How many Quebec euthanasia deaths actually occur?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Alex Schadenberg

In early February I wrote an article stating that: There were approximately 16,000 Canadian euthanasia deaths in 2023 and more than 60,000 since legalization I made my prediction based on the euthanasia data from Ontario, Quebec, Alberta and Nova Scotia. I wrote in my February article:

The Quebec Commission on End-of-Life Care released it's Eighth Annual Report which indicated that there were 5211 reported euthanasia deaths (April 1, 2022 - March 31, 2023) which was up from 3663 in the previous year (April 1, 2021 - March 31, 2022). According to the data there have been 15,997 reported euthanasia deaths from legalization until March 31, 2023 in Quebec.

This represents more than a 42% increase in Québec euthanasia deaths in 2023 representing 6.8% of all Québec deaths, which is the highest in the world.

The report also indicates that from April 1 - June 30, 2023 the number of reported Québec euthanasia deaths increased by another 24%, a slower pace of growth, but substantial considering the massive number of euthanasia deaths.

Amy Hasbrouck

When analyzing the Québec data I noticed some significant concerns. Were there 5211 Quebec euthanasia deaths or were there 5401?

Amy Hasbrouck from Toujours Vivant - Not Dead Yet, provided further analysis of the data found in the Eight Annual Report of the Québec Commission on End-of-Life care. Hasbrouck's indicates the following: 

How many Euthanasia deaths? 

• 5,211 MAiD reported by doctors in declaration forms (§ 3.2 p. 13)
• 5,401 euthanasia reported by hospitals and institutions (table C6 p. 46) 
• 5,208 MAiD declaration forms received by the Commission (§ 2.1, p. 6)
  

Total euthanasia deaths since legalization?

• 15,997 Adjusted MAiD from declaration forms (figure 3.2 p. 13, Row 3) or
• 16,044 (p. 28, “Observations”) 
• 18,532 Total declared by hospitals and institutions. (AR Table C6, QAR stats Row 7) 
  

Non-compliance with the law:

• The Commission concluded that 16 people did not have a serious and incurable illness
• Some people had loss of independence due to aging,
• Others had serious symptoms, but not clear diagnosis,
• Three people had disabilities, but no serious illness, which is a requirement for Québec’s statute 
• One non-compliant because doctor did not get confirmation from a second physician,
• One form was not signed by a health or social service professional,
• Two did not have valid QC health insurance. Since May 2022, the Commission no longer declares as “non-compliant” cases where the health insurance card has expired. This applied to 11 additional cases documented in the 8th annual report.

It must be noted that every year the Québec report admits to cases of non-compliance with the law. None of these cases have resulted in legal or professional actions. In August 2023, Dr. Michel Bureau, the President of the Québec Commission on End-of-Life Care sent a letter to euthanasia doctors urging them to stop abusing the law. In that letter Bureau claimed that there were two to three euthanasia deaths each month that did not fit the criteria of the law.

The 2022 - 2023 report was not the first year with concerns. In fact, all of the reports of the Québec Commission on End-of-Life Care have contained issues.

Hasbrouck reported in her article on the 7th Annual report that:

The seventh annual report from Québec’s Commission on end of life care was filed in Québec’s National Assembly on December 9, 2022. The report covers the 2021-2022 period (April 1, 2021 to March 31, 2022).

The Commission reported 3,663 euthanasia deaths declared by doctors during the fiscal year (p. 13), while the number of euthanasia deaths reported by facilities (3,629) and the Collège des Médecins du Québec (323) totalled 3,952 (p. 25 at note 25); a discrepancy of 289 deaths.

Hasbrouck stated in that article:

In light of the discrepancy (289 deaths) between the number of euthanasia reported in doctors’ declaration forms (3,663) and the facilities’/CMQ reports (3,952), and the unaccounted MAiD requests that didn’t end in euthanasia, (78 people) it’s hard to take seriously the Commission’s claim that 99.6% of euthanasia complied with the requirement of the MAiD law.

Québec is the only Canadian province that has two streams for euthanasia reporting, enabling the uncovering of under-reported euthanasia deaths. Quebec is also the only province that provides information indicating that some of the euthanasia deaths were outside of the law.

It is likely that under-reporting and non-compliance with the law exists in other provinces except that the other provinces don't have a dual reporting system and they are not analyzing the reports to determine if all of the deaths fit the criteria of the law. 

For the sake of brevity, I will provide links to previous articles concerning anomalies from the Québec reports on End-of-Life Care. 

Previous Quebec reports on End-of-Life Care:

• Quebec euthanasia deaths increase by 51% in 2021 - 22 annual report. A discrepancy of 289 deaths (Link).
• Quebec 2020 - 2021 annual euthanasia report. Euthanasia deaths increase by 37% unreported deaths continue (Link).

Québec: Natural death is being replaced by assisted death.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Article: Québec Commission on End-of-Life Care warns that some euthanasia deaths do not comply with the law (Link).

Scott Norvell in writing for the New York Sun on August 15, 2023, comments on how in Canada natural death is being replaced by an assisted death. Norvell comments on the letter from Dr Michel Bureau, who is the President of the Quebec Commission on End-of-Life Care who recently told Québec physicians to stop killing people by euthanasia for conditions that are "outside of the law." Bureau stated that, by the end of 2023, it is likely that 7% of all deaths in Québec will be by euthanasia. Norvell quotes Bureau as stating:

“We see, more and more, that the cases receiving medical aid in dying are approaching the limits of the law,” the head of the commission, Michel Bureau, told the Canadian Broadcasting Corporation. “We’re now no longer dealing with an exceptional treatment, but a treatment that is very frequent.”

If current rates continue, more than one in 14 deaths in Quebec will be doctor-assisted by the end of the year. Dr. Bureau notes that the rate is higher than any other place that allows the practice — 4.5 times the rate of Switzerland and three times as high as in Belgium. The rate is twice as high as in neighboring Ontario, he said.

Norvell further explains:

In Quebec, doctor-assisted deaths accounted for 4.7 percent of all deaths in 2021. In 2022, that number rose to 6.1 percent, according to provincial statistics, and at the current pace, it will reach more than 7 percent by the end of the year, Dr. Bureau told the CBC. Doctors in the province, he said, are under increasing pressure from elderly patients who say they are ready to die, but their conditions do not qualify them for the suicide route.

Norvell ends the article by quoting Bureau as stating:

“It’s no longer just terminal cancer, there are all kinds of illnesses — and that’s very good, but it requires a lot of rigor from doctors to ensure they stay within the limits of the law,” Dr. Bureau said. “Medical aid in dying is not there to replace natural death.”

Bureau has been a strong proponent of euthanasia and has become critical of the implementation of the law. During the Québec euthanasia debate the Euthanasia Prevention Coalition pointed out that the law was designed to be abused, and like Belgium, euthanasia would not only grow quickly but there would be deaths outside of the law. Sadly this has happened. 

More articles on this topic:

• Québec Commission on End-of-Life Care warns that some euthanasia deaths do not comply with the law (Link).
• Québec is the world's euthanasia hotspot at 6.1% of all deaths (Link).

Quebec Death Doctors Don’t Like Being Told to Stay within the Law

This article was published by National Review online on August 9, 2023.

Wesley Smith

By Wesley J Smith

The pattern never changes. Euthanasia is legalized under the promise of “strict guidelines” preventing abuse. As time goes on, the strict guidelines are loosened, and then loosened again. Sometimes the process is slow and sometimes fast. But the direction is all one way.

In addition to that, doctors may assist the suicides or lethally inject patients who do not technically qualify for hastened death. Little, if anything, is done about it.

In the Netherlands, such cases have never resulted in meaningful punishment. Ever. Rather, they have been winked at by the authorities, or if prosecuted (rarely), the courts never punished the offender meaningfully.

After that, the “violation” may become the impetus for further loosening the “strict guidelines” — as in the Dutch doctor who put down her struggling dementia patient fighting to stay alive by having her family hold her while administering the lethal jab. The doctor was found not guilty in court, complimented by the judge for her good intentions, and the law was then changed to allow doctors to decide when to kill in such cases.

Now, add this to the mix: If authorities — ever so gently — try to enforce the rules, euthanasia advocates and medical associations warn that it will chill doctors from dispatching patients. We’ve seen that pattern followed repeatedly in Netherlands — and now in Quebec, where authorities asked doctors to please, please, please, stay within the law, which is very loose already. From the CBC story:

The memo reminds doctors of several guidelines, including that requests due to old age do not meet provincial criteria for the procedure, and an independent opinion from a second doctor isn’t a formality — it’s a requirement. Bureau said any deviation from the rules can be a slippery slope, especially as the commission is seeing an increasing number of requests for MAID.

It’s just too ridiculous. The slippery slope is already slip-sliding away. This is precisely how it works.

Even that gentle reminder was too much for death doctor activists:

However, Georges L’Espérance, a neurosurgeon and the president of the Quebec Association for the Right to Die in Dignity, says the numbers are going up because of the increased understanding that MAID is an option.

He criticizes the memo, saying it might stigmatize the procedure or even dissuade some doctors from providing it.

“The problem is that many doctors will be intimidated by that kind of memo,” he said. “They will say that they don’t want to [administer] any MAID because they have fear.”

So predictable. Some doctors won’t stay within the law. They are rarely caught and will not face discipline or meaningful punishment if they are. And the law will be further loosened as time goes on. Repeat, and repeat again.

Similar article:

• Québec Commission on End-of-Life Care warns that some euthanasia deaths do not comply with the law (Link).

Québec Commission on End-of-Life Care warns that some euthanasia deaths do not comply with the law.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

CBC News reporter, Rowan Kennedy, reported on August 6 that Dr. Michel Bureau, the President of Québec's Commission on End-of-Life Care sent a letter to euthanasia doctors urging them to stop abusing the law. Kennedy reported:

The head of the commission says he sent out a memo this week to try and clear up any confusion about expanded availability of MAID — which came into effect in June — and advise doctors of the proper application of the law.

Recent reports indicate that Québec euthanasia deaths increased by more than 50% in 2022 giving them the highest euthanasia rate in the world at approximately 6.1% of all deaths. 

According to Bureau, every month 2 or 3 euthanasia deaths do not meet the guidelines. Kennedy reported:

The commission reviews about 500 requests for doctor-assisted death every month, but Bureau says two to three of those monthly applications don't meet provincial guidelines. He says doctors must recognize those cases.

"At times, [physicians] don't know really if they are right or not and at times, they're not," he said.

The memo reminds doctors of several guidelines, including that requests due to old age do not meet provincial criteria for the procedure, and an independent opinion from a second doctor isn't a formality — it's a requirement.

Bureau said any deviation from the rules can be a slippery slope, especially as the commission is seeing an increasing number of requests for MAID.

The Euthanasia Prevention Coalition (EPC) believes that more euthanasia deaths fall outside of the law. The reporting procedure requires the doctor who carried out the euthanasia death to also report the euthanasia death. This self-reporting system enables doctors to "cover-up" controversial euthanasia deaths.

EPC asks, "Why have none of the doctors been sanctioned for killing patients outside of the law?"

Dr Georges L'Espérance, the president of the Quebec Association for the Right to Die in Dignity, told CBC news that the number of euthanasia deaths are increasing because of the knowledge that MAID is an option. He also criticizes the memo, saying it might stigmatize the procedure or even dissuade some doctors from providing it.

Clearly L'Espérance is not concerned that doctors are killing people outside of the law.

The Living with Dignity network sent out a media release on August 7 challenging the non-compliance with the euthanasia law.

Media Release: Memo to Quebec physicians practising medical aid in dying.

For Immediate Release: Link to the original release (Link).

Memo to Quebec physicians practising medical aid in dying

The Commission on End-of-life care had to act

A welcome intervention that unveils some important issues

Montreal, August 7, 2023 – Over the past few days, the Commission on End-of-life care has issued a memo to the hundreds of Quebec physicians who provide medical aid in dying. This information comes from the work of journalists Davide Gentile and Daniel Boily in a text published Saturday in French by Radio-Canada information, then adapted to English by CBC News’ Rowan Kennedy. Living with Dignity citizen network welcomes this intervention by the Commission on End-of-life care and its president, Dr. Michel Bureau. Living with Dignity invites political decision-makers to support the reminders contained in the memo, which highlight important issues that need to be taken very seriously.

The memo addresses three themes, as seen in these excerpts (in quotation marks, our translation) from the e-mail sent by the Commission on end-of-life care:

1) Non-compliance of a growing number of medical aid in dying procedures

"...a growing number of MAiD procedures with very borderline compliance with the conditions contained in the law, and a growing number of non-compliant MAiD procedures administered";

2) The importance of a second physician's opinion and doctor-shopping for a favourable opinion

"...the opinion of a second independent physician confirming the admissibility of MAiD is not just a formality; it must be critical and contemporaneous with the MAiD application";

"Doctor-shopping for a favourable second opinion is not an acceptable practice";

3) Advanced age is not a criterion for MAiD eligibility

"...advanced age and age-related problems do not constitute a serious and incurable disease, and do not justify MAiD".

Comments from Living with Dignity

By Jasmin Lemieux-Lefebvre, coordinator of the Quebec citizen network:

These warnings confirm the information we are receiving on the ground. To avoid refusals, people applying for medical aid in dying may be tempted to turn to MAiD providers who have a broader vision of MAiD access. Doctor-shopping for a favourable second opinion is also a well-known problem in this country. In his essay, No other options, published in The New Atlantis last winter, journalist Alexander Raikin explores the subject in depth in the section Easy to die.

At a conference of the Canadian Association of MAID Assessors and Providers, it was said that “you can ask as many clinicians as you want or need” and that "disagreement doesn't mean you must stop".

It should also be borne in mind that this memo comes at a time when the situation is probably more serious than that described by the Commission on End-of-Life care, which refuses to acknowledge any abuses for the time being. The scientific article The realities of Medical Assistance in Dying in Canada, published by Cambridge Press this summer, addresses the issue of inadequate data collection on MAiD in Canada:

The data are acquired from the MAiD providers via self-reporting. There is no mechanism for objectively, prospectively, or retroactively identifying or uncovering any errors or abuses of the process. Providing assisted suicide and euthanasia outside the parameters of the law remains prohibited. MAiD providers filling out the forms know that any deviation of the key criteria may result in criminal prosecution, making self-declarations of error or deviation unlikely. (see the Inadequate data collection section of the article by Ramona Coelho, John Maher, K. Sonu Gaind and Trudo Lemmens).

On March 7, 2024, medical aid in dying will be available in Quebec to people living with a serious physical impairment (a term adopted by the Act to amend the Act respecting end-of-life care and other legislative provisions and suggested by a group of experts on disability). As of December 7, 2023, it will be required in all palliative care hospices. The revelations of the Commission on end-of-life care must lead to concrete action to avoid the abuses that can be expected.

- 30 -

Media contact:

Jasmin Lemieux-Lefebvre
Coordinator
Living with Dignity citizen network
directionVDD@gmail.com
438 931-1233

Québec forces palliative care homes to provide euthanasia.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

On June 7, The Physicians’ Alliance against Euthanasia joined with the Living with Dignity citizen network to express their great disappointment that Bill 11, An Act to amend the Act respecting end-of-life care and other legislative provisions was passed in the Québec legislature.

The Physicians' Alliance and Living with Dignity reported that Bill 11 will expand euthanasia in Québec in the following ways:

• creating an obligation for palliative care homes to offer MAID (in 6 months);
• offering MAID in cases of serious physical disability* (in 9 months); 
• offering MAID by advance request* (in a maximum of 24 months).
• *together with the other criteria of the Act respecting end-of-life care.

The Canadian Press reported that Bill 11 "also allows Quebecers to receive a doctor-assisted death in places other than hospitals, such as funeral homes and long-term care facilities."

Lee Harding, writing for the Epoch Times, was published on June 13, 2023 concerning the fact that Bill 11, which recently passed in Québec, forces palliative care institutions in Québec to provide euthanasia. Harding reported:

A new Quebec law that mandates palliative care facilities to provide medical assistance in dying has drawn criticism from euthanasia opponents and a palliative care advocate.

Bill 11 to expand medical assistance in dying (MAiD) passed in Quebec’s national assembly on June 7.

Harding reported that the Living With Dignity citizens network were particularly bothered by the requirement that all palliative care institutions would provide euthanasia. Harding reports:

The organization said it was even more “deeply disturbed” by a late amendment to the bill. Sonia Belanger, minister for health and seniors, added the provision that a hospice “cannot refuse to receive a person for the sole reason that the latter has submitted a request for medical assistance in dying” and created a deadline of six months for palliative care homes to comply.

Although only four palliative care hospices are known to not wish to offer MAiD, the government approach to admission criteria was opposed by the Alliance of Palliative Care Homes of Quebec during public consultations.

Harding reported Dr. Catherine Ferrier, a board member for Living with Dignity, as stating:

“It is of course very bad news that the law passed with such a big majority of votes. Politicians in Quebec seem to think that expansion of euthanasia is inevitable and that their role is to make it safe. It’s seen as an act of compassion,” Ferrier told The Epoch Times via email.

“But it is never safe and is an act of abandonment of the patient.”

Alex Schadenberg

Alex Schadenberg, executive director of the Euthanasia Prevention Coalition, told Harding:

...patients had access to MAiD before the law, and the change only forces palliative care homes to become active participants.

“It’s a serious issue for conscience rights because now every palliative care institution is going to have to offer this,” Schadenberg said in an interview.

“There were a couple of palliative care institutions that were created more recently, meaning after the legalization of euthanasia they were created specifically because they wouldn’t offer it and they were trying to provide what we would call a safe space.”

Angelina Ireland

Angelina Ireland, the President of the Delta Hospice Society told Harding:

“Palliative care is a 50-year medical discipline that is very clear about what it entails, and it never includes MAiD and never includes euthanasia, and the father of palliative care, Dr. Balfour Mount, is from McGill University. So it’s very ironic in this moment that Quebec is moving in that direction,” Ireland said.

“This political movement is forcing a coercive makeover of what palliative care is. They’ll scream up and down that it’s about human rights, but it looks more like a cull to me because we’ve opened up Pandora’s Box. And when they just promised it’s only a little bit of MAiD, it’s turned out to be something that every vulnerable Canadian has to be afraid of.”

Ireland said the precedent in B.C. suggests that those morally opposed to the imposition of euthanasia will exit the profession, but the palliative care facilities will remain.

In February, the Québec Euthanasia Commission announced that euthanasia represented 7% of all 2022 deaths in Québec which represents the highest rate of euthanasia in the world.

Quebec Bill 11 to permit euthanasia by advanced request.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

A CBC radio program (french) by Davide Gentile & Daniel Boily reported on February 16.2023 that more than 7% of Québec deaths were done by (MAiD) euthanasia in 2022 representing more than 5,000 people dying by euthanasia, as compared to less than 1,000 deaths five years ago.

The CBC radio program reported that based on the data, the Commission on End-of-Life Care launched a consultation to research why Québec may have the highest rate of euthanasia in the world (British Columbia may have a higher euthanasia rate but the data is not available).

At the same time, Québec's legislature is debating Bill 11 which further expands their euthanasia law. Bill 11, among other changes, will permit euthanasia by advanced request (by advanced directive) in Québec. 

Bill 11 extends euthanasia by advanced request. Bill 11 states:

this Act allows the exercise of some of those rights by patients who are not at the end of life so that they receive end-of-life care in cases where their condition requires it.”

Bill 11 defines the act in the following manner and states:

Such a request is called a “contemporaneous request for medical aid in dying” or “contemporaneous request” where it is made with a view to an administration of such aid that is contemporaneous to the request. It is called an “advance request for medical aid in dying” or “advance request” where it is made in anticipation of a person becoming incapable of giving consent to care, with a view to an administration of such aid after the onset of that incapacity.

The only good news is that Bill 11, unlike the federal legislation, specifically excludes euthanasia for mental illness alone. Bill 11 states:

"a mental disorder other than a neurocognitive disorder is not considered to be an illness."

The federal report by the Special Joint Committee on Medical Assistance in Dying (AMAD) was tabled in the House of Commons on February 15 calling for an expansion of euthanasia (MAiD) in Canada. The report recommended that children "mature minors" and patients with mental illnesses be eligible for euthanasia and that patients with illnesses such as dementia be permitted to make advanced requests by advanced directives for euthanasia.

Bill 11 is Québec's unique way of pushing the legislative agenda by permitting euthanasia by advanced request before the federal government acts on the report.

The Euthanasia Prevention Coalition urges you to write a short commentary on Bill 11 and submit it to the Québec legislation (Link to comment). Even if you fear that your comments will be ignored, it is important to oppose killing.

Euthanasia (killing) is bad enough, but killing by advanced consent changes the nature of consent, meaning, someone can be killed without a clear and present consent. When consent becomes secondary, it changes the question of who can be killed by lethal injection.

Many people may not be aware that Canada has two euthanasia laws, the federal law which legalized euthanasia by creating an exception to homicide in the criminal code and the Québec law, that only applies to Québec, and considers euthanasia as medical treatment. Québec is known for asserting its provincial constitutional powers and having unique regulations.

Bill 11 reminds us that provincial governments have the ability to amend the practise of euthanasia in their jurisdiction. For instance, the federal government has legalized euthanasia for mental illness alone and Québec is specifically excluding it.

Québec has the highest euthanasia rate (7%) in the world.

More than 7% of deaths result from medical assistance in dying in Quebec. More than 5,000 people could use it this year, compared to less than 1,000 five years ago.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

A CBC radio program (French) by Davide Gentile & Daniel Boily reported on February 16 that more than 7% of deaths result from medical assistance in dying in Quebec with more than 5,000 people use it this year, compared to less than 1,000 five years ago.

The report stated that (google translated):

Quebec now ranks well ahead of the Netherlands and Belgium in terms of the use of medical assistance in dying. To understand this rapid progression, the Commission on End-of-Life Care launched a consultation with hundreds of doctors.

According to Québec's annual euthanasia report that was released on December 9, 2022 there were 3663 reported euthanasia deaths from (April 1, 2021 to March 31, 2022) representing 5.1% of all deaths. The last report indicated that the number of euthanasia deaths was up by 51% in the past year and had more than doubled in two years.

The Québec report also indicated that there was a discrepancy of 289 deaths that may be explained by under-reporting. 

Since the release of that report the Commission on End-of-Life Care has launched a consultation since new data indicates that there will be at least 5000 reported euthanasia deaths representing 7% of all deaths in the next report.

Dr Michel Bureau, the President of the Commission on End-of-Life Care stated:

"in Quebec, there are more of them than in Ontario, more than in Europe, and it is our duty to see if there are causes obvious to that".  

"where there is a risk is that it is so embellished in the population that many suffering people will say to the doctor: 'I want medical assistance in dying' even if they don't are ineligible".

Bureau believes that euthanasia is mean't to be care of the "last resort" and he wants there to be more access to palliative care. 

But not all doctors agree. Dr Pierre Viens (right), who has been a physician since 1963 and who regularly does euthanasia, is not concerned with the number of euthanasia deaths. He stated:

“It does not indicate that there are more cases of cancer, ALS, etc. It simply indicates that more people with serious illnesses, with suffering, at the end of life, are aware that there is a way to die with dignity, humanely, through MAID."

At the same time the Québec government introduced a bill to expand the law to approve euthanasia for incompetent people who requested death by lethal injection in their advanced directive.

• Article: Québec euthanasia deaths more than double in two years (Link). 
• Article: Québec Euthanasia deaths increase by 51% in 2021-22 annual report. A discrepancy of 289 deaths. (Link).

Québec debates bill to permit euthanasia for incompetent people.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Québec National Assembly has introduced Bill 38, a bill to expand Québec's euthanasia law. Bill 38 is Québec's response to Truchon court decision, the federal passage of Bill C-7 in March 2021 and the report of a Québec government committee that supported euthanasia for incompetent people but not for mental illness.

Article: Québec Committee supports euthanasia for incompetent people but not for mental illness (Link)

Bill 38 removes the requirement that a person needs to be at the "end of life" to die by euthanasia, it permits euthanasia for incompetent people who requested it in their advanced directive and it permits euthanasia to be done by nurse practitioners, among other changes. Bill 38 does not permit euthanasia for mental illness alone, as the federal legislation, Bill C-7 had done.

Bill 38 removes conscience protections that were in the original Québec regulations which will force all hospices to provide MAiD (euthanasia). Bill 38 is expanding the law in accord with the demands of the euthanasia lobby.

Bill 38 refers to euthanasia for incompetent people who had requested it in their advanced directive as a "contemporaneous request" where the “advance request for medical aid in dying” or “advance request” where it is made in anticipation of a person becoming incapable of giving consent with a view to an administration of such aid after the onset of that incapacity.

Permitting euthanasia by advanced consent creates several problems, even for people who believe in euthanasia. First, advanced request creates the problem of who will decide the time and place of the lethal injection. Secondly, since the person is deemed incapable of consenting, it denies the person the right to change their mind.

Further to the problems with advanced requests to be killed, Bill 38 will allow a "third" person to make the request in the presence of the person, when the person is unable to sign and date the request form.

To qualify for an advanced request for euthanasia the patient must:

29.2 With the assistance of that professional, the patient must describe in detail in the request the constant and unbearable physical or psychological suffering which cannot be relieved under conditions the patient considers tolerable that will determine, when the patient has become incapable and when a competent professional finds that the patient is experiencing such suffering due to their illness, the time from which the patient considers it appropriate to obtain medical aid in dying.

The reasoning for euthanasia is completely subjective. It states that the constant and unbearable physical or psychological suffering which cannot be relieved under conditions the patient considers tolerable. A person who is seeking death simply has to say that the suffering that they are experiencing is intolerable. People can be killed without objective criteria.

The medical professional in 29.3 only needs to:

(1) be of the opinion that the patient meets the criteria set out in section 29.1

A person is killed and the medical professional is only "of the opinion" that the person meets the criteria of the law.

Bill 38 is designed to protect medical professionals from being charged or sued for misconduct rather than ensure that the person who is being killed actually meets the criteria of the law.

The advanced request can one or two trusted "third persons" who would decide when the person, who has become incompetent, should die.

Once the advanced request for euthanasia is made the information will be maintained in a register of requests.

Section 29.9 allows a person to withdraw the advanced request at any time. The problem is that the person makes an advanced request because they anticipate that their condition will lead to becoming incompetent. Once a person is incompetent, they cannot legally change their mind.

Section 29.15 states that before administering medical aid in dying following an advance request, the competent professional must

(1) be of the opinion that the patient meets the following criteria:

It doesn't matter what the criteria states, the medical professional only needs to be of the opinion. To be of the opinion means that if someone complains that something wrong has happened, the medical professional is protected since they only need to be of the opinion...

At least the Québec government recognized that someone who changes their mind might resist and indicate that they don't want to die. Bill 38 states at the end of section 29.15:

Any refusal to receive medical aid in dying expressed by a patient must be respected and it is prohibited to disregard it in any manner.

The Euthanasia Prevention Coalition recognizes that Bill 38 does not extend euthanasia to people with mental illness alone, nonetheless, the federal government extended euthanasia to people with mental illness alone with the passage of Bill C-7.

It is interesting that Bill 38 describes the process that the committee examining the euthanasia reports must go through to determine that a euthanasia death did not fit the criteria of the law and yet the medical professional must only be of the opinion that the person who was killed fit the criteria of the law. Once again, the law is designed to appear to provide effective oversight of the law, whereas, in reality the law lacks any effective oversight.

Article supporting euthanasia for mental illness provides excellent argument against euthanasia.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Article: Quebec committee opposes euthanasia for mental illness (Link).

Jocelyn Downie, one of the world's leading "academic" euthanasia (MAiD) promoters and Mona Gupta, a psychiatrist who has been promoting euthanasia for mental illness alone, responded to the Québec Commission on MAiD that recently decided to support euthanasia for incompetent people, but not support euthanasia for people with mental illness alone.

The response titled: Québec's Commission on MAiD misses the mark on mental disorders was published by Policy Options on March 2. Downie and Gupta argue that the Québec Commission on MAiD are not following the same play book as the rest of Canada by rejecting euthanasia for mental illness alone. Downie and Gupta state:

Unfortunately, this recommendation is out of step with the evolving thinking on this issue found in jurisprudence, federal legislation and the recommendations of Quebec’s regulatory authorities and professional associations. It is also based on misleading statements and logical inconsistencies.

Downie and Gupta explain that Canadian court decisions have not excluded euthanasia for mental illness alone and the federal government approved euthanasia for mental illness alone when it passed Bill C-7 last year.

What is more interesting about the article is how their arguements supporting euthanasia for mental illness alone provide a strong argument as to why euthanasia should never be legalized. Downie and Gupta state:

If people with mental disorders can access MAiD, the commission worries whether suicidality can be distinguished from a request for MAiD in such cases. However, this, too, is not exclusive to people whose mental disorders are their sole underlying condition. People with certain types of cancer (including lung and pancreatic cancer) are at higher risk of committing suicide than the general population in the first six to 12 months following diagnosis. Yet, this group’s increased risk of suicidality does not lead to exclusion. Instead, the request is assessed on a case-by-case basis, taking into consideration the totality of the individual’s circumstances.

Therefore, people with certain types of cancer (including lung and pancreatic cancer) are more likely to seek an assisted death in the first 6 to 12 months following a diagnosis. By legalizing euthanasia these people are more likely to seek death by euthanasia. If euthanasia is not legal these people are more likely to accept effective treatment and more likely to survive their cancer diagnosis.

For instance, a study by Dr Sara Moore, a University of Ottawa medical oncologist examined 45 euthanasia (MAiD) deaths of people with lung cancer living in the Ottawa region. She concluded that people with lung cancer who died by euthanasia were less likely to consult with a radiation or medical oncologist, many did not seek a confirmation of their condition and they were less likely to undergo effective treatments.

Euthanasia is never an answer to a human difficulties. We need a society that cares not kills its citizens.

• Canadian Psychiatric Association's dangerous position on euthanasia (Link).
•  The complexity of assessing mental health and capacity (Link). 
• As difficult as it is sometimes, there is always hope. Euthanasia for mental illness is abandonment (Link). 
• Canada's parliament passed Bill C-7 permitting euthanasia for mental illness (Link).
  

Mental health expert opposes euthanasia for mental illness. Based on personal experience, misdiagnosis is a problem.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

A mental health expert told the Québec committee hearings on the Evolution of the Act respecting end-of-life care on Friday May 21 that based on her personal experience (MAiD) euthanasia should not be extended to people with mental illness alone.

A Global News report by Raquel Fletcher reported that Dr. Georgia Vrakas, a psychologist and mental health researcher who was diagnosed with bipolar type-2 disorder two weeks ago told the Quebec committee that extending euthanasia to people with mental illness alone is a very bad idea. Fletcher reported:

For more than 20 years, she was mistakenly treated for depression. At one point, things got so bad she called a suicide prevention hotline: “I was that low,” she said.

This is why she said she is against offering medical assistance in dying to patients where mental illness is the sole underlying condition.

Dr Georgina Vrakas

Vrakas told the committee that she is the prime example, that not enough is known about mental illness and situations can turn around. Vrakas hopes that her concerns will be reflected within future legislation. Fletcher reports:

Dr. Vrakas said extending the option to people with severe mental illness would send a message of despair.

“The message we would be sending, the message the government would be sending to people like me, is that there’s no hope,”

The Quebec government and the federal government have both established committee's to examine the further expansion of Canada's euthanasia law.

More articles on this topic:

• Canada passes Bill C-7 permitting euthanasia for mental illness alone (Link).
• Lack of evidence surrounding euthanasia for mental illness (Link). 
• Euthanasia for mental illness ignores safeguards for vulnerable people (Link).
• Trudeau government will permit euthanasia for mental illness alone (Link).

Euthanasia for hip fractures in Québec

This article was published by the Australia Care Alliance on November 9, 2019.

Three people were euthanased in Quebec between April 2018 and March 2019 for a hip fracture. This is just one of the warnings about where legalisation of euthanasia leads that can be drawn from the latest report on euthanasia in Quebec.

* Québec - 1331 reported euthanasia deaths (April 1, 2018 - March 31, 2019) At least 13 deaths did not comply with the law.

Euthanasia in that Canadian province now accounts for nearly one out of fifty deaths (1.9%) with significantly higher rates in some health regions including the capital (3.38%) and Bas-Saint-Laurent (3.45%).

Although Canadian law requires "at least 10 clear days between the day on which the request was signed by the person and the day on which" euthanasia is provided unless "the person’s death, or the loss of their capacity to provide informed consent, is imminent" and the Quebec law requires the physician to verify “the persistence of suffering and that the wish to obtain" euthanasia "remains unchanged, by talking with the patient at reasonably spaced intervals given the progress of the patient’s condition" in a massive 40% of cases euthanasia was performed less than 10 days after a request was first made.

Québec - 1331 reported euthanasia deaths (April 1, 2018 - March 31, 2019) At least 13 deaths did not comply with the law.

Fourth report from Québec's Commission on end-of-life care

By Amy Hasbrouck and Taylor Hyatt 

Toujours Vivant - Not Dead Yet.

On October 2, Québec’s Commission on end-of-life care released its fourth report for the period April 1, 2018 to March 31, 2019. The Commission reported a substantial increase in the number of euthanasia over the previous years. They reported:

Link to the analysis by Amy Hasbrouck and Taylor Hyatt on the previous Third Québec report (Link).

• There were 1,331 euthanasia were reportedly performed this year April 1, 2018 - March 31, 2019). Added to the 1,630* for the 28 months from December 10, 2015 to March 31, 2018, bringing the total to 2,909 euthanasia in Québec since the program began. We’ll talk in a few minutes about why those numbers don’t add up.
• Continuous palliative sedation (CPS) was performed on 1,243 people during the reporting period. Added to the 1,704 CPS performed during the 28 months from December 10, 2015 to March 31, 2018, this brings the total to 2,947. 
• Euthanasia and CPS each accounted for 1.9% of deaths in Québec during the reporting period, for a total of nearly 4% of all deaths in the province. 
• *As explained in footnote 19 on page 27, 1,630 euthanasia deaths is a corrected total from the Commission’s summary report issued last spring. Apparently “two MAiD reported by an institution as having been administered were not administered.” 

The exact number of euthanasia deaths is hard to pin down from the report.

• On pages iii, 12, 27 (footnote 19), 37 and 38, the report says “1,279 people received MAiD between April 1, 2018 and March 31, 2019.” This figure, when added to the 1,630 from previous years, gives the reported total of 2,909.
• But on page 23, the report says “according to reports from institutions, 1,937 requests for MAiD were made between April 1, 2018 and March 31, 2019; of these, 1,271 were administered and 672 were not administered.” 
• The 1,271 figure, added to the 60 euthanasia performed by doctors outside of institutional settings and reported by the Collège des médecins du Québec (CMQ), gives a total of 1,331 euthanasia. 
• Maybe you’ve noticed that 1,937 minus 672 does not equal 1,271, but rather 1,265. The six missing people are accounted for in a note in figure 3.17 which does not show the outcome of the six euthanasia requests in region 10. The Commission explains: 
• “In order to respect the rules of confidentiality, and because of the risk of identification related to the disclosure of a small number of individuals, the exact distribution of the euthanasia administered and not administered could not be provided.” 
• As for the 1,279 figure used elsewhere in the report, we don’t know where it comes from, or if it includes the 60 euthanasia reported by the CMQ. And if you think we’re being nit-picky, just remember that euthanasia laws are supposed to impose “stringent limits” that are “scrupulously monitored and enforced.” 

This year, the Commission received 1,400 euthanasia reports, some of which document euthanasia performed before the reporting period. 

“The Commission notes that 86 forms were received more than six months after the administration of MAiD and some of them more than one year later.” 

A few things to note about the Commission’s process:

• The Commission can only evaluate compliance with the law; it has no influence over other aspects of the medical practice, even if they could affect euthanasia. So, for example, if the doctor makes a mistake in diagnosis or the cause of a decline in capacity, that would probably fall outside the Commission’s area of responsibility.
• Two-thirds of the commissioners must agree that a violation has occurred for a finding of non-compliance to be made. Such cases are referred to the institution’s Council of Physicians, Dentists and Pharmacists (CPDP) and the Collège des médecins du Québec. There is no remedy for the loved ones of ineligible people who are euthanized, or where safeguards are ignored. 
• This year the Commission introduced a new procedure for evaluating reports, in response to the growing number of euthanasia. Declarations are examined by a sub-group including at least three commissioners; if all group members agree that the eligibility criteria were met and the safeguards complied with, the case is recommended for approval by the whole commission. If there is disagreement in the small group, the case is referred to the full commission for further discussion. 

The commission took a first look at 1,384 reports, and needed more information or had questions on 31%, or 430 of them. The Commission found that 96% of the 1,354 cases it ruled on complied with the law, but it could not reach a decision in 41 cases (3%) because they didn’t get the information they requested from the doctor. The commission found that 13 euthanasia (1%) did not comply with the law.

• Four people were not eligible: 
• Three people did not have a serious and incurable illness (they all had broken hips); 
• One person’s medical insurance card had expired. 

• In nine cases, safeguards were violated. 
• The second doctor examined the person before the euthanasia request was signed in five cases. 
• The doctor did not conduct the interviews to ensure that the request was informed, that the person’s suffering persisted and they still wanted euthanasia. “In two cases, the physician who administered the MAiD met the person only on the day of the [euthanasia].” 
• One request form was witnessed by a non-qualified person. 
• “In one case, the second doctor consulted had a family connection with the doctor who asked for the opinion.” 

Of those who asked for MAiD, 65% received it.
The three most common reasons euthanasia was not administered were:

• The person was not eligible (246 people, or 37%)
• The person died before the evaluation process was completed or before MAiD could be administered (224 people, or 33%) 
• The person withdrew their request (127 people, or 19%). 

Forty percent of those approved were euthanized within ten days of making the request.

The Régie d’assurance maladie du Québec (RAMQ) reports that 682 doctors billed for services related to MAiD. According to the CMQ, of 23,478 doctors registered, 480 say they performed euthanasia in 2018.

If there’s a take-away message from this report, it would probably be that the number of euthanasia deaths is increasing rapidly, and procedures are still handled in a slip-shod manner. We still wouldn’t get on an airplane with a 1% chance of crashing, and a 3% uncertainty factor.

Summary Report on End-Of-Life Care (euthanasia) In Québec.

The following report was published by the disability rights group, Toujours Vivant - Not Dead Yet on April 12, 2019 and republished with permission.

By Amy Hasbrouck and Taylor Hyatt

Québec’s Commission on end-of-life care issued a summary report of the status of end-of-life care in Québec. The report deals with palliative care, continuous palliative sedation (CPS), euthanasia (administered or not), and the activities of the Commission itself. But the document only includes data up through March of 2018.

The report presents some obvious findings:

• The number of euthanasia and CPS are increasing. 
• Some doctors, hospitals, and regions provide more palliative care, CPS, and euthanasia than others. 
• Most of the people who die by euthanasia and CPS are over 60 years old and have cancer.
  

The report identifies some problems, such as that the Commission doesn’t have the data necessary to say how many people who need palliative care aren’t getting it. But we are aware of, or can predict other problems that are not addressed by the report, such as:

• People forced to live in institutions are requesting and receiving euthanasia; 
• We don’t know how doctors decide if a person is subject to “external pressure” to request euthanasia, and whether psychosocial, economic and discrimination-related factors are taken into account, besides coercion and abuse. 

Palliative care
 
The Commission admits it doesn’t have data to prove that the gaps in palliative care services observed in a report published in 2000 still exist, but they’re pretty sure that’s the case. The only data available count people who are receiving palliative care services, or who apply for euthanasia.

Service gaps exist in all areas where palliative care is delivered; home-hospice services, hospital-based palliative care units and free-standing hospices.

The report focuses on palliative care as an option only for people at the end of life. This despite the fact that effective pain relief is essential to many people with disabilities, and the authors propose expanding euthanasia to people who are not at the end of life.

The section on palliative care doesn’t address services to prevent institutionalization and requests for euthanasia, which are central to the Truchon/Gladu and Lamb cases.

Continuous Palliative Sedation
 
Of the people who died by Continuous palliative sedation:

• The report provides more detail about symptoms that justified CPS than about the kind of suffering that lead to requests for euthanasia: 
• Psychological / existential distress = 58%; 
• Physical pain = 28%; 
• Difficulty breathing = 25%; 
• Delirium and agitation = 20%.
  

• Ninety-four percent filled out and signed the consent form. In the other cases: 
• The form was not signed, but was in the medical file; 
• The form was missing from the file; 
• “oral” consent was given by the person or their family; 
• The form was not signed because the substitute decision-maker was absent.
  

• According to medical records, 83% of people received palliative care before asking for CPS and 6% never had palliative care. Information was not available in the remaining 11% of cases.

• Eighty-one percent died within three days of when CPS was started.

Euthanasia (administered)

• The number of requests was ten times more than anticipated before the program started. 
• “According to data gathered by the Commission, 1,632 people received MAiD in Québec between December 10, 2015 and March, 31, 2018.”  
• Footnote 33 states “the Commission is aware that the total of MAiD (1,632) … does not exactly correspond to the total declared in the reports from institutions and the Collège des Médecins du Québec shown in the latest report of the Commission’s activities,” published in December of 2018. That figure was 1,664, a difference of 32 euthanasia. The Commission does not explain this discrepancy. 
• It’s unclear whether the 1,632 figure comes from the total reported by institutions and the CMQ, or from doctors’ forms. In fact, nowhere in the 124-page summary report does the Commission explain why the number of euthanasia reported by institutions and the CMQ has been higher in the three annual reports, than the number declared by doctors. 
• Of the doctors’ declaration forms submitted to the Commission, 84 came in more than six months after euthanasia was provided. 
• By the Commission’s count, more than 60 euthanasia had not been reported by doctors as of March 31, 2018; 11 doctors’ reports were still missing when the summary report went to press. 
• As well, footnote 57 mentions “around 20” euthanasia that were not reported by the doctors or facilities, but which came to light following audits by institutions that found the information in their pharmacy records.
  

• The average time between signing the request and administration of euthanasia was 12 days. 
• The Commission describes the reasons for euthanasia request (suffering) in the broadest possible terms; Physical suffering, psychological suffering, or both. Not surprisingly, 89% reported both. The report did not specify how many people had what kind of discomfort (physical pain, breathing problems, nausea, existential suffering, feelings of loss of dignity, problems with self-esteem, grief, etc). 
• Of note, the Commission appears to have checked off “physical suffering” even where it wasn’t an issue. Footnote 43 states: “In light of the totality of information listed on the forms, physical suffering was determined to be present even if the form indicated that it was well managed or that there was only minor physical discomfort.” 
• The Commission says that 80% of people were receiving palliative care when they requested euthanasia, and 89% were getting it when MAiD was administered. However the Commission makes no assurances as to the quality or quantity of that service. This percentage of palliative care access is higher than that reported in a study from McGill University we reported on last December. 
• The authors note that the number of euthanasia performed at home in Quebec (20%) is half that of other parts of Canada (>40%) and Europe. Some people were admitted to hospital just to be euthanized. 
• The Commission estimates there could be up to 1,500 euthanasia performed in Québec during the fiscal year ending March 31, 2019. That’s almost as many as in the 28 previous months. 
• The data confirm the theory that there are a few “death doctors” who specialize in medical homicide, plus many other physicians who do one or two euthanasia per year.
  

Euthanasia not administered

• Of the 2,462 requests, 830, or just over 1/3, did not result in euthanasia. Such requests are not reported, so the commission had to look at the medical records of the people who made a request to determine the outcome, and to learn why euthanasia did not take place. The reasons fell into three broad categories: 
• the person was deemed ineligible, 
• the request was withdrawn; or 
• the person died before euthanasia can be carried out.
  

• The reasons euthanasia was not administered: 
• The person was not eligible when the request was made (191) because:  
• They were not at the end of life – 97; 
• They were incapable of giving consent when the request was made – 58; 
• They did not have “intolerable suffering” when request was made – 48; 
• They did not have a “grievous and irremediable medical condition” – 37; 
• Their medical condition was not in an advanced state of irreversible decline – 35; 
• (Some people were ineligible for multiple reasons.)
  

• The person became ineligible during the evaluation process (164) because: 
• They lost capacity to give consent – 156; 
• Their suffering was relieved such that it was no longer intolerable – 3; 
• Other – 5.
  

• The person died before the evaluation was completed – 168; 
• The person withdrew their request or changed their mind – 167; 
• The person died before euthanasia could be administered – 67 
• Other / information not available – 73.
  

• The authors note that the variability between different locations comes from diverse interpretations of eligibility criteria, especially “end of life” and “constant and unbearable” suffering. 
• The Commission suggests that the fact that 51% of people who asked for euthanasia were not at the “end of life” and 30% were incapable of giving informed consent corresponds with the public’s desire to expand eligibility to these populations. Our view is that the fact that some people are excluded means the eligibility criteria are working, at least somewhat.
  

The application process

• Oral requests are often not documented on the request form until the evaluation process is nearly completed. 
• The authors say people are being discouraged from making a written request for euthanasia, and are being told, informally, that they wouldn’t be eligible. 
• The Commission downplayed problems with delays in receiving form, and numbers of errors and incomplete forms.
  

The activities of the Commission

• The report says nothing about what the Commission intends to do about the deaths of people who were deemed ineligible, or where the safeguards were not complied with
•  In 11 cases, the person was not eligible for euthanasia; 
• In 10 cases, the doctor didn’t talk with the person to ensure they were giving free and informed consent, and the persistence of their suffering; 
• In 9 cases, the consulting doctor examined the person before the euthanasia request was even signed; 
• In 5 cases the form was countersigned by someone who was not a health-care professional; 
• In 2 cases the doctor did not ensure that the safeguards were complied with.
  

• The Commission’s backlog of evaluations is glossed over. They’ve evaluated 1,498 of the 1,632 euthanasia declared (92%), leaving a backlog of 134 cases even a year later. This is especially pressing given the commission’s estimate for the number of euthanasia for the fiscal year just ended. 
• There are references to improvements promised by the electronic reporting system. But the report skips over problems mentioned in the annual reports related to:  
• How many forms are incomplete or have errors; 
• How many letters and phone calls are necessary to correct or complete the forms, or to track down missing forms; 
• Euthanasia reports that are not transmitted at all.
  

• Nor is there any discussion as to how these problems will be dealt with in the future. 
• The media coverage of the release of this summary report was a frenzy of pro-euthanasia propaganda, criticism of the number of people who are being denied their “right” to euthanasia, and calls to expand eligibility and speed up the evaluation process. We hope that our observations, our sober second thoughts, will not be completely lost in the hubbub.