A widowed, elderly man with a body tremor was approved for medical assistance in dying (MAID) despite loneliness and poor self-esteem motivating his application, a new report from Ontario’s chief coroner’s office says.
The man, called Mr. C in the report, had an essential tremor, which causes uncontrollable shaking, often of the hands. Tremors are incurable neurological conditions, but not fatal.
Mr. C’s tremors had made it difficult for him to participate in hobbies and social activities. A widower in his 70s, he “did not perceive that he had much to offer in a new relationship” because of the tremor, the report says.
Mr. C said he “experienced profound hopelessness and loneliness” and could not find meaningful relationships or fulfillment after his spouse’s death. His MAID provider noted he applied because of bereavement and emotional suffering.
He was approved for Track 2 MAID, which is MAID for people whose deaths are not reasonably foreseeable.
Mr. C is one of three individuals profiled in a new report by Ontario’s MAID Death Review Committee, which examines how MAID assessors interpret the legal eligibility criteria for MAID.
The report raises concerns that MAID assessors are determining people have incurable conditions because patients have refused routine medical treatments, and that some assessors regard disability-related needs as signs of ongoing decline.
Refusing treatment
In Ontario, a team of nurses reviews every MAID death to ensure compliance with the legal eligibility criteria. It refers cases of concern to Ontario’s MAID Death Review Committee, a 16-person committee that includes doctors, lawyers, social workers and MAID assessors and practitioners.
The committee’s reports are available upon request only. The new report, published Aug. 25, is the committee’s fifth report.
Federal law, which lists the eligibility criteria for MAID, says two medical professionals must find a person has an incurable and serious disease, illness or disability and is in an “advanced state of irreversible decline in capability.” The person’s condition or decline must cause “enduring physical or psychological suffering” the person considers intolerable, and which cannot be relieved in a way acceptable to them.
Guidance released by Health Canada in 2023 says a patient and doctor must together decide if a patient’s condition is incurable, after considering available treatments and the patient’s overall health and values. Patients are not required to try treatments, but must be informed of means to relieve their suffering.
The guidance says a person cannot make themselves eligible for MAID by refusing all or most available treatments.
But the MAID Death Review Committee’s report raises concerns that people are being approved even when it is unclear why they refused all treatments.
In one case, a woman in her 60s was approved for MAID after declining every treatment offered to treat her obesity and related chronic conditions, including type 2 diabetes and depression.
The woman, called Mrs. A, was approved for Track 1 MAID, which is MAID for people whose natural death is reasonably foreseeable.
In the years before her death, Mrs. A refused offers of health care and stopped taking her medications because she “no longer had the will to live,” the report says.
Her MAID assessors believed she would improve with proper health and home care. They offered her weight loss surgery, medication and disability supports. She declined everything, saying they would not help her.
Some committee members said Mrs. A should not have been eligible for MAID because she declined all treatments. Some also said it was not clear whether the MAID assessors had determined why she refused treatments.
“MAID legislation requires more than a respect for autonomy, it also mandates the application of clinical expertise to ensure that reasonable care options are considered,” they said.
Other members said Mrs. A’s MAID assessors respected her autonomy and that refusing treatment is a personal decision.
‘Ableist perspective’
Health Canada’s guidance helps MAID assessors determine if a patient has an “irreversible decline in capability.”
According to the guidance, the decline in capability does not need to be related to symptoms of an illness or disability. It can include decreased job opportunities or ability to participate in meaningful activities.
The report raises concerns about how a decline in capability is determined when patients have disabilities.
The report tells the story of a man in his 60s, known as Mr. B, who had cerebral palsy and had lived in long-term care for several years.
Mr. B “expressed profound psychological suffering and loneliness,” the report says, which increased when he moved to long-term care.
He used a wheelchair, but was able to push it, transfer out of his chair and toilet himself. He was scared that he would lose those abilities as he aged.
Six to eight weeks before his MAID death, Mr. B voluntarily stopped eating and drinking. The report does not say why or whether MAID assessors tried to determine his reasons for doing so.
In approving him for Track 1 MAID, his assessors said Mr. B’s death was reasonably foreseeable because he had stopped eating and drinking and had signs of kidney failure. His dependency on others showed he was in an “irreversible state of functional decline,” the assessors said.
A few members did not think Mr. B’s dependency and need for long-term care fulfilled that criteria. Needing help is part of many disabilities, including cerebral palsy, they said.
“Framing such dependency as evidence of an irreversible decline in capability potentially risks introducing an ableist perspective, wherein inherent disability-related needs are mischaracterized as functional decline that is aligned with an irreversible trajectory, rather than a person’s basic care needs,” these members said.
Psychological suffering
The report also raised concerns about unmet psychological needs influencing MAID requests. Currently, the law prohibits eligibility for MAID on the basis of a mental health condition alone.
Yet, Mr. B’s MAID assessors noted his suffering was “primarily psychosocial and existential.” Several committee members said he should have had a psychiatric assessment to determine whether he was suicidal.
Members also said a psychiatric assessment would have helped determine Mrs. A’s MAID eligibility. If she had declined, the MAID practitioner would have had to say that her eligibility could not be determined.
In a statement to Canadian Affairs, a spokesperson for Ontario’s ministry of the solicitor general said MAID requests have become more complex since 2021 when the federal government removed the requirement that someone’s death be reasonably foreseeable to qualify for MAID.
“The interpretation of illness and function of decline are more challenging for MAID assessors and providers to evaluate,” the statement says.
A few members of the committee said current MAID practices need to be re-evaluated.
They said clarity is needed about whether a person’s refusal of routine treatments or food and water qualifies them as being in an irreversible state of decline.
These members also said further guidance is needed about how to assess a decline in capability when a person’s disability means they always depend on others for some care.
There were 4,958 MAID deaths in Ontario in 2024; coroners’ investigations were started in 299 — or six per cent — of these cases, the office of the solicitor general said in its statement. Five investigations are ongoing.
Let people make their own decisions. We don’t all have reasons to keep going.
Thank you Meagan for sharing with us information from the report. It is important to know about how MAiD is being carried out since most of us will face, at some time in our life, difficult health conditions. We want some protection when we are at a low time in our life.
I am very appreciative of this article. MAID is not about mercy, though that was how it was intended. It is about exterminating the weakest in our society. That is how it began in Nazi Germany. Germans, many of them children, who were physically or mentally challenged were the first to go. It was framed as a benefit to society. This is our descent into a world that looks upon the worth of human beings in terms of utility. Worth is a simply a calculation, determined by purpose and productivity.
I agree. So many people living with untreated depression combined with lack of adequate, timely Healthcare, mental health support, the high cost of living, lack of adequate and affordable housing and food, lonliness and social isolation amounst seniors in particular, and it’s cheaper to just kill people off rather then give them the help they need and deserve. It’s a slippery slope and we have been sliding down it for years now as a society. Truly terrifying and this should be of great concern to every decent human being.
My hope is that I can pre-arrange my wish for MAID if the time comes when I can no longer recognize my family members. I see this as a way to avoid my increasing the mental burden on on my family, increasing the financial burden on my family, avoiding the possibility of causing harm to health workers and becoming an unnecessary burden on the healthcare system. I have seen and heard of cases where all of these burdens go on for years. Please don’t interfere with my wishes for my own body and my own future.