‘I Cried' Reading Some Death Review Cases: Doctor Raises MAID Eligibility Concerns

A nurse holds the hand of a patient in the palliative care unit in a hospital on the French Mediterranean island of Corsica in a file photo. Pascal Pochart-Casabianca/AFP via Getty Images

An Ontario doctor is sounding the alarm about loopholes in Canada’s euthanasia policy, saying it is endangering socially disadvantaged patients whose lives could have been improved had they not been cut off so early.

A trend is emerging whereby people in desperate social or economic situations appear to qualify for medical assistance in dying (MAID) “quite easily” despite not being close to natural death, said Ramona Coelho, a family physician in London, Ont., and member of the Ontario chief coroner’s MAID death review committee, in an interview with the Ottawa-based think tank Macdonald-Laurier Institute published on Oct. 31.

“I cried when I read some of these cases,” said Coelho. “They are very similar to the cases of desperation I’ve seen in my own office, but these are being approved and they are dead.”

The MAID death review committee, established in January and comprised of 16 members from different disciplines, is tasked with providing independent expert review of medically assisted deaths in Ontario.

In some cases it’s a matter of MAID professionals lacking expertise in rehabilitation and recovery, Coelho said, describing cases from the death review committee’s recently released first report. It cites cases of patients who experts say could have survived if they had received social, economic, or mental health support.

Coelho gave the example of a man with inflammatory bowel disease, a history of mental illness, and ongoing addiction issues who was given the choice of MAID without being offered mental health or addiction treatment. The MAID provider personally transported him to an external location for his assisted death, according to the report.

The Canadian Association of MAID Assessors and Providers says all assisted dying assessments are patient-driven, and that this is ensured through multiple safeguards.

“Any individual seeking MAID goes through a rigorous, patient-initiated process that prioritizes autonomy, dignity, and compassionate care,” said the association in a Nov. 5 press release.

The association added it is committed to guiding MAID professionals to act in accordance with legal and ethical frameworks, and that its guidelines do not include advising patients to seek assisted dying if their assessment does not require it.

Canada has one of the most liberal euthanasia laws in the world, and is currently working toward legalizing the procedure for those whose only medical condition is mental illness.

Death Review Committee’s Report

In the report, the case of the man with inflammatory bowel disease was examined in terms of social vulnerability. He was in his 40s, and the committee learned his illness prevented him from maintaining employment or social relationships. He was dependent on his family for housing and financial support, and he struggled with alcohol and drug addiction. He also had a history of suicidality.

His MAID journey began when a psychiatrist asked him during an assessment if he was aware of assisted dying and presented information on the option. During the MAID process, there was no documented input from his family, other than that they “had concerns about his request for MAID,” says the report.

“Could this not be actually inadvertently pushing someone to get MAID?” questioned Coelho in the interview. “You know? Suggesting it to them when they are there for a mental health consult.”

The man’s assisted death was reported as having met the eligibility criteria based on the “irreversible decline and intolerable suffering” caused by his inflammatory bowel disease. However, committee members noted in the report that “the approach did not address significant concerns regarding mental health and addictions, social well-being and support, and family involvement.”

Another case examined by the committee was that of a man in his 40s living with quadriplegia due to a vehicle collision. He was receiving rehabilitation but did not see improvements, and given the complexity of his medical conditions, he had to live away from his family.

He also seemed distressed by perceived limits to his relationship with his young children.

The MAID assessor determined his death was “non-reasonably foreseeable,” but documented the possibility of “reducing the timeline should his natural death become reasonably foreseeable,” such as in the event of untreated bacteria-caused blood poisoning, said the report.

The man eventually received MAID within two years of his injury, a timeframe that is typically insufficient for a patient to adapt to life with a disability, the committee said. The report said MAID assessors should become aware of any biases that might “influence clinical interpretations of recovery and the presentation and evaluation of options to alleviate suffering.”

The committee recommended MAID assessors work with those who have expertise in the patient’s condition.

Trends

Coelho said there is growing concern that MAID applicants who are classified as having “non-reasonably foreseeable natural death,” or Track 2, may be expedited to Track 1, the category for those facing a “reasonably foreseeable death.”

“You can move someone from Track 2, someone who’s not dying, to the dying kind of track, which is a faster track with less safeguards, if they make themselves sick enough,” she said.

People in Track 2 are more likely to come from the poorest areas in Ontario, be younger, and have no immediate family. “The people that we have really failed, are likely the people most accessing MAID,” she said. 

In 2023, Ontario recorded 116 Track 2 deaths, a slight decrease from 121 the previous year, according to the report. In contrast, Track 1 deaths rose significantly from 3,813 in 2022 to 4,528 in 2023.

Medically assisted deaths accounted for 4.1 percent of all deaths in the country in 2022.