Author: Dr. Ramona Coelho, Family Physician; Senior Fellow of Domestic and Health Policy at the Macdonald-Laurier Institute; Member of Medical Assistance in Dying (MAiD) Death Review Committee; Ontario, Canada.

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Introduction:

As a family physician in Ontario, Canada, my practice largely serves marginalised groups: refugees, individuals facing incarceration or facing legal charges, or those living with disabilities or mental illness, including substance use disorders. My patients can experience extensive wait times to access medical care and may be unable to access or afford certain medications, counseling and other necessary services. Many endure discrimination and isolation, and all these structural inequalities significantly harm their health. I now view euthanasia and assisted suicide as introducing a new risk to my patients: the risk of wrongful, premature death.

 

Background:

In 2016, Canada legalized euthanasia and assisted suicide using the umbrella term medical assistance in dying (MAiD). This was initially presented as an exceptional measure for persons with intolerable suffering at the end of their life. However, our system evolved at an alarming pace, with MAiD expanding far beyond its initial scope. In 2023, there were over 15,000 MAiD deaths, pushing the total to 60,000 by the year’s end. Quebec announced their MAiD annual death rate has surpassed 7%—staggering in comparison to initial provincial estimates of 100 requests per year. Meanwhile, recent reports from Ontario’s MAiD Death Review Committee (MDRC) raise red flags, warranting a closer look at the unintended yet foreseeable risks tied to the legalization of euthanasia and assisted suicide.

 

Cases:

As a MDRC committee member, I work with the Office of the Chief Coroner of Ontario,  reviewing cases flagged by the Coroner’s MAiD Review Team. Members offer expertise to help shape recommendations for future MAiD practice. The 2 released reports, include MAiD for those suffering with inadequately treated mental illness and MAiD for social and housing vulnerability.

Some examples are summarized here:

 

• A man in his 40s with inflammatory bowel disease, mental illness, a history of suicidality, and ongoing addictions, dependent on his family for housing and finances. During a psychiatric assessment, the psychiatrist introduced MAiD as an option. After undergoing the MAiD assessments, with his mental health and addictions untreated, his provider drove him to the location where his life was ended—without consulting his concerned family.

 

• A woman in her 50s with multiple chemical sensitivities and a history of depression, anxiety, suicidality, and PTSD from childhood trauma. She applied for MAiD after struggling to find suitable housing for her medical needs, with her suffering worsened by loneliness and isolation.

 

• A man in his 40s experiencing unexplained physical decline after COVID-19 vaccinations, with a significant mental health history, including depression and trauma. While managing his physical symptoms, he was hospitalized due to intrusive thoughts of dying. After a second episode of suicidal ideation, he was involuntarily hospitalized. MAiD assessors concluded that his severe functional decline was most likely due to post-vaccine syndrome. After MAiD, the post-mortem examination revealed no pathological findings, suggesting his symptoms were likely caused by mental illness.

 

• A man in his 40s, who became quadriplegic due to a motor vehicle collision, chose MAiD while isolated in the hospital during the pandemic. He was concerned about maintaining his relationship with his family while grappling with multiple complications and adjusting to his new condition—during a time when medical evidence shows an increased risk of suicidality. The MAiD assessors determined he was not near the end of his life, so they proceeded with what is known as Track 2 safeguards, which include a 90-day assessment period for people whose death is not imminent. However, one of the assessors documented the possibility of reducing that timeline and moving him to Track 1 (for those in the end-of-life context) if he refused treatment to make his health status deteriorate.

Discussion:

These cases expose gaps in MAiD assessors’ understanding of recovery, quality care, and community life. They seemingly overlook how psychosocial suffering fuels despair, and they fail to recognize their role in offering state-sanctioned death to those who are denied options to live. The cases also highlight many inadequacies in the safeguards for MAiD. One of the most egregious instances of circumventing safeguards is highlighted in the last case. Some assessors, following guidance from the Canadian Association of MAiD Assessors and Providers, inform individuals who are not dying (i.e., the Track 2 pathway) that they can refuse treatment to worsen their health. The purpose of this strategy is to reinterpret their health status as Track 1 (the end-of-life pathway), allowing for quick MAiD.

The report further highlights troubling demographic trends. Less than half of Track 2 MAiD recipients had access to mental health, counselling or disability supports. Only 8.6% were offered housing support, and just 6% received income support. Nearly 30% of Track 2 cases involved individuals living in poverty, and 61% were women. Research shows that women are disproportionately affected by intimate partner violence, frequently receive inadequate medical care, and are twice as likely to attempt suicide as men. Those opting for Track 2 were less likely to list an immediate family member as their next of kin, often naming a friend, lawyer, or healthcare provider instead, underscoring a significant lack of social support. These patterns suggest that MAiD may exploit systemic neglect, particularly at the intersections of gender, poverty, and isolation, and may better be described as structural coercion to die—essentially the opposite of autonomy.

The findings reveal a troubling pattern: marginalized groups—those in greatest need of support—can be pushed toward euthanasia and assisted suicide through subtle coercion. This occurs largely due to pervasive, unconscious ableism. Ableism, like sexism, racism, and other forms of oppression, is a deeply embedded value system that subjugates disabled individuals by asserting—often unconsciously and structurally—the superiority of non-disabled persons. This bias is pervasive and influences health care and MAiD practices. Studies show that disabled people rate their quality of life higher than doctors do, highlighting this prejudice. Canada’s MAiD policies, under the guise of autonomy, can push disabled individuals with unmet needs toward death, while able-bodied individuals would receive recovery-focused care. The implicit message is clear and alarming: some lives are valued more than others.

Conclusion:

This normalization of MAiD threatens suicide prevention strategies, as illustrated when a patient seeking emergency care for suicidal thoughts was offered information about MAiD. Suicide prevention literature consistently shows that exposure to suicidal messaging and easy access to lethal means increases the risk of suicide. Yet, MAiD is framed as a compassionate option, with the implication that death is a solution to suffering, and the lethal means are readily provided.

The report’s findings demand accountability for questionable MAiD practices, yet no physicians in Canada have faced criminal sanctions, and families have no means to challenge decisions. Recent media revealed forums where MAiD providers worry about media scrutiny, not legal consequences while another article exposed the absence of serious repercussions despite numerous documented cases of non-compliance with MAiD laws and policies.

Canada’s experience with MAiD should serve as a cautionary tale. Governments must prioritize the care of their most vulnerable citizens by investing in mental health services, disability supports, housing, palliative care, and community life, while rejecting ableism and recognizing the inherent value of all lives. International evidence is also concerning, with a recent BMJ rapid response article highlighting that young people with eating disorders have died via assisted suicide, even where legislation is limited to terminal illness. And like Canada, many other jurisdictions have expanded their criteria since the initial legalization.

We must confront the uncomfortable truths about our society. MAiD may appear compassionate, but we risk being blindsided by discrimination that makes it seem justifiable to end some lives over others. As physicians, we pride ourselves on compassion, yet the Ontario report reminds us that, despite our claims of progress, we often fail our most vulnerable populations. The deep-seated discrimination ingrained in our healthcare system and society is further exacerbated by the legalization of euthanasia and assisted suicide, heightening the risk of death driven by discrimination.

 

Dr. Ramona Coelho is a family physician based in London, Ontario, whose practice largely serves marginalized individuals. She is a Senior Fellow of Domestic and Health Policy at the Macdonald-Laurier Institute and co-editor of the forthcoming book Unravelling MAiD in Canada: Euthanasia and Assisted Suicide as Medical Care. Additionally, Dr. Coelho is a member of the MAiD Death Review Committee, where she collaborates with the Office of the Chief Coroner of Ontario to provide expertise in reviewing MAiD deaths and enhancing public safety.

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