MAiD and marginalized people: Coroner’s reports shed light on assisted death in Ontario

Earlier this month, the Office of the Chief Coroner for Ontario released news reports highlighting some of the reasons Canadians have chosen medical assistance in dying (MAiD, which in Canada involves euthanasia—meaning medically-administered injection rather than self-administered—over 99.9% of the time).

The reports have received international attention for what they highlight, including patients being euthanized despite untreated mental illness and addictions, unclear medical diagnoses and suffering fueled by housing insecurity, poverty and social marginalization.

Some are shocked by what these reports reveal, but none should be surprised. This is what happens when you let the foxes run the henhouse, as Canada has arguably done by allowing right-to-die advocacy to shape policy and replace evidence.

Canada’s medical assistance in dying (MAiD) laws, introduced for those in terminal situations, were expanded by the Trudeau government in 2021 to allow death by MAiD via “Track 2” for Canadians struggling with disabilities who were not dying. In 2023, Track 2 represented 2.6% of the 4,644 MAiD deaths in Ontario, or 116 people.

I am not a conscientious objector. I am a psychiatrist and previously chaired my former hospital’s MAiD team. However, I believe we’ve experienced a bait and switch: Laws initially intended to compassionately help Canadians avoid suffering a painful death have metastasized into policies facilitating suicides of other Canadians seeking death to escape a painful life.

The coroner’s reports show how far over the cliff we’ve fallen with Track 2 MAiD.

Marginalization and MAiD

Many have warned for years that when facilitated suicide is expanded to those with disabilities who have decades left to live, it is impossible to filter out suffering due to poverty, loneliness and other marginalization fueling MAiD requests. Medical disability becomes the foot in the door to open eligibility for MAiD, but social suffering pushes the marginalized through that door to seek state-sponsored death for their life struggles.

The coroner’s report uses a marginalization index based on area of residence (similar to the way impacts on marginalized populations were identified during COVID-19) to divide the population into five levels, each representing 20% of the population. The data shows a much higher proportion of Track 2 MAiD recipients come from highly marginalized categories than Track 1 MAiD recipients, or the general population.

People in the lowest “material resource” category (i.e. poverty) represent 20% of the general population, but they make up 28.4% of Track 2 MAiD recipients, compared to 21.5% of Track 1 recipients.

People in the lowest 20% of the population with the worst housing instability made up 48.3% of Track 2 MAiD recipients, compared to 34.3% of Track 1 recipients. Track 2 recipients were also far more likely to come from the most vulnerable 20% of the population in terms of age and labor force participation, with 56.9% of Track 2 MAiD recipients coming from this category compared to 41.8% of Track 1 MAiD recipients.

Gender gaps of more women than men receiving Track 2 MAiD are also emerging.

Additionally, the report sheds light on specific cases of concern, including people receiving Track 2 MAiD for social and housing vulnerability, and for unclear reasons while still suffering from inadequately treated mental illness and addictions.

This includes a man with a history of suicidal ideation and untreated addictions whose psychiatrist asked during a session whether he was aware of MAiD. After being approved, he was “personally transported (by the MAiD provider) in their vehicle to an external location for the provision of MAiD.”

Denialism

Policy mistakes can occur, but these marginalized deaths result from willful avoidance and denial of evidence-based cautions. I have previously written of the lack of safeguards and absence of evidence informing MAiD expansion.

Beyond the evidence in the coroner’s report, there are clear signs of this denial:

• The federally appointed chair of the MAiD expansion panel charged with recommending safeguards for psychiatric euthanasia recommended no additional legislative safeguards and said the gender gap of twice as many women as men being euthanized for mental illness in Europe “doesn’t concern” her, testifying: “It doesn’t concern me, in the sense that I don’t think anybody knows what it means. We can make all sorts of hypotheses about what it might mean, but nobody really knows. What I would caution you about is drawing inferences, like the one in your question with respect to male-to-female suicide ratios, because we don’t know what it means.” (It should be noted that there is longstanding evidence of a 2:1 gender gap of more women than men attempting suicide when mentally ill, most of whom do not die by suicide and do not try again.)

• Groups presenting as experts continue providing false reassurances that their CAMAP (Canadian Association of MAiD Assessors and Providers) training guidelines filter out suicidality, despite criticisms their guidelines lack any evidence-based factors distinguishing motivations for expanded MAiD requests from traditional suicide

These repeated refusals to have our MAiD expansion be informed by evidence have led to a MAiD house of cards willfully blind to suicide risks.

Denialism of all sorts is dangerous. Canada’s expanded MAiD policies have fallen prey to a new form of it: suicide denialism. What else can it be called when expansion ideologues repeatedly ignore and deny the fact that some Canadians are getting Track 2 MAiD fueled not by illness suffering, but by known suicide risk factors of social deprivation?

‘Social murder’

Some expansion advocates have already creatively dismissed concerns about the coroner’s reports. The head-scratching argument is that since marginalization leads to higher death rates of the marginalized anyway (gently referred to as “decedents”), the fact that Track 2 MAiD is provided to marginalized people at the same or slightly lower rates than their usual high “decedent” rates means MAiD is not a risk to the marginalized. There is even the bold suggestion that “MAiD narrows the gap between privileged and deprived.”

The remarkable blind spot of this privileged perspective is obvious: none of the marginalized receiving Track 2 MAiD would have died if they had not gotten MAiD; even their own MAiD assessors predicted they would have over another decade of life to live (otherwise they would have been Track 1).

Arguing that a higher proportion of marginalized people dying from Track 2 MAiD is acceptable because they die at similar rates anyway is disturbing and revealing. Most people in Canada are aware of the issue of Indigenous youth disenfranchisement and suicide. Consider the natural implications of this dangerous argument. Death rates for First Nations youth under 20 are three to five times higher than youth death rates for non-Indigenous populations, driven by suicide and unintentional injuries. Does MAiD expansionist logic suggest that it would be acceptable to provide high levels of Track 2 MAiD to First Nations 19-year-olds since their social disenfranchisement puts them at higher risk of death anyway?

Claiming that state-facilitated death fueled by social deprivation is acceptable since more marginalized people die from social deprivation and structural inequities anyway is indistinguishable from eugenics.

During COVID-19, some suggested our social policies linked to marginalized deaths were enabling “social murder,” a term coined by Friedrich Engels in the 19th century describing working conditions causing premature deaths of English workers. How should we describe Canadian policy providing state-facilitated deaths to non-dying marginalized individuals fueled by social suffering?

I previously wrote about how our MAiD expansion is setting the stage for a future prime minister issuing a national apology. Beyond apologies, tobacco companies recently were held accountable for a $32.5 billion settlement resulting from claims they “knew their product was causing cancer and failed to warn consumers adequately.”

No medication comes to market without evidence of safety, yet policymakers have ignored known evidence and have instead expanded MAiD while failing to warn Canadians adequately of the risks of premature death posed by Track 2 MAiD to those suffering from social marginalization.

Social murder is a jarring term. If we don’t want to be charged with providing it, it’s time policymakers honestly acknowledged the suffering for which some marginalized Canadians are receiving state-sponsored MAiD, rather than taking refuge behind “small numbers” justifications and suicide denial.

This article is republished from The Conversation under a Creative Commons license. Read the original article.