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MacDonald Laurier Institute

Barriers to care persist but access to MAiD keeps expanding

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17 minute read

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.

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Canada needs to get serious about securing its border

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From the Macdonald Laurier Institute

By Todd Hataley for Inside Policy

US President-elect Donald Trump has made clear his intention to call out Canada on weak enforcement on migration, money laundering, and the cross-border trafficking of narcotics, especially fentanyl.

Until just very recently, Canada has remained largely silent on these issues. Security agencies, such as the Royal Canadian Mounted Police (RCMP), Ontario Provincial Police (OPP), Sûreté du Québec (SQ) and the Canada Border Services Agency (CBSA), have tried to secure the border via memorandums of understanding, framework agreements, and legislated agreements that allow them to share information and even work together.

However, resources are limited for cross-border law enforcement co-operation. CBSA remains  understaffed and RCMP Integrated Border Enforcement Teams (which work with US security agencies) have limited geographic reach, leaving much of the enforcement between ports of entry left to police of jurisdiction, who already are hard pressed to provide services to the communities they serve.

The Canadian government’s apparent strategy of largely ignoring the problem is becoming more difficult to maintain. With the United States Border Patrol intercepting increasing numbers of illegal migrants crossing into that country from Canada, it’s clear the porous border is a concern. Exacerbating the situation is the recent discovery of illegal narcotic super labs in Canada – where production far outstrips the market – and Canada’s unfortunate, albeit well-deserved reputation as a haven for global money launderers.

Thanks to Trump’s 25 per cent tariff threat, the crisis is now endangering Canada’s relationship with its largest and most-important trading partner. This announcement sent all sectors of government and the private sector into a frenzy, prompting Prime Minister Justin Trudeau to fly to Florida to seek out an early audience with Trump at his Mar-a-lago resort home. Trudeau’s team spun the trip as proof that the federal government is serious about working with the US to address its border security and public safety concerns.

But with political crises piling up, it will be difficult for Trudeau to also manage the political optics of kowtowing to Trump, who is widely unpopular among Canadians. Spending extra money to appease Trump during the ongoing housing, immigration, and health care crises could make the Trudeau’s popularity nosedive even further. Adding insult to injury, Trump is essentially demanding that Canada do America’s work by stopping illicit goods and people from entering the United States: customs and border security officials generally work on the principle of stopping goods from entering their country.

Trudeau faces many practical challenges, including the need to ramp up the number of border and law enforcement agents who have the skill sets and training required to police offences such as drug production, money laundering, and the cross-border smuggling of goods and humans. Purchasing helicopters and drones to conduct surveillance will do little to aid enforcement, since most goods smuggled across the border pass through legitimate border crossings. RCMP Commissioner Mike Duheme even suggested putting RCMP cadets along the border – a challenging proposition since vast swathes of the border are either wilderness or water. Surveillance is one thing, but the act of enforcement takes skilled people with the capacity to investigate, gather evidence, and articulate that evidence into something that can be used by the courts for convictions. These concerns are not being addressed in this current frenzy to spend money on border security.

There is also good evidence that fortifying the border, or what has become known as forward deployment along the border, does nothing to stop the cross-border transit of contraband goods and people. One need only look as far as the United States-Mexico border to see the failure of forward deployment.

As authorities increase border enforcement activities, the costs of smuggling goods and people mounts for criminals. Eventually, it drives out amateurs, leaving only the professional, skilled, and well-equipped criminal groups. This, in turn, often leads to increasing levels of violence along the border, making interdiction and disruption far more difficult for law enforcement agencies.

Canada has several clear options to address Trump’s border concerns. It can increase the staffing of frontline CBSA officers, including border agents, inland enforcement units that actively investigate and remove individuals from Canada, international liaison officers, and customs processing staff. It can also create a plan for CBSA to take over enforcement between ports of entry. Currently, CBSA enforces entry into Canada at the ports of entry and the RCMP are responsible for the areas in between. Having a single agency manage the border builds capacity and expertise, avoiding inter-bureaucracy competition and confusion.

Canada can also work to better integrate law enforcement, intelligence units, and border services at all levels of government and across international boundaries. Cross-border crime operations are often planned and execute far from the border.

Some of this already takes place, as noted above, but it needs to go much deeper and be more supportive at both institutional and individual levels. This process must also include private sector stakeholders: companies such as FedEx, UPS, and Amazon, as well as freight forwarders, trucking companies, and customs brokers, are all involved in cross-border trade. Their participation as partners in reducing cross-border criminal activity is essential.

Finally, the government needs to designate laws specific to cross-border crime and include meaningful penalties as a means of deterrence.

Hyper-focusing on the border while ignoring other aspects of cross-border crime may be good political optics, but it is a bad strategy. What we really need is functional enforcement – including an integrated process extended vertically and horizontally across all sectors of border stakeholders, at and away from the border, supported by strong policy and legislation. This is the path forward to better cross-border crime enforcement.


Dr. Todd Hataley is a professor in the School of Justice and Community Development at Fleming College. A retired member of the Royal Canadian Mounted Police, he worked as an investigator in organized crime, national security, cross-border crime, and extra-territorial torture. He is a contributor to the Macdonald-Laurier Institute.

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Canada can – and should – crack down on trade-based money laundering

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From the Macdonald Laurier Institute

By Jamie Ferrill for Inside Policy

Neglecting to take decisive action enables organized criminal networks whose activities cause significant harm on our streets and those of our international partners.

Financial crime bears considerable political and economic risk. For the incoming Trump administration, the threat that transnational organized crime and the illicit financial flows pose to global financial stability is a top priority. The threat of tariffs by the Trump administration makes the costs to Canada in enabling global financial crime all too apparent. In addition to the cost of tariffs themselves, the associated reputational risk and loss of confidence in Canada’s financial system has implications for investments, credit, supply chains, and bilateral co-operation and agreements.

Canada’s proximity to major international markets, stable economy, high standard of living, and strong institutions and frameworks make it an attractive place to do business: for both legitimate and criminal enterprises.

Trade is a key contributing sector for Canada’s economic security. It represents two-thirds of Canada’s GDP, and exports alone support nearly 3.3 million Canadian jobs. Trade is also highly vulnerable to criminal exploitation. Ineffective oversight, regulatory complexity, and lagging technology adoption, coupled with a lack of export controls, make it possible to move vast proceeds of crimes, such as those from drug trafficking, human trafficking, corruption, and tax evasion through the global trade system.

These vulnerabilities are well-known by transnational organized crime groups. They are able to effectively move billions of dollars of dirty money through the global trade system every year, a method commonly referred to as Trade-Based Money Laundering (TBML).

While any statistics must be interpreted with caution, evidence shows that TBML is a prevalent method of money laundering.

What is it?

There are several types of Trade-Based Financial Crimes such as terrorism financing through trade, sanctions evasion, and simply trade fraud. However, the TBML definition is necessarily specific. Essentially here, TBML is a money laundering method: the processing of criminal proceeds to disguise their illegal origin. TBML involves the movement of value through the global trade system to obfuscate the illicit origin. This is usually done through document fraud: undervaluing, overvaluing, phantom shipping, or multiple invoicing. Different techniques employ different aspects of the supply chain. And TBML may be just one method used within larger money laundering operations.

By way of example, US authorities allege that two Chinese nationals living in Chicago laundered tens of millions of dollars for the Sinaloa and Jalisco Cartels. Drugs were smuggled into the United States and sold throughout the country. The proceeds from these sales were collected by the Chinese nationals. Those proceeds were used to purchase bulk electronics in the United States, which were then shipped – with a falsified value – to co-conspirators in China, who sold them locally. The legitimacy provided by the electronics sales and the trade transaction provide cover to “clean” proceeds from precursor crime.

Either the importer and/or the exporter of the goods can shift value. Chances here are the electronics shipped were undervalued: on leaving the country, they are declared at a (much) lower value than they are actually worth. The importer in China pays the undervalued invoice, then sells the goods for what they are worth. The profit from those electronics now appears clean, since it was used for a “legitimate” sale. The ensuing value gap can be transferred informally or stored as illicit wealth. The value has now shifted, without fiat currency leaving the country of origin.

But the cycle does not stop there. The value and money itself continue to traverse around the world, through various intermediaries such as financial institutions or cryptocurrency exchanges. It then goes right back into the system and enables the very crimes and organized crime groups that generated it in the first place. It is, in short, the business model of organized crime.

The Canadian problem

Ultimately, the proceeds of crime that have been legitimised through TBML (and other money laundering methods) supports the criminal enterprises that generated the value in the first place. In the example, these are prolific cartels who have been behind the fentanyl crisis, migrant trafficking and abuse, corruption, and widespread violence that destabilizes communities and undermines governments across North America and beyond.

With new actors, drug routes, and ways of doing business, the cartels are very much active in Canada. The Sinaloa cartel in particular has established a significant presence in Canada where it controls the cocaine market, manufactures and distributes fentanyl, and is embedded in local criminal networks. This increases Canada’s role as a strategic location for drug trafficking and a base to export abroad, notably to Europe, the US, and Australia.

Hells Angels, Red Scorpions, ’Ndrangheta, and other organized crime groups are also exploiting Canada’s strategic location using their transnational links. These groups are active in criminal activities that generate proceeds of crime, which they launder through Canadian institutions. From drug trafficking to extortion to human and sex trafficking, the foundation of organized crime relies on generating and maximizing profits. The proceeds generally need to be laundered; otherwise, there are direct lines back to the criminal organizations. They are, without a doubt, exploiting the trade sector; the very sector that provides so much economic security for Canada.

Canada’s regulation, reporting, and prosecution record for money laundering is notoriously weak. Its record for regulation, reporting, and prosecution for trade-based financial crimes, namely here TBML, is even weaker.

As financial institutions and other regulated entities face increased scrutiny following the TD Bank scandal and the Cullen Commission’s inquiry into money laundering in BC, more criminal activity is likely to be displaced into the trade sector and the institutions it comprises.

TBML is difficult for financial institutions to detect, especially given that 80 per cent of trade is done through open accounts. It exploits established trade structures that are meant to protect the system –like documentation and invoicing processes – by manipulating transactions outside traditional payment systems, which requires more sophisticated anti-money laundering strategies to address these hidden vulnerabilities.

Addressing the problem

Trade is a gaping vulnerability. Yet, it attracts minimal attention in countering transnational financial crime. Containing the fentanyl crisis for one requires a collaborative effort to bolster supply chains and the trade sector against financial crime. This means global cooperation, technological advances (such as blockchain technology), appropriate resourcing, more scrutiny on high-risk countries and shippers, and regulatory innovation.

But political will is in short supply. The federal government’s Budget 2024 and the resulting proposed Regulations Amending Certain Regulations Made Under the Proceeds of Crime (Money Laundering) and Terrorism Financing Act will grant CBSA new authorities to counter TBML, but limited resources to make good on them. And CBSA cannot do it alone.

Transnational organized crime and the illicit financial flows that support it poses a threat to global financial stability. The enabling of financial crime hurts Canada’s reputation abroad. With a new political regime emerging in the US, Canada cannot afford to be seen as a weak link. Loss of confidence in a country and its financial system has implications for investments, credit, supply chains, and bilateral cooperation and agreements.

By neglecting to take decisive action, we inadvertently enable organized criminal networks whose activities cause significant harm on our streets and those of our international partners. With profits as their primary driver, it is imperative that we scrutinize financial pathways to disrupt these illicit operations effectively.

Organized crime groups are not bound by privacy laws, bureaucracy, political agendas, and government budgets. They are continually evolving and staying many steps ahead of what Canada is equipped to control: technologically, geographically, strategically, logistically, and tactically. Without appropriate regulations, technological advances, and resources in place, we will continue to be a laggard in countering financial crime.

More systematic change is needed across regulatory frameworks, law enforcement coordination and resourcing, and international partnerships to strengthen oversight, close loopholes, and enhance detection and disruption.  It would be a low-cost signal to the Trump administration that Canada is committed to upping its game.


Jamie Ferrill is senior lecturer in Financial Crime at Charles Sturt University and co-editor of Dirty Money: Financial Crime in Canada.

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