Private forums show Canadian doctors struggle with euthanizing vulnerable patients

By MARIA CHENG and ANGIE WANG
Associated Press

TORONTO — A homeless man refusing long-term care, a woman with severe obesity, an injured worker given meager government assistance, and grieving new widows. All of them requested to be killed under Canada’s euthanasia system, and each sparked private debate among doctors and nurses struggling with the ethics of one of the world’s most permissive laws on the practice, according to an Associated Press investigation.

As Canada pushes to expand euthanasia and more countriesmove to legalize it, health care workers here are grappling with requests from people whose pain might be alleviated by money, adequate housing or social connections. And internal data obtained exclusively by AP from Canada’s most populous province suggest a significant number of people euthanized when they are in unmanageable pain but not about to die live in Ontario's poorest and most deprived areas.

Some doctors fear moving forward even with cases that meet Canada’s legal requirements, which allow euthanasia for people with “irremediable suffering” from serious but nonfatal medical conditions and disabilities. On private forums, doctors and nurses have expressed deep discomfort with ending the lives of vulnerable people whose deaths were avoidable, according to messages provided to AP by a participant on condition of anonymity due to their confidentiality.

Some of the requests from the forums were approved and acted upon. Others were denied. But the discourse about patients who are poor, disabled or lonely shows a fraught process where medical professionals test the limits of what conditions warrant euthanasia. The controversial cases in the forums have never been disclosed through Canada’s oversight system, even in an anonymized manner.

When Canada legalized assisted dying in 2016, officials said they wanted to reduce suffering and support individual autonomy and freedom of choice — and polls have consistently shown public approval. Prime Minister Justin Trudeau promised then that safeguards would prevent vulnerable people from being euthanized “because you’re not getting the support and care you actually need.”

But experts tasked with delivering euthanasia to people who aren't dying have called it “morally distressing” and say the legal provisions are too vague to be protective, obliging doctors and nurses to at times end the lives of people they believe might otherwise be saved.

“I don’t want (euthanasia) to become the solution to every kind of suffering out there,” a physician wrote to colleagues on one of the private forums.

Euthanasia programs are increasing

Canada has the world’s fastest-growing program for euthanasia, the practice of doctors and nurse practitioners killing patients with an injection of drugs at their request. Medically assisted suicide — patients themselves taking prescribed, lethal medication — also is legal.

But virtually all of Canada’s MAiD cases — as it’s widely known here, for medical assistance in dying – are euthanasia, with a doctor or nurse practitioner giving the fatal injection.

Unlike many other countries, Canada doesn't require that patients exhaust all medical treatments before seeking death.

After legalizing euthanasia in 2016, Canada broadened its law in 2021 to allow people with incurable, but not terminal, conditions – including disability alone – to seek a way to die. This vastly expanded the number of people eligible, and medical groups in some territories and provinces require doctors to inform, offer or help provide euthanasia to any patients who might qualify.

Adults with serious, incurable conditions must have a written request approved by two independent doctors or nurse practitioners. Those with nonterminal cases must be informed of other ways to relieve their suffering, among other requirements, and there’s a minimum 90-day assessment period.

As the eligibility pool has grown, so has criticism among academics, disability advocacy groups and religious communities.

Doctors and nurses “do not treat MAiD as an option of last resort,” said an August report published by the Christian think tank Cardus.

The nonprofit organization Inclusion Canada regularly hears from people with disabilities who are offered euthanasia, including one disabled woman whose physiotherapist suggested it when she sought help for a bruised hip, said executive vice president Krista Carr.

“Our response to the intolerable suffering of people with disabilities is: 'Your life is not worth living,’” she said. “We'll just offer them the lethal injection, and we'll offer it readily.”

Data suggest marginalized people are affected

Critics have long warned that Canada’s policies have led to euthanasia among disadvantaged people whose deaths weren't imminent. Despite publicized cases of people asking to be killed because of insufficient support, government officials have largely refuted the idea that socially disadvantaged people are being euthanized.

But in Ontario, more than three quarters of people euthanized when their death wasn't imminent required disability support before their death in 2023, according to data from a slideshow presentation by the province’s chief coroner, shared with AP by both a researcher and a doctor on condition of anonymity due to its sensitive nature.

Of people killed when they weren’t terminally ill, nearly 29% lived in the poorest parts of Ontario, compared with 20% of the province's general population living in the most deprived communities, the data show.

People euthanized with nonterminal conditions were “more likely to live in neighborhoods where there’s higher levels of residential instability, higher material deprivation and greater dependency on government support,” Ontario Chief Coroner Dr. Dirk Huyer said during his May presentation.

The figures suggest poverty may be a factor in Canada’s nonterminal euthanasia cases.

But Huyer told AP that the data was only an early analysis and “it’s tough to know exactly what it means,” saying that his job was only to present the statistics.

Poverty doesn't appear to disproportionately affect patients with terminal diseases who are euthanized, according to the leaked data. And experts say no other country that has legalized euthanasia has seen a marked number of deaths in impoverished people.

Overall for Ontario, the data show, nonterminal patients account for a small portion of all euthanasia cases: 116 of 4,528 deaths last year. But the presentation and discussion among Ontario officials and medical professionals show rising awareness of euthanasia deaths for social reasons.