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.

By David L. Thomas for Inside Policy

Canadians are rightly under the impression that migrants have been properly vetted before coming into our country. But it’s clear we’re not living up to expectations.

A recently de-classified 2022 report of the National Security and Intelligence Review Agency (NSIRA) suggests we’ve entirely misplaced our priorities when it comes to protecting Canadians from foreigners with dangerous backgrounds. Apparently referring prospective immigrants from places in the world beset with violent extremism for deeper background checks could constitute discrimination against those individuals that is “not justifiable on security grounds.”

Arbitrary discrimination on a prohibited ground is wrong. However, it is obviously important, for example, for the government to conduct proper security checks when we admit people into Canada as immigrants. There are times when certain discrimination might be warranted.

Essentially, for fear of being accused of discrimination, our national security oversight committee has deemed that checking prospective immigrants for ties to terrorist organizations is not a matter of national security. This is plainly absurd and is a grave risk to our national security.

The decision-style report of the NSIRA tribunal related to a group of complaints before the Canadian Human Rights Tribunal (CHRT) under the Canadian Human Rights Act (CHRA). The large group of complainants were citizens of Iran seeking temporary or permanent visas to Canada and who were subjected to security background checks. They alleged discrimination on the basis of race and that the CSIS checks delayed the processing of their visa applications (reported by NSIRA as an average delay of 14 days for temporary visas and 26 days for immigration visas). Iran is a country with which we have no diplomatic relations and we have designated as a state sponsor of terrorism since 2012.

Without the resources of CSIS and a deeper security check, how could an immigration officer in the field determine if a visa applicant may have once been a member of a terrorist organization, like al-Qaeda, or a drug cartel? CSIS security checks are designed to look deeper into an individual’s background, sometimes with the co-operation of foreign spy agencies.

These complaints came across my desk in the final months of my term as the Chairperson of the CHRT. Having previously practiced immigration law for more than 20 years, I was well aware of CSIS security background checks. My expectation was that the NSIRA would recommend dismissal of the complaints because, well of course, checking whether a prospective immigrant is connected to a terrorist organization has to be related to the security of Canada, no?

Apparently not.

The CHRT complaints were suspended under a never-before-used section of the CHRA. Under Section 45, the Minister of Immigration, Refugees and Citizenship Canada gave notice “that the (alleged discriminatory) practice to which the complaint relates was based on considerations relating to the security of Canada.” Despite this notice, the Human Rights Commission declined to dismiss the complaints and instead referred the matter to the NSIRA to provide a report on the matter.

The NSIRA report was the first of its kind and acknowledged there is little legislative guidance on the nature of its role under a Section 45 referral. However, in my view, the NSIRA has usurped the role of the CHRT by determining that the criteria applied for requesting the CSIS background checks “was not justifiable on security grounds.” In my view, their determination should have been limited to only whether the alleged discriminatory practices related to national security.

Nevertheless, the complaints are now proceeding before the CHRT to determine if it was discriminatory to make referrals for security background checks.

Arbitrary discrimination is, in most cases, against the law. However, there are exceptions, and one of them is Section 45 of the CHRA which creates a “carve out” from the normal rules when a matter of national security is on the line. And yet, the NSIRA decision bizarrely set aside national security and failed to grant the exception.

Canada has drastically increased its intake of migrants in recent years. Since 2021, the annual target for permanent residents was almost doubled to 500,000. Non-immigrant foreigners, mostly students and temporary workers, accounted for 2.5 million people, or 6.2% or the population in 2023. As these are people entering Canada legally, Canadians are rightly under the impression that migrants have been properly vetted before coming into our country. But it’s clear we’re not living up to expectations.

Canada recently admitted Muhammad Shahzeb Khan from Pakistan, accused of plotting a massive attack against Jews in New York last October. When this news broke Canada was still reeling from the embarrassment of having just granted Canadian citizenship to Ahmed Fouad Mostafa Eldidi. Along with his son, Mostafa Eldidi, he was arrested in July last year as the pair was accused of being in the advanced stages of  planning a violent attack on behalf of ISIS in Toronto. Apparently, Ahmed appears in a 2015 video dismembering an ISIS prisoner with a sword.

All prospective immigrants to Canada are subject to checks for past criminal activity. However, sometimes an immigration officer might flag an applicant for a security screening by the Canadian Security Intelligence Service (CSIS) to determine if a visa applicant has ties to terrorist groups, espionage, war crimes, crimes against humanity, etc.

In order to protect Canada, immigration officers in the field should have the unfettered discretion to refer any non-Canadian for a CSIS security background check. The referral is not a denial of entry into Canada. Applicants are just being asked to wait a little longer until we’re satisfied about their background. Immigration officers should not be second-guessing themselves about this discretion for fear of a human rights complaint.

Now is the time for Canada to set its priorities right. Our national security must be paramount and should not be hamstrung by unrealistic idealism.

David Thomas, a senior fellow at the Macdonald-Laurier Institute, is a lawyer and mediator in British Columbia. From 2014 to 2021, he was the chairperson of the Canadian Human Rights Tribunal.