Gabriel Peters: MAiD builds discrimination, not a remedy to it.

The following was published by Gabriel Peters on her substack on April 23, 2026.

 

By Gabriel Peters

Re: Eligibility of Persons Whose Sole Underlying Medical Condition is a Mental Illness

The following is a longer version of my testimony to Special Joint Committee on MAiD. Due to time restrictions I had to edit severely. However the session is an hour long and I had hoped some of the Committee members would use their time to ask me questions. Only one did.

Thank you for the opportunity to provide some brief comments. One of the hats I wear is that I sit as a care partner on the Providence Health Care Psychiatry Lived Experience Research Advisory Committee and I am always struck by the urgency accorded expansion of MAID for mental illness versus that of providing funding for comprehensive mental health care, supports, livable income and housing for those with mental illness.

Injustice can often be measured in time.

Today, I am speaking as co-founder of the Disability Filibuster.

As policy makers I am certain you are aware that neither people nor policies are islands unto themselves. And yet MAID is discussed as if it exists inside a vacuum, free of influence from, or consequence to, society.

In what little time I have I will address a couple of persistent myths that constantly derail and impede rather than build understanding.

Myth One: The reason people oppose expanding MAiD criteria to include mental illness as a sole underlying condition is because they believe mental illness is less real than physical illness and they treat it as less significant and less worthy of support.

False: The division between physical and mental illness is one asserted and maintained by the medical model and the Canadian state. Due to the exclusion of essential elements of mental health care from Canada’s publicly funded and arguably misnamed universal health care system, Canada has a two-tier mental health care system. The average provincial and territorial mental health care funding lags behind that of many peer countries. Proportionally, Canada’s public spending on mental illness is lower than its occurrence among all illnesses. People with mental illness face particular threats to their civil rights. A BC study found that for nearly a third of people with mental illness, their first contact with mental health care involved the police. A situation that the Canadian Mental Health Association attributes to the lack of community services, the limited scope of crisis services, a reduction in hospital beds so that even short stays are only available to those in the most acute crisis. A CMHA fact sheet states: “Police officers are, by default, becoming the first point of access to mental health services for persons with mental illness, earning them the nickname ‘psychiatrists in blue.’” They go on to explain that one of the consequences of this is that “​​public also receives reinforcement for the false perception that mental illness is a crime rather than an illness, and that persons with mental illness are a public danger – a common and erroneous belief which hurts both persons with mental illness and the public.”

Stigma requires power. Without power, stigma is just someone’s bad opinion.

I hope this isn’t too idiomatic a reference, but in terms of the claims asserted by the myth, the call is coming from inside your house, not ours.

As disabled people we understand disability as one large tent. Power divides and builds hierarchies. Justice unites through shared struggle and common goals.

There are differences and these do matter. Where physical disability can be met with a benevolent though also hostile othering that infantalizes, assumes helplessness, denies access and views our bodies with disgust, people with mental illness confront staggeringly pervasive, dehumanizing and isolating stigma and dangerous stereotypes while being simultaneously blamed for their illness and having its existence doubted.

The experience of oppression is not the same but the cause of it is.

And please remember that the majority of disabled people have more than one disability and a combination of both physical and mental illness is not uncommon. So when someone projects this myth onto one of us they are often accusing and pretending to defend the exact same person.

Myth Two: Failing to expand MAID is discrimination.

False: This and other assertions made by proponents of MAiD’s expansion reflect a profound lack of understanding of disability rights, history and what the causes, consequences and solutions to the discrimination and injustice disabled people experience actually are.

This myth exists as part of the hyper-individualization of human rights by neoliberalism. Instead of human rights as integral component for building a better society, your body becomes a container of assets that you manage. Universal human vulnerability is denied and instead treated as a deviance from ‘normal’ so that whatever social institutions and policies do exist, do not reflect the necessary conditions for broad resilience. Disability and illness are interpreted through the lens of self-ownership, (an extension of private property rights) and personal responsibility. That the neoliberal state is generously offering to aid you into the grave – for free – is not a pivot, it’s an unmasking of any pretence left covering Canada’s allegiance to the dictum of Margaret Thatcher: “there is no such thing as a society.”

In a zero-sum society where the state’s responsibility for social welfare of its citizens is eroded, it was almost inevitable that human rights would become a competitive race to the bottom. A throne of nails and a poison drip awaits the victor.

The urge to distinguish oneself as ‘free’ while yoked to neoliberal and eugenic logic leads to absurdly invoking the Charter to demand something simply because someone else has it - even if what that person has is killing them and those around them. MAID is particularly exploitative as it uses the same hierarchy of deservingness as the charity model to suggest you can reverse your way out of pity and ableist oppression, assert your freedom and prove your equality by asking the state to kill you. Surely this committee and the Canadian state is capable of a more sophisticated understanding of discrimination and human rights.

In a forthcoming chapter entitled, The Case Against Legalizing Assisted Death for Psychiatric Disorders,” Trudo Lemmens and Scott Kim demonstrate why parity arguments logically lead to absolute autonomy (death on demand for anyone).

“..the parity argument is difficult to restrain. For instance, it is not clear whether one can

draw a principled line around ‘medical and psychiatric suffering’ so that all other suffering is excluded, if all that matters is some formal criterion of equal treatment. What is unique about medically based suffering (both somatic and mental) that suggests a clear, principled line around it (Braun, 2023; Davis & Mathison, 2020; Kim, 2023)? That is, one could apply the parity principle to whether persons suffering from non-medical causes are being discriminated against. There is a perennial debate in the Netherlands about extending legal EAS [euthanasia, assisted suicide] to, for example, elderly persons who do not have irremediable medical suffering, but who are ‘tired of life’ and would like EAS. What principle would exclude suffering from abject poverty? The logical destination of the parity argument seems to be a pure autonomy-based EAS system.”[i]

This aligns with disability analysis that for years has asked “Why Us?” The actual discrimination exists at the level of deciding that our suffering - and only our suffering - makes us killable. Humans suffer in a myriad of ways and among the worst is feeling helpless while someone you care for is suffering. And those feelings also happen when you are the person who others might be feeling powerless to help. It makes me wonder how much unprocessed grief and feelings of powerlessness lead to a misguided desire to add meaning and purpose by participating in the construction of MAiD. Once you unravel and disentangle your thoughts and definitions of words like dignity from ableism, you are left with the realization that ableism is the only thing defining the perimeters of MAiD.

Disability analysis has evolved from its early focus on individual rights, independence and integration into existing systems. Breaking free of the medical and charity model and the explosion of knowledge that followed the freeing of many, (though not all), from institutions, led to the realization that the tools we were using were pre-coded to build ableism not dismantle it. As Jean-Sebastian Beaudry, Canada Research Chair in Health, Inclusion and Policy at McGill Law School explains, “Disability justice…requires the dismantling of the multifaceted ableist ideology that pervades the very tools used to achieve justice, and disguises policy shortcomings as unavoidable economic or biological necessities.” [ii]

MAiD is built discrimination, not a remedy to it. The Canadian state decided no dignity is possible for someone who is disabled and, as consolation prize, branded a lethal injection from a state-sanctioned provider “dignified” declaring, “There’s your human rights!”. Conveniently, this aligns with the commodification of human rights. A new revenue stream was created for some but, overall, killing us is vastly cheaper than building the necessary infrastructure and policy to make a dignified life plausible.

The reasoning behind this myth is akin to suggesting that ugly laws were discriminatory not because they banned visibly disabled people from public space but because they didn’t ban all disabled people from public space.

Those presenting the astroturf-autonomy of “access” to death to an actual-autonomy-deprived population are certainly making a choice to do so. But why?

At least one study found that support for euthanasia on the basis of mental illness was positively correlated with stigma towards people with mental illness. Not only the opposite of what one would expect if the myth were true but suggests that those spreading this myth may be projecting their own beliefs onto us.

The co-opting or, at best, outdated and incorrect understanding of disability rights invoked in the name of support for MAiD is made possible by the absence of disabled knowledge and understanding. The mythmaking - or some would call it misinformation – reflects broader epistemic injustice that has remained largely unchallenged and become more entrenched and fictitious as a result of MAID.

MAiD is discrimination not a solution to it. It must be repealed not expanded.


[i] Scott Kim & Trudo Lemmens, The Case Against Legalizing Assisted Death for Psychiatric Disorders

(Forthcoming in Matthé Scholten, Kelso Cratsley, and Tania Gerkel, eds., Mental Health Ethics:

Current Controversies and Emerging Debates (Oxford University Press))

[ii] Jonas-Sebastien Beaudry Ableism’s new clothes: Achievements and challenges for disability rights in Canada

University of Toronto Law Journal 2024 74:1, 1-40

British Columbia lacks oversight of it's euthanasia regime.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

An investigative report by Terry O'Neill that was published by the BC Catholic on July 21, 2025 uncovers a shocking lack of oversight of the euthanasia (MAiD) law in British Columbia (BC). The investigative report was carried-out by O'Neill who uncovered the information by filing multiple freedom of information applications.

O'Neill begins his article by pointing out a position of the BC MAiD "oversight" committee:

At the same time, oversight should provide opportunities for education or warning depending on the severity of an infraction, as overly strict or severe use of referrals to law enforcement or professional colleges may discourage physicians or nurse practitioners from providing MAiD despite the high demand.

O'Neill writes:

A B.C. Catholic investigation has uncovered systemic failures in the province’s euthanasia program, including thousands of paperwork errors among the 2,767 MAiD (medical assistance in dying) deaths recorded in 2023, a lack of public reporting of violations, and an oversight unit led by the same health official responsible for delivering MAiD in B.C.

Leading critics of Canada’s permissive legalized-euthanasia regime call the findings “staggering” and “stunning,” saying the newly disclosed British Columbia government documents show a lack of effective oversight of (MAiD) in the province.

O'Neill then quotes me (Alex Schadenberg) as saying:

“It’s an actual life-and-death issue,”

“And what we’re seeing in B.C. is evidence that the scales have been tipped in favour of death.

Trudo Lemmens

O'Neill explains how he obtained the information and points out that the BC MAiD oversight committee has not published any public reports. O'Neill questions the oversight of the committee:

The unit is led by social worker Sara Bergen, whose biography states that she also heads the overall administration of MAiD in British Columbia. This dual role is, in itself, cause for concern, says Trudo Lemmens, professor and Scholl Chair in Health Law and Policy at the University of Toronto. Lemmens also serves on Ontario’s independent MAiD-oversight body, which operates under the auspices of the province’s chief coroner.

Lemmens told O'Neill that

“Somebody combining the organization of a practice with the oversight of a practice is unhealthy,”

O'Neill reports on his exchange with the BC Ministry of Health.

The Ministry of Health said in an email reply that the province’s MAiD Oversight Unit does not investigate wrongdoing but reviews documentation submitted by practitioners to ensure compliance with federal and provincial safeguards. While the unit may follow up to clarify missing or incomplete information, it does not determine misconduct or impose disciplinary action.

In rare cases, the ministry said, the unit may refer concerns to a health professional’s regulatory college or to law enforcement. Such referrals, it emphasized, “do not represent allegations of misconduct.” Police referrals are reserved for “the most serious compliance issues,” including significant deviations from eligibility or safeguard requirements, or cases where a deliberate breach of statutory obligations is suspected. Practitioners are not notified of referrals to police to protect the integrity of potential investigations.

The ministry also confirmed that Sara Bergen, who leads the MAiD Oversight Unit, serves concurrently as the provincial Director of MAiD. In that role, she oversees the strategic direction of MAiD policy and its implementation across the health system, including coordination with regulators, care providers, and service delivery agencies.

Remaining questions about the outcome of past referrals and details of disciplinary action, the ministry said, would need to be submitted as Freedom of Information requests.

O'Neill explains the MAiD oversight committee's response to infractions of the law.

Among the problematic information contained in the 28-page FOI release is a “briefing decision note,” written by an unidentified bureaucrat, which argues that the oversight unit should not be overly strict in reporting infractions of MAiD-delivery protocols to professional colleges or the police.

“… Overly strict or severe use of referrals … may discourage physicians or nurse practitioners from providing MAiD despite high demand,” states the November 2023 memo, addressed to Stephen Brown, deputy minister of health.

Brown approved the note’s concluding recommendation to establish a new “weighted criteria model” for judging practitioner infractions.

Christopher Lyon

O'Neill asks Christopher Lyon, a Canadian who teaches at UK’s University of York to respond. Lyon's comments:

“This is staggering,”

He said the memo essentially gives permission to “Unlawfully kill someone, but we won’t enforce it because it might discourage practitioners from playing loose with the law.”

Lyon said the province should be “very concerned” about what’s driving an apparent high demand for euthanasia rather than working out ways to address it.

Trudo Lemmons also responded to O'Neill with shock.

Lemmens too was shocked by the bureaucrat’s reasoning that MAiD is too popular to worry about rules. “Indeed, [it’s] stunning to state that so explicitly.”

O'Neill outlines the data:

The FOI document also contains a spreadsheet showing that, in 2023 alone, the oversight unit found 2,833 “reporting issues” and “completion errors” in the paperwork for 2,767 MAiD deaths and for 1,041 cases in which MAiD was applied for but not completed.

Nevertheless, since 2018, the unit has made only 22 referrals to regulatory bodies for possible disciplinary action and just two referrals to law enforcement for potential criminal charges, according to an unattributed declaration appended to the end of the FOI document. The statement concludes by saying the referrals “represent less than 0.2 per cent of the total number of cases of MAiD reviewed by the unit.”

Isabel Grant

O'Neill spoke to Isabel Grant, a law professor at the University of British Columbia who responds:

“It was alarming to read about the error rate in MAiD assessments in B.C.,” Grant said in an emailed statement. “Looking at only one indicator—errors around the eligibility requirements—we see an error rate of 4.9 per cent. When we are talking about close to 3,000 deaths, that is a very high number.”

Grant said that when the cost of a mistake is a potential wrongful death, society should not tolerate such a high error rate. “Couple this with the concern raised in the report that we cannot have an ‘overly strict’ referral to law enforcement or professional colleges … [and] we can see the approach of the British Columbia government to MAiD deaths—err on the side of making MAiD accessible, not on the side of compliance with the Criminal Code,” she said.

The government’s approach is especially troubling, Grant said, considering “we are talking about exemptions from Canada’s murder and aiding-suicide laws.”

O'Neill examined public records and found no records related to concerns with MAiD in BC:

The B.C. Catholic examined seven years’ worth of public disciplinary records of the College of Pharmacists of B.C., the College of Physicians and Surgeons of B.C., and the B.C. College of Nurses and Midwives and was unable to find any record of disciplinary action related to MAiD. Likewise, there are no public records of any criminal charges related to a professional’s handling of MAiD.

Curiously, there is no public record of the lone disciplinary case for which the FOI papers provided any detail. The case is described in a three-page “Ministry of Health Decision Briefing Note” drafted in January 2021. It outlines the case of a B.C. doctor, whose name is not disclosed, who filed a report to the oversight unit that “failed to include a second assessment concluding eligibility, as required under federal law.”

As well, the briefing note reported that the oversight unit “also identified additional issues with the physician’s documentation of this case, which contravene the College of Physicians and Surgeons MAiD Practice Standards.”

“… The absence of a second independent opinion is exacerbated by an apparent disregard of an assessment of ineligibility,” the note states. It concludes by recommending that the oversight unit refer the case to both police and the doctors’ college “for appropriate investigation.” It is not known whether Deputy Minister Brown acted on the recommendation.

A spokesperson for the doctors’ college said that privacy concerns prevent it from releasing information about any referrals from the MAiD Oversight Unit.

A spokesperson for the nurses’ college said a B.C. Catholic request for follow-up information on disciplinary matters would be treated as an FOI application and be answered by the end of August.

However, the B.C. government did make that very information available in 2023 in response to an FOI request by Dr. Deborah Cook, a Member of the Order of Canada inducted into the Canadian Medical Hall of Fame last month.

The government response lists two B.C. referrals to law enforcement—one in 2019 and the other in 2021—related to breaches of Section 241.2 of the Criminal Code of Canada, which sets out the eligibility criteria and safeguards for medical assistance for MAiD. The document does not say which professions were involved in the criminal referrals.

In addition, the single-page document to Cook listed three referrals to the pharmacists’ college, two to the nurses’ college in 2019, and 15 to the doctors’ college from 2019 to November of 2023. The unit found that in four of the doctors’ cases and in the two nurses’ cases, the medical assessor had concluded that a patient was eligible for MAiD even though the assessment “did not find they met all individual eligibility criteria.

Alex Schadenberg

O'Neill ends his article by quoting from his conversation with me:

Schadenberg said the apparent lack of disciplinary action or criminal charges is further evidence that B.C.’s MAiD oversight is ineffectual, despite the Supreme Court of Canada’s Carter decision, which led to the 2016 legalization of MAiD, carrying a requirement for stringent oversight.

Schadenberg remarked that prosecuting such crimes will always be frustratingly difficult because “any witness on the other side is dead.”

Indeed, “it’s like the perfect crime,” he said. “You don’t get into trouble, and anybody who could effectively complain about it is dead.”

O'Neill has opened up a can of worms that has forced him to seek more information through freedom of information requests. The story will continue.

In October 2024 the Ontario MAiD review committee released a report that uncovered 428 non-compliant MAiD deaths from 2018 - 2023.

Sonu Gaind: Unravelling MAiD in Canada.

EPC has copies of the book Unravelling MAiD in Canada available for purchase.

Purchase the book from EPC for $40 (after tax) + shipping (Order Link).

Previous article: Ramona Coelho: Unravelling MAiD in Canada (Link).

The following speech was presented by Dr Gaind for the April 15 launch of the book: Unravelling MAiD in Canada.

Dr. Sonu Gaind is a Professor of Psychiatry at the University of Toronto and Chief of Psychiatry at Sunnybrook Health Sciences Centre. He is an Executive Member and Medical Practice & Tariff Chair of the Ontario Medical Association (OMA) Section on Psychiatry and Chair of the OMA Relativity Advisory Committee, and a Past-President of the Canadian Psychiatric Association.

Sonu Gaind speaking at book launch.

Dr K. Sonu Gaind

You know, we often say it’s the journey and not the destination, but in this case I’m not so sure. It’s been a pretty rough journey for many advocating in this area, and it is pretty great to finally see this important work see the light of day. 

I’m so appreciative of the chance to be standing here with my co editors, Ramona Coelho and Trudo Lemmens, as we launch this book. I truly hope it contributes to our national discourse as we, as a society, continue navigating the challenging waters of how, and what, we should or should not be helping people die for. I also want to thank all of our authors, whose wisdom and compassion shine through both in this volume and through their own advocacy, and also our publisher McGill/Queen’s University Press for their support and guidance through this process.

And of course, thank all of you for being here today, both in person and online (we have another about 40 or 50 people online ). A particular shout out to my dad, who couldn’t be here for health reasons but is watching - Dada, I think by now you’ve probably read and re-read the book more carefully than me, Trudo and Ramona put together. And while I’m doing shout outs, the loudest has to be to my wife Lystra and my kids Dante and Sabine even when this work has taken me away from you, you’ve always still been there for me.

When I look around this room I’m amazed by the range of friends and colleagues who have come out to celebrate this occasion with us. Thank you all so much. We have university colleagues, hospital and workplace colleagues, old friends and new confreres we’ve met and made through this journey. The diversity is remarkable, and I think a testament to how important this issue is, and how deeply people want to think about and engage in it, if given a chance.

Why we might choose, as a society, to provide death to fellow Canadians is a hugely complex issue, and one that should engender robust and honest debate. It’s legitimate to debate when it might be compassionate to help relieve suffering, versus when it might be abandonment to facilitate suicide.

Unfortunately that honest debate is not what has driven our MAiD expansion so far. Instead, as outlined in my chapter, Fall of Duty: The Breach of Trust and Moral Failure of Canada’s Entrusted Experts, and other chapters in the book, we’ve had troubling processes that have led to Canada becoming the world’s canary in a coal mine on euthanasia expansion. As Trudo will mention, the United Nations has explicitly raised concerns that our own policy makers refuse to acknowledge, of the existential risks our current MAiD expansions pose to marginalized Canadians.

That’s why I think this book is so important. From lived experience, expertise, cultural considerations and lenses of diversity, the authors unflinchingly explore not only why our most privileged, who have lived well and want autonomy to die well, might seek MAiD; but also why our most marginalized, struggling with access to social care, who society never afforded a chance to live with dignity, might (and are) increasingly seeking available euthanasia to escape life's suffering.

What we provide death for is the flip side of how we help people live.

It’s not an easy message to hear, but it’s an essential one, since I can’t think of much that defines us more as a society is that we help people live with dignity before they need to "choose" death as their only option. And for bringing these perspectives forward with eloquence, clarity, humanity and humility, often in the face of privileged voices trying to stifle any cautions, I’m deeply grateful to all our authors and co-editors to have been part of this endeavour.

Book Launch on April 15, 2025 (Link to Video)

Ramona Coelho: Unravelling MAiD in Canada.

The following speech was written by Dr Ramona Coelho for the April 15 launch of the book: Unravelling MAiD in Canada.

EPC has copies of the book available for purchase. 

Order the book from EPC for $40 (after tax) + shipping (Order Link).

By Ramona Coelho

Dr Ramona Coelho speaking on April 15.

Thank you so much for being here. I’m deeply grateful to share this moment with all of you, and especially honoured to stand alongside Dr Harvey Schipper and my co-editors, Dr. Sonu Gaind and Professor Trudo Lemmens. The book we’re launching tonight is the result of years of lived experience, medical care, research, and a common concern — concern for Canadians, and for the future of medical care and societal culture in this country.

We release this book at a critical time. As Trudo has mentioned, the UN Committee on the Rights of Persons with Disabilities has recommended the repeal of Track 2 MAiD. Likewise, the Ontario Coroner’s MAiD Death Review Committee — of which both Trudo and I are members — has begun publishing reports that document serious public safety concerns in MAiD cases. What we see confirms what many of us in healthcare have long feared and have tried to bring to the attention of politicians: people are accessing MAiD through lax application of the law, often without a thorough or humane exploration of their suffering. In some cases, death is being offered more readily than medical care and supports.

As a family physician, I work every day with people who face enormous barriers: refugees, individuals living in poverty, those with disabilities, mental illness, or incarceration histories. Earlier in my career, I provided home care in Montreal for people with dementia, addiction, or severe physical disabilities. These patients — like all of us — need to know their lives are valued, but sadly often don’t. Canadians need support, not an easy exit when life becomes unbearable. They need care, not assisted death as a substitute for our societal collective failures.

MAiD was introduced to Canadians as an “exceptional measure for exceptional cases,” intended to relieve suffering at the end of life when nothing else could. It has rapidly shifted. Private MAiD provider forums leaked by AP journalists- like Maria Cheng – have revealed cases where people qualified because of loneliness, lack of housing, or feelings of being a burden. When death is given because systems failed to offer support — that is not autonomy. That is abandonment.

Our book aims to expose these troubling patterns with clarity, evidence, and compassion. We highlight not only the stories and legal pathways, but also the ethical crossroads we now face as a society.

This is not an abstract debate. These are real people — people whose deaths were approved despite untreated mental illness, poverty, social isolation, or perhaps even the pressure of caregiver burnout.

We must ask ourselves, as the human rights commissioner of Canada also asked last year: Are we building a society where everyone’s life is seen as equally worth living? Or are we creating a system that quietly accepts some lives as more expendable?

We hope this book serves as a resource for those asking these hard questions — and a call to action for those in healthcare, law, policy, and beyond. Because at the end of the day, our task is not just to offer choices — it is to ensure those choices are grounded in dignity, support, and the belief that every person deserves to live a life of meaning, regardless of their challenges.

Thank you.

Order the book from EPC for $40 (after tax) + shipping (Order Link).

Book: Unravelling MAiD in Canada

Alex Schadenberg
Executive Director,
Euthanasia Prevention Coalition

I was pleased to attend the launch of the book: Unravelling MAiD in Canada in Toronto on April 15. 

The Euthanasia Prevention Coalition shares the hopes of the editors of the book - that this book will change the Canadian debate.

Unravelling MAiD in Canada is a thorough 530 page book that features chapters by: Ramona Coelho, K. Sonu Gaind, Trudo Lemmens, Mary Shariff, Leonie Herx, Alexander Simpson, Roland Jones, Gabrielle Peters, Hon Graydon Nicholas, Isabel Grant, Derek Ross, Mark Sinyor, Ayal Schaffer, Catherine Ferrier.

EPC has copies of this important book available for purchase. Order the book from EPC for $40 (after tax) + shipping (Order Link).

Unravelling MAiD in Canada was edited by:

• Dr. Ramona Coelho, family physician and Senior Fellow of domestic and health policy, Macdonald-Laurier Institute
• Dr. K. Sonu Gaind, Professor, Temerty Faculty of Medicine, University of Toronto and Chief of Psychiatry, Sunnybrook
• Dr. Trudo Lemmens, Professor and Scholl Chair in Health Law and Policy, Faculty of Law, University of Toronto

Unravelling MAiD in Canada has chapters that focus on: general medicine, psychiatry, palliative care, Canadian law, health policy, disability rights and ethics.

With the number of (MAiD) euthanasia deaths in Canada and how the law expanded in 2021 (Bill C-7), Unravelling MAiD in Canada is an important book for Canadians and other people in countries that are debating the legalization of euthanasia and/or assisted suicide. 

EPC has copies of this important book available for purchase. Order the book from EPC for $40 (after tax) + shipping (Order Link).

The Concentration of Canada's Euthanasia Providers Signals a Critical Juncture for Meaningful Policy Reform.

Yuriko Ryan

By Dr. Yuriko Ryan

A new article published on January 10, 2025 in The American Journal of Bioethics examines the rapid increase in Medical Assistance in Dying (MAID) deaths in Canada. 

Dr. Lyon, the lead author witnessed a MAID death in BC; Dr. Lemmens is a member of the MAID Death Review Panel of the Office of the Chief Coroner for Ontario, and Dr. Kim along with Dr. Lemmens, were members of the Council of Canadian Academies Expert Panel on Medical Assistance in Dying.

The authors describe the rise of MAID deaths in Canada, suggesting it is influenced by policy rather than widespread societal acceptance. They argue that organizations such as the Canadian Association of MAID Assessors and Providers (CAMAP) and Dying with Dignity Canada (DWDC) have significantly influenced MAID policy, emphasizing access over patient safety and protection against premature death. This, according to the authors, has resulted in concerning cases and potential legal violations. They call for substantial reform, advocating for more transparent, evidence-based, and multi-perspective policymaking to ensure a safer and more ethical MAID system in Canada.

The key issues discussed in this article include:

Drivers for the Exponential increase in MAID deaths

Provider Concentration: A small group of clinicians are responsible for the majority of MAID deaths. The Fifth Annual Report on MAID 2023 (Canada, 2024) shows that practitioners who performed MAID 11 or more times in 2023 provided 66.4% of Track 1 (a requester’s natural death is reasonably foreseeable) cases and 58.4% of Track 2 (a requester's natural death is NOT reasonably foreseeable) cases. Some clinicians have made MAID their full-time practice, and the number of cases per provider has increased from 5.1 in 2019 to 7.2 in 2022.

Problematic Cases: There have been instances where individuals sought MAID due to lack of access to other resources, non-compliance with eligibility criteria, incomplete documentation, and clinicians refusing to cooperate with oversight bodies. A concerning number of unlawful MAID deaths have been reported.

Expansion of Eligibility: There is an active movement toward further expansions in MAID eligibility, including for mature minors and those with mental disorders. There are concerns that the focus is on facilitating access to MAID rather than protecting against premature death. Some cases suggest that individuals with mental illness, poverty, or lack of adequate support have received MAID.

Lack of Safeguards: The criteria for MAID, such as "serious and irremediable" conditions, have been interpreted flexibly, with heavy reliance on self-reporting. The MAID law does not require a high level of expertise for assessments.

Influence of Advocacy Groups: CAMAP and DWDC have played a disproportionate role in influencing MAID policy. CAMAP has close ties to DWDC, an expansionist advocacy group, and this has resulted in a conflict of interest that has been disregarded by the Canadian government.

CAMAP's Role and Influence:

Activist Ideology: CAMAP promotes an activist approach to MAID and has its origins in the leading global MAID advocacy organization, DWDC. CAMAP's bylaws require that more than half of its directors must be assessors or providers who have approved or provided MAID for at least five people each year.

Policy Influence: CAMAP has been consulted by Health Canada and has received public funds ($3M CAD) to develop a national training curriculum. CAMAP members’ expertise appears to be based on informal accumulation of patient requests and deaths rather than formal training.

Guidance Documents: CAMAP's guidance documents have been geared toward expansion, with advice on how to circumvent requirements for those not approaching natural death. CAMAP advises clinicians to mention MAID to potentially eligible patients, which some consider a risk of coercion. The organization also suggests that the imminent loss of capacity can be seen as an "advanced state of irreversible decline."

Flaws in Canadian MAID Law:

Subjective Preferences: The irremediability is reduced to the subjective preference of the requester. The law allows the co-opting of the healthcare system for the delivery of ideologically driven deaths.

Lack of Medical Expertise: The majority of MAID delivery is by non-specialist family practitioners and nurse practitioners. The law allows a person with "expertise in the condition" to be consulted rather than requiring a specialist, explicitly to avoid barriers to access.

Prioritizing Access over Safety: The Canadian MAID law prioritizes access to MAID over safety measures. Some providers construct MAID in ideological terms, as ‘social justice,' 'a crusade,' or 'empowering people.'

Conclusion:

The rapid increase in MAID deaths in Canada is not solely a reflection of widespread public support but is influenced by a small group of activists. The close relationship between CAMAP and DWDC, along with the government's reliance on these organizations, has led to an expansionist approach to MAID. There is a need for substantial review of MAID policy and practice. Reforms are urgently needed to insulate policy development from the influence of minority views. The government should establish an independent and transparent public body more representative of clinical specialties and other stakeholder groups, as well as a public meta-regulator to provide oversight and standardization. Increased transparency is necessary for public accountability and patient safety.

What Can We Learn?

These findings are relevant to ongoing debates about assisted suicide and euthanasia globally. The Canadian example highlights the need for safeguards and transparent processes to prevent similar issues elsewhere. Policymakers, medical professionals, and the public should be aware of these risks when considering end-of-life options.

Dr. Yuriko Ryan is a Canadian bioethicist and gerontologist who explores emerging topics including end-of-life care, mental health and addiction, and artificial intelligence. She is an ethicist with more than 25 years experience in health policy research and healthcare administration. She has a doctorate in bioethics and a Master's degree in gerontology from Simon Fraser University. 

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).