MacDonald Laurier Institute
Barriers to care persist but access to MAiD keeps expanding

From the Macdonald Laurier Institute
By Ramona Coelho
Our government has allowed the incredible power of certain lobby groups to control the public discourse and policies around MAiD and its expansion, prioritizing access to MAiD over the safety of Canadians.
My family medicine practice serves predominantly low-income and marginalized patients, including refugees, those who have been in our prison system or are facing charges, and many with disabilities and mental health issues. My patients experience high barriers to care and support and face social isolation and all kinds of discrimination. Observing the impacts of this has left me deeply concerned about our government’s priorities.
When the federal government introduced MAiD (a medical procedure that causes death) to those not at imminent risk of dying, I was appalled to learn that my patients, who are frequently blocked from care as a result of hurdles created by our government and systems, could potentially be offered an expedient death provided by the government.
In 2016, assisted suicide and euthanasia were first legalized in Canada and the term medical assistance in dying (MAiD) was created. Originally MAiD was presented as an exceptional lethal procedure for ending the lives of consenting adults who were experiencing intolerable suffering and were near death. The legislation required that patients meet certain criteria, including having a “grievous and irremediable” medical condition, such as organ failure or cancer, and a “reasonably foreseeable natural death.”
But the Canadian discourse around MAiD rapidly shifted to facilitating access and there has been a broadening of the number and criteria of those who qualify for MAiD. In 2021, Bill C-7 came into effect and removed some of the safeguards within the original pathway, now called Track 1, and created a new, second track, Track 2, for adults with physical disabilities[1] who are not dying. Furthermore, there is a planned expansion, though the timing is currently being debated in Parliament, for patients whose only medical condition is mental illness. Parliamentary recommendations in 2023 included future expansion to children and to incapable adults who signed advance directives for euthanasia.
Currently, those in Track 1 with a “reasonably foreseeable natural death” can potentially have their life ended the same day as the initial request if all the criteria are met and practitioners are available.
For those in Track 2, those not dying, death by lethal injection is set at a minimum of 90 days after the completion of the first MAiD assessment. To qualify for this track, a patient must also have a “grievous and irremediable” condition and experience intolerable psychological or physical suffering. Suffering is treated as purely subjective with no requirement for further validation. There is also no legal requirement for standard treatment options to be accessible or tried, only that a patient be informed that they exist. This means that a patient who says they are suffering intolerably could access MAiD having declined treatments that would remediate their condition. This could be because the treatment is inaccessible, or unaffordable, or if the patient declines therapy.
The Canadian Association of MAiD Assessors and Providers (CAMAP) has received 3.3 million dollars in funding from Health Canada to educate clinicians assessing and providing for those who have requested the service. So although the existing Track 1 and Track 2 pathways have different safeguards, in aiming to allow those near death to have access to MAiD quickly and with no barriers, CAMAP has created a guidance document that suggests clinicians can be flexible as to whether someone fits Track 1’s reasonably foreseeable natural death, since the law does not require that the person be terminally ill or likely to die within 6 or 12 months. It also states that a person may meet the reasonably foreseeable criterion if they’ve demonstrated a clear and serious intent to take steps to “make their natural death happen soon, or to cause their death to be predictable.” This could come about from a refusal to take antibiotics for an infection, stopping oxygen therapy, or refusing to eat and drink.
This means that people with disabilities can state their intention to or make themselves sick enough to qualify as having a reasonably foreseeable natural death, as is currently happening with adults who are not dying and yet are having their lives ended within days of their first MAiD assessment. In one case, a man had a mild stroke and received MAiD shortly after, even though he wasn’t terminally ill. The reason? He was approved for track 1 as he was temporarily eating less. This was due to following a cautious meal plan ordered by the treating team which was intended to prevent choking and aspiration risks.
Currently, some places in Canada have MAiD rates that are the highest in the world. By the end of 2022, there had been almost 45,000 MAiD deaths across Canada since legalization—more than 13,000 of which took place in 2022 with 463 of those individuals accessing MAiD through Track 2. Estimates based on provincial reporting approximate 16,000 deaths in 2023. Health Canada and MAiD expansionists have tried to reassure the public that the overwhelming number of MAiD deaths have been mostly Track 1 deaths (implying they were dying anyway) but we do not know how many of those persons were “fast-tracked” and may have had many decades of life left to live and the potential to recover with time and care.
The CAMAP guidance document that seems to circumvent Track 2 safeguards is just the beginning of many serious problems with MAiD legislation and practice in Canada.
Patient safeguards for MAiD are lacking
Other jurisdictions in the world where MAiD practices are legalized, such as New Zealand and Victoria, Australia, frown on or prohibit raising death as a treatment option. This is due to the power imbalance that exists between physician and patient, coupled with the patients’ assumption that the provider will only suggest the best options for their health. Raising MAiD unsolicited could cause undue pressure to choose death. Yet Health Canada’s 2023 Model Practice Standard for Medical Assistance in Dying recommends that MAiD should be raised to all who might qualify if the practitioner suspects it aligns with a patient’s values and preferences.
The model practice standard’s approach to “conscientious objection” is equally troubling. Health care providers who object to providing MAiD, even in specific cases, are considered conscientious objectors. A physician who is concerned that MAiD is not a patient’s best option is supposed to ignore their conscience or professional opinion and simply refer the patient on so they can seek access to a MAiD death.
This is further echoed in a CAMAP video training session where experts explain that patients might be driven to MAiD by unmet psycho-social needs. The expert leading the session responds to a trainee’s concerns: “If withdrawing is about protecting your conscience, you have [an] absolute right to do so.” But he adds: “You’ll then have to refer the person on to somebody else, who may hopefully fulfill the request in the end.” This demonstrates precisely how effective referrals can funnel patients toward death despite legitimate professional concerns and obligations that should have instead led to the process being stopped or paused.
In response to this legislation, many from the disability community have advocated for safe spaces where MAiD can’t pose a risk to their lives. The Disability Filibuster, a national grassroots disability community, stated in an open letter that its members have raised fears about seeking health care where death could be offered to them and if at their lowest, they might agree.
The disability community is not being alarmist in this concern. Health care providers often rate the quality of life of those with disabilities as poor despite those patients rating their own quality of life as the same as aged-matched healthy individuals. Put differently, many physicians might consider that patients with disabilities are better off dead, consciously or unconsciously, which might lead them to suggest MAiD.
Besides the problems of mandatory referral and raising MAiD unsolicited, there is another important factor to consider. Persons with physical disabilities systemically lack much of the essential care they need to live and consequently suffer higher rates of isolation, poverty, and marginalization, all of which can make death their most accessible option. The Canadian government commissioned a University of Guelph study, published in 2021, in which the researchers noted that some persons with disabilities were encouraged to explore the MAiD option—even though they had not been contemplating doing so—because of a lack of resources that would enable them to live. Those with disabilities can be approved for MAiD based on their disability, but it is their psycho-social suffering that can drive their requests.
The United Nations Special Rapporteur on the rights of persons with disabilities, the Independent Expert on the enjoyment of all human rights by older persons, and the Special Rapporteur on extreme poverty and human rights have all warned the Canadian government that the current MAiD framework could lead to human rights violations. Their concerns are validated by the numerous fact-checked stories about MAiD abuses that are emerging in Canada. These should give us pause. For example, Sathya Dhara Kovac, 44, ended her life through the MAiD program. She lived with a degenerative disease and her condition was worsening, but she wanted to live but lacked the home care resources to do so. “Ultimately it was not a genetic disease that took me out, it was a system,” Kovac wrote in an obituary to loved ones. All Canadians have a right to humane living conditions, to be treated with respect and dignity, and to receive appropriate timely medical care. Considering the living conditions and lack of care that as a society we allow persons with disabilities to have, choices to die might be understandable for those like Sathya. But we should ask ourselves if choices, made under inhumane conditions, are made freely if driven by structural coercion.
Disturbingly, there are MAiD assessors and providers who seem to be ok with proving MAiD under such inhumane conditions. One such provider testified at a parliamentary committee on MAiD that if someone had to wait a long time for a service that would remediate their suffering, she would still consider that waiting to be irremediable suffering and grant them MAiD in the interim. Therefore, it is not surprising that patients with unaddressed psycho-social suffering are being given MAiD by assessors like her.
When it was considering Bill C-7, the federal government asked the Parliamentary Budget Officer to estimate cost savings to our health care system of the legalization of MAiD. The office did this by looking at the comparative cost savings of MAiD versus palliative care at the end of life. Through this impoverished lens of valuation, it is clear that the cost savings will be even greater when, by many years, we prematurely end the lives of people who have higher care needs, especially when we factor in social services, disability benefits, equipment, and other costs on top of the direct savings to health care budgets. But this is not how we should create budgets or measure outcomes. Our socialized health care system is meant to serve those with disabilities, not consider them a cost to the system.
The Canadian government is currently deciding on the timing for its further roll-out of MAiD, this time for mental illness and with no legislative changes to the current safeguards. This expansion is alarming given what we know is happening already to disabled Canadians under the existing MAiD regime. The Canadian Association of Chairs of Psychiatry wrote a letter in 2022—and some testified more recently in Parliament—that we are not ready for this development. They have warned that there is no evidence to guide decisions about who with mental illness would not get better. The evidence suggests that for every 5 people whose lives would be ended based on the sole medical condition of mental illness, 2 or 3 would have recovered. We expect to have much higher numbers qualifying for MAiD on the grounds of mental illness in Canada than in other jurisdictions that allow assisted death for this reason, since barriers to care and unmitigated psycho-social suffering do not have to be rectified in this country (as they do elsewhere) before being granted MAiD.
Our government has allowed the incredible power and influence of certain lobby groups and their members to control the public discourse and policies around MAiD and its expansion, prioritizing access to MAiD over the safety of Canadians. Besides the current discussion about when to legalize MAiD for mental illness, the parliamentary committee has also recommended expansion to children and MAiD by advance directives. With eligibility for MAiD continuing to broaden, we are not giving priority to serving those most in need, but instead seem intent on rapidly expanding a path to end their lives.
[1] Disabilities is an umbrella term that includes impairment, chronic illness and/or other conditions.
Dr. Ramona Coelho is a family physician in London, Ontario. Her practice largely serves marginalized patients.
Business
Closing information gaps to strengthen Canada’s border security and track fentanyl

By Sean Parker, Dawn Jutla, and Peter Copeland for Inside Policy
To promote better results, we lay out a collaborative approach
Despite exaggerated claims about how much fentanyl is trafficked across the border from Canada to the United States, the reality is that our detection, search, and seizure capacity is extremely limited.
We’re dealing with a “known unknown”: a risk we’re aware of, but don’t yet have the capacity to understand its extent.
What’s more, it may be that the flow of precursor chemicals—ingredients used in the production of fentanyl—is where much of the concern lies. Until we enhance our tracking, search, and seizure capacity, much will remain speculative.
As border security is further scrutinized, and the extent of fentanyl production and trafficking gets brought into sharper focus, the role of the federal government’s Precursor Chemical Risk Management Unit (PCRMU)—announced recently by Health Canada—will become apparent.
Ottawa recently took action to enhance the capabilities of the PCRMU. It says the new unit will “provide better insights into precursor chemicals, distribution channels, and enhanced monitoring and surveillance to enable timely law enforcement action.” The big question is, how will the PCRMU track the precursor drugs entering into Canada that are used to produce fentanyl?
Key players in the import-export ecosystem do not have the right regulatory framework and responsibilities to track and share information, detect suspect activities, and be incentivized to act on it. That’s one of the reasons why we know so little about how much fentanyl is produced and trafficked.
Without proper collaboration with industry, law enforcement, and financial institutions, these tracking efforts are doomed to fail. To promote better results, we lay out a collaborative approach that distributes responsibilities and retools incentives. These measures would enhance information collection capabilities, incentivize system actors to compliance, and better equip law enforcement and border security services for the safety of Canadians.
Trade-off bottleneck: addressing the costs of enhanced screening
To date, it’s been challenging to increase our ability to detect, search, and seize illegal goods trafficked through ports and border crossings. This is due to trade-offs between heightened manual search and seizure efforts at ports of entry, and the economic impacts of these efforts.
In 2024, the Canada Border Services Agency (CBSA) admitted over 93 million travelers. Meanwhile, 5.3 million trucks transported commercial goods into Canada, around 3.6 million shipments arrived via air cargo, nearly 2 million containers were processed at Canadian ports, roughly 1.9 million rail cars carried goods into the country, and about 145.7 million courier shipments crossed the border. The CBSA employs a risk-based approach to border security, utilizing intelligence, behavioral analysis, and random selection to identify individuals or shipments that may warrant additional scrutiny. This triaging process aims to balance effective enforcement with the facilitation of legitimate travel and trade.
Exact percentages of travelers subjected to secondary inspections are not publicly disclosed, but it’s understood that only a small fraction undergo such scrutiny. We don’t learn about the prevalence of these issues through our border screening measures, but in crime reporting data—after it’s too late to avert.
It’s key to have an approach that minimizes time and personnel resources deployed at points of entry. To be effective without being economically disruptive, policymakers, law enforcement, and border security need to strengthen requirements for information gathering, live tracking, and sharing. Legislative and regulatory change to require additional information of buyers and sellers—along with stringent penalties to enforce non-compliance—is a low-cost, logistically efficient way of distributing responsibility for this complex and multifaceted issue. A key concept explored in this paper is strengthening governance controls (“controls”) over fentanyl supply chains through new processes and data digitization, which could aid the PCRMU in their strategic objectives.
Enhanced supply chain controls are needed
When it comes to detailed supply chain knowledge of fentanyl precursor chemicals moving in and out of Canada, regulator knowledge is limited.
That’s why regulatory reform is the backbone of change. It’s necessary to ensure that strategic objectives are met by all accountable stakeholders to protect the supply chain and identify issues. To rectify the issues, solutions can be taken by the PCRMU to obtain and govern a modern fentanyl traceability system/platform (“platform”) that would provide live transparency to regulators.
A fresh set of supply chain controls, integrated into a platform as shown in Fig. 1, could significantly aid the PCRMU in identifying suspicious activities and prioritizing investigations.

Our described system has two distinctive streams: one which leverages a combination of physical controls such as package tampering and altered documentation against a second stream that looks at payment counterparties. Customs agencies, transporters, receivers, and financial institutions would have a hand in ensuring that controls in the platform are working. The platform includes several embedded controls to enhance supply chain oversight. It uses commercially available Vision AI to assess packaging and blockchain cryptography to verify shipment documentation integrity. Shipment weight and quantity are tracked from source to destination to detect diversion, while a four-eyes verification process ensures independent reconciliation by the seller, customs, and receiver. Additionally, payment details are linked to shipments to uncover suspicious financial activity and support investigations by financial institutions and regulators like FINTRAC and FINCEN.
A modern platform securely distributes responsibility in a way that’s cost effective and efficient so as not to overburden any one actor. It also ensures that companies of all sizes can participate, and protects them from exploitation by criminals and reputational damage.
In addition to these technological enhancements and more robust system controls, better collaboration between the key players in the fentanyl supply chain is needed, along with policy changes to incentivize each key fentanyl supply chain stakeholder to adopt the new controls.
Canadian financial institutions: a chance for further scrutiny
Financial institutions (FIs) are usually the first point of contact when a payment is being made by a purchaser to a supplier for precursor chemicals that could be used in the production of fentanyl. It is crucial that they enhance their screening and security processes.
Chemicals may be purchased by wires or via import letters of credit. The latter is the more likely of the two instruments to be used because this ensures that the terms and conditions in the letter of credit are met with proof of shipment prior to payment being released. Payments via wire require less transparency.
Where a buyer pays for precursor chemicals with a wire, it should result in further scrutiny by the financial institution. Requests for supporting documentation including terms and conditions, along with proof of shipment and receipt, should be provided. Under new regulatory policy, buyers would be required to place such supporting documentation on the shared platform.
The less transparent a payment channel is in relation to the supply chain, the more concerning it should be from a risk point of view. Certain payment channels may be leveraged to further mask illicit activity throughout the supply chain. At the onset of the relationship the seller and buyers would link payment information on the platform (payment channel, recipient name, recipient’s bank, date, and payment amount) to each precursor or fentanyl shipment. The supplier, in turn, should record match payment information (payment channel, supplier name, supplier’s bank, date, and payment amount).
Linking payment to physical shipment would enable data analytics to detect irregularities. An irregularity is flagged when the amounts and/or volume of payments far exceed the value of the received goods or vice versa. The system would be able to understand which fentanyl supply chains tend to use a particular set of FIs. This makes it possible to conduct real-time mapping of companies, their fentanyl and precursor shipments and receipts, and the payment institutions they use. With this bigger picture, FIs and law enforcement could connect the dots faster.
Live traceability reporting
Today, suppliers of fentanyl precursors are subject to the Pre-Export Notification Online (PEN Online) database. This database enables governments to monitor international trade in precursor chemicals by sending and receiving pre-export notifications. The system helps prevent the diversion of chemicals used in the illicit manufacture of drugs by allowing authorities to verify the legitimacy of shipments before they occur.
To further strengthen oversight, the platform utilizes immutability technologies—such as blockchain or secure immutable databases—which can be employed to encrypt all shipping documents and securely share them. This presents an auditable form of chain-of-custody and makes any alterations apparent. Customs and buyers would have the capability to verify the authenticity of the originating documents in a way that doesn’t compromise business confidentiality. With the use of these technologies, law enforcement can narrow down their investigations.
An information gap currently exists as the receivers of the shipments don’t share their receipts information with PEN. To strengthen governance on fentanyl supply chains, regulatory policy and legislative changes are needed. The private sector should be mandated to report received quantities of fentanyl or its precursors, as well as suspicious receiving destinations. This could be accomplished on the platform which would embed the receiving process, a reconciliation process of the transaction, the secure upload and sharing of documents, and would be minimally disruptive to business processes.
Additionally, geo-location technology embedded in mobile devices and/or shipments would provide real-time location-based tracking of custody transactions. These geo-controls would ensure accountability across the fentanyl supply chain, in particular where shipments veer off or stop too long on regular shipping routes. Canadian transporters of fentanyl and its precursor chemicals should play an important role in detecting illicit diversion/activities.
Digital labelling
Licensed fentanyl manufacturers could add new unique digital labels to their shipments to get expedited clearance. For example, immutable digital labelling platforms enable tamper-proof digital labels for legitimate fentanyl shipments. This would give pharmacies, doctors, and regulators transparency into the fentanyl’s:
- Chemical composition and concentrations (determining legitimate vs. adulterated versions of the drug)
- Manufacturing facility ID, batch ID, and regulatory compliance status
- Intended buyer authentication (such as licensed pharmaceutical firms or distributors)
Immutable digital labelling platforms offer secure role-based access control. They can display customized data views according to time of day, language, and location. Digital labels could enable international border agencies and law enforcement to receive usable data, allowing legal shipments through faster while triggering closer shipment examinations for those without of a digital label.
International and domestic transporter controls
Transporters act as intermediaries in the supply chain. Their operations could be monitored through a regulatory policy that mandates their participation in the platform for fentanyl and precursor shipments. The platform would support a mobile app interface for participants on-the-move, as well as a web portal and application programming interfaces (APIs) for large-size supply chain participants. Secure scanning of packaging at multiple checkpoints, combined with real-time tracking, would provide an additional layer of protection against fraud, truckers taking bribes, and unauthorized alterations to shipments and documents.
Regulators and law enforcement participation
Technology-based fentanyl controls for suppliers, buyers, and transporters may be reinforced by international customs and law enforcement collaboration on the platform. Both CBSA and law enforcement could log in and view alerts about suspicious activities issued from the FIs, transporters, or receivers. The reporting would allow government personnel to view a breakdown of fentanyl importers, the number of import permit applications, and the amount of fentanyl and its precursors flowing into the country. Responsible regulatory agencies—such as the CBSA and PCRMU—could leverage the reporting to identify hot spots.
The platform would use machine learning to support CBSA personnel in processing an incoming fentanyl or precursor shipment. Machine learning refers to AI algorithms and systems that improve their knowledge with experience. For example, an AI assistant on the traceability system could use machine learning to predict and communicate which import shipments arriving at the border should be passed. It can base these suggestions on criteria like volume, price, origin of raw materials, and origin of material at import point. It can also leverage data from other sources such as buyers, sellers, and banks to make predictions. As an outcome, the shipment may be recommended to pass, flagged as suspicious, or deemed to require an investigation by CBSA.
It’s necessary to keep up to date on new precursor chemicals as the drug is reformulated. Here, Health Canada can play a role, using its new labs and tests—expected as part of the recently announced Canadian Drug Analysis Centre—to provide chemical analysis of seized fentanyl. This would inform which additional chemical supply chains should be tracked in the PCRMU’s collaborative platform, and all stakeholders would widen their scope of review.
These new tools would complement existing cross-border initiatives, including joint U.S.-Canada and U.S.-Mexico crackdowns on illicit drug labs, as well as sovereign efforts. They have the potential to play a vital role in addressing fentanyl trafficking.
A robust, multi-pronged strategy—integrating existing safeguards with a new PCRMU traceability platform—could significantly disrupt the illegal production and distribution of fentanyl. By tracking critical supply chain events and authenticating shipment data, the platform would equip law enforcement and border agencies in Canada, the U.S., and Mexico with timely, actionable intelligence. The human toll demands urgency: from 2017 to 2022, the U.S. averaged 80,000 opioid-related deaths annually, while Canada saw roughly 5,500 per year from 2016 to 2024. In just the first nine months of 2024, Canadian emergency services responded to 28,813 opioid-related overdoses.
Combating this crisis requires more than enforcement. It demands enforceable transparency. Strengthened governance—powered by advanced traceability technology and coordinated public-private collaboration—is essential. This paper outlines key digital controls that can be implemented by global suppliers, Canadian buyers, transporters, customs, and financial institutions. With federal leadership, Canada can spearhead the adoption of proven, homegrown technologies to secure fentanyl supply chains and save lives.
Sean Parker is a compliance leader with well over a decade of experience in financial crime compliance, and a contributor to the Macdonald-Laurier Institute.
Dawn Jutla is the CEO of Peer Ledger, the maker of a traceability platform that embeds new control processes on supply chains, and a professor at the Sobey School of Business.
Peter Copeland is deputy director of domestic policy at the Macdonald-Laurier Institute.
MacDonald Laurier Institute
Rushing to death in Canada’s MAiD regime

By Ramona Coelho for Inside Policy
Canada legalized Medical Assistance in Dying (MAiD) in 2016, encompassing both euthanasia and assisted suicide. Initially limited to those nearing their natural death, eligibility expanded in 2021 to individuals with physical disabilities, with eligibility for individuals with mental illness in 2027. Parliamentary recommendations include MAiD for children. A recent federal consultation explored extending MAiD to those who lack capacity via advance directives, an approach Quebec has already adopted, despite its criminal status under federal law.
Despite its compassionate framing, investigative journalists and government reports reveal troubling patterns where inadequate exploration of reversible suffering – such as lack of access to medical treatments, poverty, loneliness, and feelings of being a burden – have driven Canadians to choose death. As described by our former Disability Inclusion Minister, Canada’s system at times makes it easier to access MAiD than to receive basic care like a wheelchair. With over 60,000 MAiD cases by the end of 2023, the evidence raises grave concerns about Canada’s MAiD regime.
I am a member of Ontario’s MAiD Death Review Committee (MDRC). Last year, the Chief Coroner released MDRC reports, and a new set of reports has just been published. The first report released by the Office of the Chief Coroner, Waivers of Final Consent, examines how individuals in Track 1 (reasonably foreseeable natural death) can sign waivers to have their lives ended even if they lose the capacity to consent by the scheduled date of MAiD. The second, Navigating Complex Issues within Same Day and Next Day MAiD Provisions, includes cases where MAiD was provided on the same day or the day after it was requested. These reports raise questions about whether proper assessments, thorough exploration of suffering, and informed consent were consistently practised by MAiD clinicians. While MDRC members hold diverse views, here is my take.
Rushing to death, Ignoring Reversible Causes of Suffering
In the same-day or next-day MAiD report, Mrs. B, in her 80s, after complications from surgery, opted for palliative care, leading to discharge home. She later requested a MAiD assessment, but her assessor noted she preferred palliative care based on personal and religious values. The next day, her spouse, struggling with caregiver burnout, took her to the emergency department, but she was discharged home. When a request for hospice palliative care was denied, her spouse contacted the provincial MAiD coordination service for an urgent assessment. A new assessor deemed her eligible for MAiD, despite concerns from the first practitioner, who questioned the new assessor on the urgency, the sudden shift in patient perspective, and the influence of caregiver burnout. The initial assessor requested an opportunity for re-evaluation, but this was denied, with the second assessor deeming it urgent. That evening, a third MAiD practitioner was brought in, and Mrs. B underwent MAiD that night.
The focus should have been on ensuring adequate palliative care and support for Mrs. B and her spouse. Hospice and palliative care teams should have been urgently re-engaged, given the severity of the situation. Additionally, the MAiD provider expedited the process despite the first assessor’s and Mrs. B’s concerns without fully considering the impact of her spouse’s burnout.
The report also has worrying trends suggesting that local medical cultures—rather than patient choice—could be influencing rushed MAiD. Geographic clustering, particularly in Western Ontario, where same-day and next-day MAiD deaths occur most frequently, raises concerns that some MAiD providers may be predisposed to rapidly approve patients for quick death rather than ensuring patients have access to adequate care or exploring if suffering is remediable. This highlights a worrying trend where the speed of the MAiD provision is prioritized over patient-centered care and ethical safeguards.
MAiD without Free and Informed Choice
Consent has been central to Canadians’ acceptance of the legalization of euthanasia and assisted suicide. However, some cases in these reports point to concerns already raised by clinicians: the lack of thorough capacity assessments and concerns that individuals may not have freely chosen MAiD.
In the waiver of final consent report, Mr. B, a man with Alzheimer’s, had been approved for MAiD with such a waiver. However, by the scheduled provision date, his spouse reported increased confusion. Upon arrival, the MAiD provider noted that Mr. B no longer recognized them and so chose not to engage him in discussion at all. Without any verbal interaction to determine his current wishes or understanding, Mr. B’s life was ended.
In the same-day or next-day MAiD report, Mr. C, diagnosed with metastatic cancer, initially expressed interest in MAiD but then experienced cognitive decline and became delirious. He was sedated for pain management. Despite the treating team confirming that capacity was no longer present, a MAiD practitioner arrived and withheld sedation, attempting to rouse him. It was documented that the patient mouthed “yes” and nodded and blinked in response to questions. Based on this interaction, the MAiD provider deemed the patient to have capacity. The MAiD practitioner then facilitated a virtual second assessment, and MAiD was administered.
These individuals were not given genuine opportunities to confirm whether they wished to die. Instead, their past wishes or inquiries were prioritized, raising concerns about ensuring free and informed consent for MAiD. As early as 2020, the Chief Coroner of Ontario identified cases where patients received MAiD without well-documented capacity assessments, even though their medical records suggested they lacked capacity. Further, when Dr. Leonie Herx, past president of the Canadian Society of Palliative Medicine, testified before Parliament about MAiD frequently occurring without capacity, an MP dismissed her, advising Parliament to be cautious about considering seriously evidence under parliamentary immunities that amounted to malpractice allegations, which should be handled by the appropriate regulatory bodies or police. These dismissive comments stand in stark contrast with the gravity of assessing financial capacity, and yet the magnitude is greater when ending life. By way of comparison, for my father, an Ontario-approved capacity expert conducted a rigorous evaluation before declaring him incapable of managing his finances. This included a lengthy interview, collateral history, and review of financial documents—yet no such rigorous capacity assessment is mandated for MAiD.
What is Compassion?
While the federal government has finished its consultation on advance directives for MAiD, experts warn against overlooking the complexities of choosing death based on hypothetical suffering and no lived experience to inform those choices. A substitute decision-maker has to interpret prior wishes, leading to guesswork and ethical dilemmas. These cases highlight how vulnerable individuals, having lost the capacity to consent, may be coerced or unduly influenced to die—whether through financial abuse, caregiver burnout, or other pressures—reminding us that the stakes are high – life and death, no less.
The fundamental expectation of health care should be to rush to care for the patient, providing support through a system that embraces them—not rush them toward death without efforts to mitigate suffering or ensure free and informed consent. If we truly value dignity, we must invest in comprehensive care to prevent patients from being administered speedy death in their most vulnerable moment, turning their worst day into potentially their last.
Dr. Ramona Coelho is a family physician whose practice largely serves marginalised persons in London, Ontario. She is a senior fellow at the Macdonald-Laurier Institute and co-editor of the new book “Unravelling MAiD in Canada” from McGill University Press.
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