Canada (2015- )

Canada was ordered by its Supreme Court to undertake an experiment in euthanasia and assisted suicide. The initial terms of the experiment were very broad – a person’s death “must be reasonably foreseeable” and no objective assessment of a person’s assertion of suffering is allowed. 

This initial experiment has confirmed that euthanasia is much more readily taken up and normalised than assisted suicide with 10,064 deaths (3.3% of all deaths in Canada) from euthanasia in 2021  - up 32.4% from 2020. 

From 21 March 2021 the requirement that "death be reasonably foreseeable" was abolished, opening the way to an expansion of euthanasia for people with chronic but not terminal conditions, with 219 cases reported for 2021.

History of legalisation

On 21 April 2010 the Canadian House of Commons defeated Bill C-384 An Act to amend the Criminal Code (right to die with dignity) by 228-59.

The Quebec National Assembly passed an “An Act respecting end-of-life care” by a vote of 94-22. It came into effect on 10 December 2015. This Act permits euthanasia on the request of an adult who is “at the end of life; with a serious and incurable illness; and in an advanced state of irreversible decline in capability”.

On 6 February 2015 the Supreme Court of Canada in Carter v Canada (Attorney General) declared that provisions in the Canadian Criminal Code making it an offence to aid or abet suicide “unjustifiably infringe” section 7 [“Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.”] of the Charter of Rights and Freedoms “and are of no force or effect to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” The declaration was suspended for a year, giving the opportunity for the Parliament to amend the offending laws by providing a scheme for physician assisted suicide.

The core paragraph in the judgement reads that “The right to life is engaged where the law or state action imposes death or an increased risk of death on a person, either directly or indirectly. Here, the prohibition deprives some individuals of life, as it has the effect of forcing some individuals to take their own lives prematurely, for fear that they would be incapable of doing so when they reached the point where suffering was intolerable. The rights to liberty and security of the person, which deal with concerns about autonomy and quality of life, are also engaged. An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.”

The argument based on the right to life is specious as it takes no account of the inevitability that a law permitting euthanasia will result in wrongful deaths based on medical errors, coercion, discrimination against or differential treatment of the disabled and mentally ill and suicide contagion.

The argument from liberty, if pressed to its logical conclusion, would require a law permitting assisted suicide or euthanasia on request by any person, including a minor, with capacity.

The argument from security is based on a false claim that pain and other physical symptoms cannot be relieved by best practice palliative care.

In response to the Supreme Court judgment, the Canadian parliament passed Bill C-14 which came into effect on 17 June 2016 and legalised euthanasia and assisted suicide on request for any adult who has “a serious and incurable illness, disease or disability”; is in “an advanced state of irreversible decline in capability”; and whose “natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining”.

Increase in numbers

In July 2022 the Third Annual Report on Medical Assistance in Dying in Canada was published. It stated that there had been 10,064 reported cases of euthanasia and assisted suicide in 2021, bringing the total of such deaths since legalisation to 31,664.

The number of cases each year has tripled and a half (355%) in 5 years from 2,838 in 2017, the first full year of legalisation, to 10,064 in 2021 with annual increases of 57.8% (2018); 26.4% (2019) 34.2% (2020) and 32.4% (2021).

“Fewer than seven” cases of assisted suicide have occurred each year since 2019. Canadian practice overwhelming uses euthanasia. The 2019 report states that “providers are less comfortable with self-administration [assisted suicide] due to concerns around the ability of the patient to effectively self-administer the series of medications, and the complications that may ensue”.

In 2021 euthanasia and assisted suicide accounted for 3.3% of all deaths in Canada, with the provincial rates highest in British Columbia (4.8%) and Quebec (4.7%), both with rates higher than the Netherlands which was 4.5% in 2021.

In Quebec for the 12 months from April 2021 to March 2022 the percentage of deaths by euthanasia reached 5.1%.

Underlying conditions

Very limited data is provided on the “main condition” for which euthanasia is performed.

In 2021, for 10% of cases the “main condition” is reported as “multiple comorbidities” and a further 11.5% as “other conditions” - that is other than cancer, cardiovascular, respiratory, neurological or organ failure – a combined 30% increase in these two categories from 2020.

For women these two categories now account for over one in four (25.2%) deaths by euthanasia.

The 2021 report comments “Multiple comorbidities and other conditions encompassed a wide range of diseases or conditions, including frailty, diabetes, arthritis, and osteoporosis”. Note that these are not terminal conditions.

In only 129 (2%) of the 6527 cases of euthanasia in Canada in 2021 did the clinician administering euthanasia give their specialty as oncology. Additionally, 1,234 of these cases involved some consultation with an oncologist.

This means that in 2021, at least 5,164 Canadians were euthanased because they had cancer with no discussion with an oncologist about this course of action.

The majority (68.2%) of those administering euthanasia were primarily engaged in family medicine. Oddly, given euthanasia is not yet officially permitted in Canada for psychiatric conditions, 80 cases of euthanasia were administered by psychiatrists.

The 2019 report also notes that among those administering euthanasia were “a small number of practitioners identifying themselves as “MAID Providers.” While this specialty is not officially recognized by medical certifying bodies in Canada, it may be considered a functional specialty by some providers when MAID is the primary focus of their practice.”, that is doctors whose primary practice is euthanasia.

The 2021 report notes that the second opinion on eligibility was given by a nurse practitioner in 7% of cases.

“Death be reasonably foreseeable” - no longer required

The Canadian law initially required that “death be reasonably foreseeable”. The decision of the Ontario Superior Court of Justice in AB v Attorney General of Canada delivered on 19 June 2017, in paragraph 81, interpreted this requirement as not requiring any connection whatsoever between the underlying conditions for which euthanasia is sought and the reasonable foreseeability of death – which can be based simply on advanced age. The woman in this case was 79 years old.

On 11 September 2019, the Quebec Superior Court, in the case of Truchon c. Procureur général du Canada, invalidated the relevant provisions in the Canadian law which limiting euthanasia to cases where “natural death has become reasonably foreseeable” and the Quebec law which required that the person be “at the end of life”. The effect of this decision was suspended for six months.

The Canadian Government introduced Bill C-7 into the House of Commons in February 2020 to give statutory effect to the decision. The Bill became law from 21 March 2021 opening the way for euthanasia to be given to people with chronic, non-terminal conditions, including people with a disability. 

219 such cases were reported for 2021.

In Ontario in 2022, 121 out of 3934 (3.1%) euthanasia cases involved a person whose natural death was not reasonably foreseeable.

Short time between initial request and euthanasia being performed

Section 241.2 (3) (g) of the Canadian Criminal Code required a physician to “ensure that there are at least 10 clear days between the day on which the request was signed by or on behalf of the person and the day on which the medical assistance in dying is provided or — if they and the other medical practitioner or nurse practitioner referred to in paragraph (e) are both of the opinion that the person’s death, or the loss of their capacity to provide informed consent, is imminent — any shorter period that the first medical practitioner or nurse practitioner considers appropriate in the circumstance”.

Of the 7,384 people killed by euthanasia in Canada in 2020 for whom data is available on the length of time between first request and when euthanasia was administered some 34.3% or 2,532 people were euthanased in less than 10 days of first requesting it.

For 905 of these people the only justification given for the haste with which euthanasia was performed was that loss of capacity to consent was imminent. This raises real questions about the validity of the original request. If a person is on the verge of losing capacity what degree of certainty can there be that the person currently has full capacity?

In the period April 2021 to March 2022 in Quebec, 50% of people were euthanased less than 10 days after making a request. However, only 13% of people had a prognosis of less than 2 weeks to live.

Under the revised law from 21 March 2021 there is no longer any required waiting period for any person whose death is said to be “reasonably foreseeable”. Same day request and lethal injection is acceptable. 

In other cases, a 90 day waiting period is specified but  if the two assessing practitioners think that loss of decision making capacity is imminent this can be waived entirely.

Advanced directive

Euthanasia can now (since 21 March 2021) be provided on the basis of an advanced directive to persons who have lost decision making capacity. This is not supposed to be done if the person resists or refuses by "words, sounds or gestures".

However, this requirement is undermined by a provision that "involuntary words, sounds or gestures made in response to contact do not constitute a demonstration of refusal or resistance". How do we know they are "involuntary"?

In Ontario in 2022, 190 out of 3934 (4.83%) involved euthanasia of a person who at the time they were killed was incapable of giving consent.

Reasons for requesting euthanasia

The 2021 annual report states that loss of ability to engage in meaningful life activities (86.3%) followed closely by loss of ability to perform activities of daily living (83.4%) were the most common reasons for a euthanasia request.

Inadequate control of pain, or concern about it (57.6%) ranked much lower.

Disturbingly 35.7% reported as a reason for their euthanasia request “Perceived burden on family, friends or caregivers” and 17.3% reported “Isolation or loneliness”. 

So in 2021 some 1,721 Canadians were given a lethal injection because they were lonely: Why didn't the doctor or nurse practitioner just have a cup of tea and a chat with them instead of giving them a lethal injection?

For Quebec, between April 2021 and March 2022, 1700 (47%) of people euthanased gave a reason as “Perceived burden on family, friends or caregivers” and 824 (23%) of people reported “isolation or loneliness” as a reason.

Needed disability services and palliative care not provided

In 2021 there were 201 cases in which palliative care was NOT accessible if needed (up from 126 cases in 2020 – an increase of 60%) and 537 cases where disability support services were needed but NOT received (up from 332 in 2020 – an increase of 62%). This includes 12 of the 219 people whose deaths were “not reasonably foreseeable”.

“Disability support services could include but are not limited to assistive technologies, adaptive equipment, rehabilitation services, personal care services and disability based income supplements.” The 2021 report admits that, even for those who were reported as having received disability support services, the data “does not provide insight into the adequacy of the services offered”.

Denied assisted living but offered assisted suicide

Roger Foley, who has a crippling brain disease, has been seeking support to live at home. He is currently in an Ontario hospital that is threatening to start charging him $1,800 a day. The hospital has told Roger that his other option is euthanasia or assisted suicide under Canada’s medical assistance in dying law.

Candice Lewis: pressure for euthanasia based on disability

Candice Lewis is a 25 year old Canadian woman who happened to have cerebral palsy.

In September 2016 Candice went to the emergency room at in St. Anthony after having seizures.

Dr. Aaron Heroux told her she was very sick and likely to die soon. He offered her assisted suicide. The doctor also proposed assisted suicide for Candice to her mother Sheila Elson.

This offer was repeated despite both Candice and her mother making it clear that this was not an option Candice would consider. Dr Heroux told Sheila she was being selfish by not encouraging her daughter to choose assisted suicide.

Candice describes how bad it made her feel that a doctor was offering her assisted suicide.

More than twelve months later Candice had recovered well and her health was much improved. Candice wasn’t having any seizures, was now able to feed herself, walk with assistance, use her iPad. She was more alert, energetic and communicative. She was able to walk down the aisle as a bridesmaid at her sister’s wedding in August 2017. She was doing what she loved most, painting and being with her family.

Candice and her mother Sheila were interviewed by Kevin Dunn, who is producing a film on euthanasia and assisted suicide called Fatal Flaws. The film of the interview can be viewed here.

Sadly, Candice has since passed away from natural causes.

There are several take home lessons from Candice’s experience:

• Doctors can get the prognosis wrong. Candice was told she was dying but is flourishing twelve months later. A wrong prognosis can lead to assisted suicide or euthanasia. A life can be thrown away needlessly;
• People with a disability already suffer discrimination in health care. When assisted suicide and euthanasia are legal, people with a disability are more at risk of being offered death as a solution because doctors and others consider that they would be better off dead;
• Once doctors are authorised by the law to provide assisted suicide and euthanasia some of them will feel empowered to offer it to anyone they think would be better off dead. This undermines patients’ trust in doctors and can cause great distress.

Conclusion

Canada's court ordered experiment with euthanasia is already out of control with significant rates of failure to comply with the legal requirements and processes. No action appears to have been taken in response to identified cases in which euthanasia is performed contrary to the law. People with disabilities are being harassed to choose assisted suicide against their will.

Download a summary on Canada