 76 identified issues, Huyer responded by 16 cases - Informal conversation/email with the provider, 51 cases - sent an educational email, 9 cases - sent a notice email. Raikin continues:

Yet the concerns were not insignificant. They fell into two categories, the first of which was problems with “documentation and compliance with legislation.” This included “poor/no completion of accompanying assessment notes” on how eligibility for euthanasia was decided by the clinician. It also included “missing documents,” and “partial completion / no completion of federal reporting requirements by clinicians.”

That this information is missing or incomplete in some cases should be a very serious matter. After all, the mandatory reporting exists to establish that the requirements under criminal law for ending thousands of lives were met.

Raikin points out that ignoring the 10-day reflection period (waiting period) in the law, that was removed from the law in March 2021, was a common issue and the capacity to consent was a second serious issue with non-compliance.

When Canada legalized euthanasia it did so under the pretense that the law would be limited to people who were competent adults who were capable of consenting and yet one of the key areas of non-compliance was the capacity to consent.

Raikin continues:

Compounding these problems for the Coroner’s review process is that, after the patient’s death, it is very difficult and perhaps impossible to find out whether a patient in fact did or did not have capacity to consent to be euthanized. In his presentation, Huyer notes “consequent challenges in determining the capacity of a patient seeking MAiD from an oversight perspective after death has occurred.”

In his presentation to the 2024 annual conference of the Canadian Association for MAiD Assessors and Providers (CAMAP) Huyer gave a presentation titled: “Lessons Learned from the Coroner," Raikin reports that Huyer:

providing more detailed information up through 2023. The slides The New Atlantis has obtained of this presentation show that for 2023 alone, Huyer’s office identified 178 compliance problems — an average of one every other day — bringing the total since implementation of the level system to 428.

Raikin explains that of the 428 known cases of non-compliance that only 4 cases triggered a response to the regulatory body and not a single case was reported to the police.

Raikin points out that a quarter of all euthanasia providers have had a compliance issue, 12% of all dementia euthanasia cases had compliance issues, 8% of chronic pain euthanasia deaths had compliance issues, 15% of euthanasia cases for people who are not terminally ill had compliance issues. Raikin reports that Huyer presented this at the CAMAP conference:

Again for euthanasia deaths where the patients were not terminally ill, in some cases practitioners reported that they were not experts in the illness that caused the person’s suffering, and no outside expert was consulted — violating a safeguard mandated by federal criminal law. In a recorded video of Huyer’s conference presentation, also obtained by The New Atlantis, he described these cases as “a learning opportunity, let’s put it like that.” (The share of cases Huyer stated at the time, both in the video and the slide show, was 6 percent. In a revised report by the Coroner’s Office that has since been publicly released, the number is 1.7 percent.).

It is interesting to note that 10 euthanasia providers in Ontario had provided 25% of the euthanasia deaths.

Violations of the assessment period for non-terminal Track 2 euthanasia deaths.

In March 2021 Canada expanded it's euthanasia law to people who were not terminally ill but may have had chronic conditions. These cases are known as Track 2 euthanasia deaths and they require a 90-day assessment period before the death can be completed. Raikin uncovers significant violations concerning Track 2 deaths. Raikin writes:

In a May 2024 memo to Ontario euthanasia practitioners, the Coroner’s Office describes the “case example” of a person suffering from stroke, neurocognitive disorder, and vision loss whose assessment period was 71 days. The memo notes as a “learning point” both that the counting of the 90 days began too early in the process and that “the assessment period was incorrectly shortened” — the person was not imminently losing capacity to consent. Rather, the date of death was chosen by the person’s spouse “based on the spouse’s preference of timing.” Parenthetically, the memo notes that this “raised considerations regarding potential impacts to voluntariness and coercion.” Notably, this public report — unlike Huyer’s private presentations — did not identify whether physicians failed to comply with legislation.

Raikin then comments on the normalization of non-compliance in Ontario concerning it's euthanasia law.

Canada’s criminal law on euthanasia states that “Medical assistance in dying must be provided with reasonable knowledge, care and skill and in accordance with any applicable provincial laws, rules or standards.” And yet the Office of the Chief Coroner of Ontario has decided that euthanasia practitioners’ ongoing failures to comply are best resolved through emails. The highest-level response it routinely applies, Level 3, happens “when there are identified issues with statutory requirements and/or repeated practice issues.” The Coroner’s Office in these instances sends a “notice email.”

Level 4 is applied in cases of statutory requirements (such as “eligibility requirements”) and cases of “significant” issues with practice. This level triggers a report to a regulatory body. Huyer’s 2024 presentation offers as a hypothetical example the euthanizing of a minor. In other words, according to the Chief Coroner’s rubric in the presentation, and to the Coroner’s public website, last updated in May 2024, euthanizing a minor would not automatically lead to a police report.

Raikin explains that in 2024 there was one Level 4 reponse but no information has been made available about that case but he did find information about another earlier Level 4 reponse. Raikin explains:

This is the case of a woman whose son brought before the College a complaint that she was improperly assessed before being euthanized and that the roughly 4 weeks between her MAID request and her death was not enough time to understand her condition, since she was not in any physical pain.

Upon reviewing the case, the College’s investigative committee decided to not take any action. The committee reasoned that “the Coroner’s office … is responsible for reviewing each case to ensure that all the proper checks and balances were in place and that the process was followed properly,” and it “did not find any concerns.”

Raikin points out, even a case that is deemed to be serious by the Ontario Coroner and sent to the Ontario College of Physicians and Surgeons for assessment does not lead to any redress.

I notice that there wasn't even a temporary suspension of a medical license.

Raikin also questions why information is not being shared with the public. Huyer reponded by stating that:

“We share regularly through Health Canada and our presentations. Nothing was confidential — we are working to more systematic reporting.” In a follow-up, he added: “we have widely shared our response framework and have shared the number of levelled responses to a number of media outlets and at conferences and meetings over the past years.”

But Raikin points out that

Some of the information in this article was previously public, as noted throughout. But in many cases it was public in name only, as it remained at obscure online locations or available only to MAID professionals, and had not been previously reported on in the media. ...Finally, searches on multiple key phrases confirm that the 2020 and 2024 slideshow presentations at the center of this article had never been released publicly.

Raikin then states:

If it seems like Canada’s oversight of euthanasia should receive closer public, medical, and law enforcement scrutiny, that is a concern shared by at least two members of Ontario’s MAID Death Review Committee — an advisory group formed by the Chief Coroner to help improve the MAID system in the province — to whom I spoke for this article.

Trudo Lemmens, a University of Toronto law professor told Raikin that:

“In my opinion, any violation of the MAID law, considering that it’s a criminal law, should be reported to the police and to the College — as a matter of principle — and should certainly be investigated by an independent prosecutor…. I don’t know why that hasn’t happened,”

It’s a serious issue. I mean, this is a criminal law and I’m worried that the lack of referring for prosecution and for investigation by the College of Physicians and Surgeons reflects a kind of normalization of MAID as some kind of inherent beneficial practice.”

Dr. Ramona Coelho, a family physician from London, Ontario, and a senior fellow of the Macdonald–Laurier Institute, a public policy think tank, told Raikin by email:

“it has been distressing to learn that some authorities, well aware of non-compliance with the law, did not publicly report them.”

Raikin concludes his essay by stating:

The reason the public has been left in the dark about Canadian euthanasia providers’ noncompliance with the law is simple: the authorities have decided there is nothing to see.

Thank you to Alexander Raikin for his incredible research. It must be pointed out that Ontario represents about one-third of all euthanasia deaths in Canada. Considering the number of euthanasia deaths in British Columbia and Québec and the number of concerning cases that have been published in the media, I would not be surprised if there are a similar number of non-compliant cases in British Columbia alone and we already know from the Québec reports that a significant number of non-compliant cases have occurred in "La Belle Province."

Previous articles by Alexander Raikin:

• Insight into the cautionary tale of Canada's euthanasia regime. (Link).
• The rise of euthanasia in Canada, from exceptional to routine. (Link).
• Canada's Ministry of Death (Link).