MacDonald Laurier Institute
Barriers to care persist but access to MAiD keeps expanding
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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.
Immigration
Canada must urgently fix flawed immigration security rules
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The Macdonald Laurier Institute
By Sergio R. Karas for Inside Policy
As Canada faces increased threats of terrorist attacks, its lax, anachronistic immigration laws are putting all Canadians in jeopardy. Without urgent reforms to the Immigration and Refugee Protection Act (IRPA), Canada will face grave risks not just from terrorism but also espionage and subversion.
The critical need to tighten screening and secure the border comes as newly elected United States President Donald Trump threatens massive tariffs against Canada for failing to crackdown on the crisis earlier.
Section 34(1) of the IRPA sets out the inadmissibility criteria for individuals engaged in espionage, subversion, terrorism, being a danger to the security of Canada, engaging in acts of violence that would or might endanger the lives or safety of persons in Canada, or membership in an organization involved in such activities. This provision enables authorities to address potential threats to national security.
Canada faces several emerging security challenges, including terrorism, the rise of antisemitic violence, and Islamic radicalism. The trouble is, Section 34(1)’s overly broad definitions and inconsistencies in enforcement make it extremely challenging to address these rising threats.
Emerging threats to national security
Canada has long enjoyed a reputation for providing safe haven to refugees and other immigrants. However, the failure to properly screen newcomers – especially those from conflict zones – could exploit that weakness and allow radicals or terrorists to enter the country.
For instance, the federal government is currently accepting applications from Palestinians from Gaza to enter Canada. As of mid-January 2025, Immigration, Refugees, and Citizenship Canada has accepted 4,245 applications for processing under its temporary resident pathway for Palestinian extended family in Gaza; 733 people have been approved to come to Canada. Hamas’s control of Gaza and Canada’s limited ability to screen applicants pose heightened security risks. Since the October 7, 2023, Hamas terror attacks on Israel, Canada has been plagued by antisemitic violence and disruptive mass pro-Palestinian rallies. Meanwhile, polls indicate significant support for Hamas by Palestinians and its October 7 terrorist attacks. Although Canada has temporarily enhanced its screening protocols for Gazans, the risk of allowing Hamas terrorists or their supporters into Canada raises the risk of increased social tension and even antisemitic violence against Jewish Canadians.
Concerns about Canada’s porous border are not just hypothetical. Recently, authorities arrested a Pakistani national in Canada for allegedly planning an attack on the Jewish community in New York. Muhammad Shahzeb Khan, in Canada on a study permit, told an undercover law enforcement officer that “October 7 and October 11 were the best days to target Jews.”
Antisemitism has risen sharply in Canada since the October 7 attacks. The Canadian Security Intelligence Service (CSIS) warns that the Israel-Hamas war has led to a spike in “violent rhetoric” from “extremist actors” that could prompt some in Canada to turn to violence. According to the latest Global 100 survey conducted by the Anti-Defamation League (ADL), nearly half of people worldwide hold antisemitic views. The study found that 46 per cent of adults, an estimated 2.2 billion people, have strong antisemitic attitudes. This is more than double the level recorded in ADL’s first global survey a decade ago and the highest ever reported.
At the same time, Canada has long struggled in its efforts to identify and deport potential threats to national security. For example, in Mugesera v. Canada (Minister of Citizenship and Immigration), a former Rwandan politician accused of inciting violence against Tutsis during the Rwandan genocide, remained in Canada for over sixteen years before his deportation in 2012. His case highlights the extended timelines involved in the removal process. Former Immigration Minister Jason Kenney said that Mugesera’s case showed that Canada was too generous with suspected foreign war criminals. He also said, “At some point, it turns into a mockery of Canada’s generosity, eventually we have to remove war criminals and stop talking about it.”
In another case, Mahmoud Mohammad Issa Mohammad v. Canada, a convicted terrorist managed to drag out his deportation battle 26 years. Mohammad – a member of the Popular Front for the Liberation of Palestine (PFLP) convicted of taking part in a deadly attack on an Israeli plane at Athens airport in the 1960s – lied about his identity, his criminal past, as well as his ties to terrorist organizations. Kenney told reporters at the time “This case is almost a comedy of errors, with delays, with a system that was so bogged down in redundant process and endless appeals that it seemed to some that we would never be able to enforce the integrity of Canada’s immigration system and deport this terrorist killer.” Authorities cited Mohammad for misrepresentation on multiple grounds, yet he still managed to remain in Canada for decades. The threat of misrepresentation is a significant security concern. Thorough screening is crucial to ensure that those admitted do not pose security risks, given their possible affiliation with groups involved in violence or other activities that threaten national safety.
The recent arrest of multiple suspects on terrorism-related charges is a wake-up call for Canada, highlighting an urgent need to overhaul immigration screening processes to safeguard national security.
On July 31, 2024, the RCMP announced the arrests of Ahmed Eldidi and his son, Mostafa Eldidi, on multiple terrorism-related charges. Global News reported that the two men, originally Egyptian nationals, were allegedly involved in terrorist activity connected to the Islamic State of Iraq and Syria (ISIS). The article also revealed that in June 2015, the father allegedly took part in an ISIS propaganda video where he was seen dismembering a prisoner with a sword. On August 28, 2024, the Globe and Mail reported that the father, who became a Canadian citizen just two months before his arrest, had initially been denied a visitor visa in 2017. However, after supplying additional documents, he obtained a visitor visa in 2018 and became a permanent resident in 2021. The fact that Ahmed Eldidi was able to become a naturalized citizen, despite his violent ties to ISIS is bewildering.
Furthermore, according to Global News, Canadian Hezbollah members have taken part in several attacks overseas. They include a Vancouver man wanted for a bus bombing in Bulgaria that killed five Israeli tourists and a local driver, as well as a former Toronto grocer, Fawzi Ayub, who was a hijacker and member of Hezbollah’s Islamic Jihad unit. He was killed while fighting in Syria in 2014.
These arrests and the presence of such elements in Canada highlight the urgent need to revamp the system to prevent these security failures.
Reforming s. 34(1)
The Supreme Court of Canada in Mason v. Canada (Citizenship and Immigration) ruled that people can only be found inadmissible under section 34(1)(e) of the IRPA if they engaged in violent conduct linked to national security or the security of Canada. Since neither Mason nor his co-appellant were alleged to have engaged in acts of violence linked to national security or the security of Canada, section 34(1)(e) did not provide a basis for the inadmissibility of either person. This decision limits the ability of authorities to implement measures aimed at removing individuals from the country as it narrows the scope of grounds for inadmissibility.
Concerns about increasing Islamic radical activity in Canada have led the authorities to scrutinize events that may pose potential harm to the public. After Islamic radicals promoted a Hizb ut-Tahrir (HuT) Khilafah Conference 2025, authorities stated that “Reports of the upcoming conference, which was scheduled for January 18, 2025, in Hamilton, Ontario, were deeply concerning. Hizb ut-Tahrir has a documented history of glorifying violence and promoting antisemitism and extremist ideology.” The conference organizers ultimately cancelled the meeting, but critics are still calling for Hizb ut-Tahrir to be designated a terrorist entity under the Anti-Terrorism Act.
Narrowing legislative definitions and enhancing oversight could address security challenges. In Canada (Citizenship and Immigration) v. Harkat, which deals with inadmissibility on security grounds, the Supreme Court of Canada noted the lack of clear definitions for critical terms such as “terrorism,” “danger to the security of Canada,” and “member of an organization” in Section 34(1) of the Immigration Act.
Further, in Suresh v. Canada (Minister of Citizenship and Immigration), the Supreme Court of Canada provided a functional definition of “terrorism,” drawing from international conventions. However, membership in a terrorist organization remains difficult to define. This absence of precise language has created challenges in interpreting and applying the provisions fairly and consistently.
In Charkaoui v. Canada, the Supreme Court of Canada dealt with the constitutionality of security certificates, the court noted the tension that exists between rights and security. In this complex security landscape, the responsibility to protect both national security and individual rights remains a challenge.
The overly broad definitions and terms in this section have meant that the courts have been reluctant to apply it. To address these issues, Parliament should bring forward amendments to render terms like “terrorism” and “member of an organization” more concrete by tying them to specific acts, so the courts will not have to guess what was meant in the legislation.
An internal audit of the Immigration National Security Screening Program, covering the period between 2014 and 2019, revealed that out of the 7,141 cases that were flagged due to security concerns, including war crimes, espionage, and terrorism, 3,314 were approved for temporary, permanent, and refugee status. That is nearly half (46 per cent) of the foreign nationals flagged by security agencies who have been allowed to become permanent residents despite those concerns.
In order to improve the system, Canada should conduct stricter background checks incorporating international intelligence, increase the scrutiny of applicants, and impose restrictions on individuals with links to regions dominated by extremist groups or nations known to sponsor terrorism.
Canada should also consider implementing policies and legislative initiatives such as the No Visas for Anti-Semitic Students Act introduced in the U.S. Congress to combat university encampments and antisemitic harassment, which aim to revoke visas for international students of pro-terrorist protesters, enabling immigration officials to remove foreign students engaged in illegal activities.
The federal government should also amend Section 34(1) of the IRPA to provide more flexibility to visa officers and to CBSA Port of Entry officers to deny visas and entry to individuals where there are reasonable grounds to believe that they will engage in activities that will promote hate against an identifiable group, or whose rhetoric in public will be inflammatory. Further, authorities should also deny entry to individuals suspected directly or indirectly of ties to groups providing material support of terrorist organizations. The legislation must be updated so it can be used against modern-day public threats, and to ensure that the courts can rely on a clear legislative framework and policy to deal with judicial review of visa or entry denials.
Sergio R. Karas, principal of Karas Immigration Law Professional Corporation, is a certified specialist in Canadian Citizenship and Immigration Law by the Law Society of Ontario. He is co-chair of the ABA International Law Section Immigration and Naturalization Committee, past chair of the Ontario Bar Association Citizenship and Immigration Section, past chair of the International Bar Association Immigration and Nationality Committee, and a fellow of the American Bar Foundation. He can be reached at [email protected]. The author is grateful for the contribution to this article by Jhanvi Katariya, student-at-law.
MacDonald Laurier Institute
Macdonald should not be judged through the warped lens of presentism
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From the Macdonald Laurier Institute
By Patrice Dutil for Inside Policy
Sir John A. Macdonald was born January 11, in 1815 – but too often he is judged as if he was born in the late 20th century, not 210 years ago.
It seems that for many politicians, school officials, and members of the media, this is sometimes a difficult feat.
It’s not a new habit of mind – in the mid-nineteenth century, the eminent German philosopher and historian Leopold Ranke was so outraged by those who arrogantly dismissed the motives of historical figures that he dedicated a series of lectures on the topic. He declared that “every age is next to God,” explaining that historical periods had to be judged by how the almighty would have seen the events unfold; man’s actions would be measured by His commandments and in their own time, not by the standards of a new age.
The temptation to dismiss the past as “inferior” stood against reason itself. One could not condemn previous generations for their weak knowledge and prejudices. History could not be read “backwards,” and the “Middle Ages,” for instance, could only be considered as undeveloped by people who simply did not have the knowledge to appreciate them. Times were different and progress, whatever that was, was something that happened by fits and starts. “History is no criminal court,” Ranke declared.
Over the past fifteen years a number of commentators and scholars, including the collective leadership of the Canadian Historical Association, have condemned Macdonald and his governments as particularly unworthy. His memory has been erased from schools and streets, while nine of the eleven monuments erected in his memory across the country have been removed from public view. Macdonald is seen as source of shame because he inaugurated a new wave of residential schools and because of his treatment of Métis and Indigenous communities in the West.
This is fundamentally wrong-minded because Macdonald cannot be held responsible for things he did not do. His goal in establishing residential schools was to offer an education to Indigenous children – boys and girls – who could not go to school because their numbers in remote communities were too small. There is no evidence that children perished in those schools during his tenure in power though it is undeniable that many of them were ill.
The evidence also shows that Macdonald and his government were highly responsive in reacting to the transformative crisis that beset the Indigenous peoples on the Prairies during the late 1870s and 1880s by providing food rations, inoculations and instructors as well as tools to help communities learn the hard art of farming.
Were there unintended victims? Did Indigenous peoples lose a part of their culture as a result of the grand transformation imposed on them in the second half of the nineteenth century? Undeniably. But it is also undeniable that without the blanket of protection provided by Macdonald, the consequences would have been far worse.
Did he succeed unequivocally? Hardly. But he tried. He spent the money, elaborated new programs, and sought the best outcomes possible during an era when governments simply did not venture into social and economic policy.
Macdonald’s behaviour in 1885 – the most trying year of his career – is an effective prism through which to examine his career. In 1885, he faced a series of crises, including pressure from Great Britain to join a military campaign in Sudan, a new US president that sought to rip up commercial deals with Canada, a smallpox epidemic in Quebec, an insurrection in the North-West, led by Metis firebrand Louis Riel, and a backlash in Quebec when Riel was hanged for treason. He also needed to rescue a financially floundering Canadian Pacific Railway.
That year was incredibly trying for Canada’s first prime minister: it consisted of a cascade of twists, controversies, triumphs, and violence. Through it all, Macdonald creatively dealt with foreign affairs, Indigenous questions, democratic rights, nationhood, immigration, critical infrastructure, the role of the state, of memory, environmental issues, and life and death.
In this messy, chaotic world of politics, Macdonald acted sometimes strategically, sometimes improvisationally. He was at times entirely cerebral; sometimes he performed his emotions in order to convince more people. The journalist Edward Farrer observed that Macdonald had a knack for appearing “frail,” and always “asked people to support him on that account.” It worked. Writing in 1910, Farrer conceded that Macdonald had “a sagacity for meeting each political situation as it arose” and that, in hindsight, his policies were clearly popular with the voters (he won six majorities in his years as prime minister).
Commentators and historians should be dedicated to the task of explaining how Macdonald maintained his popularity during his long career, instead of viewing – and dismissing – his accomplishments through the warped lens of presentism.
Patrice Dutil is a senior fellow at the Macdonald-Laurier Institute. His new book is Sir John A. Macdonald and the Apocalyptic Year 1885 (Sutherland House).
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