Trish Nichols feels sick to her stomach every time a relative is admitted to hospital. She immediately pictures her brother-in-law’s medically assisted death in a B.C. hospital in 2019.
“You can’t really heal from this,” she said from her home in Edmonton. “You can’t heal from your family member being taken by the government and injected with lethal injections.”
Alan Nichols was 61 when he died on July 26, 2019. He was not terminally ill; he used a device to help him hear. The medical reason given for him receiving medical assistance in dying (MAID) was hearing loss.
Alan had a history of mental illness and had been involuntarily hospitalized for his mental health for a month before he died.
Alan died just three years after Canada legalized MAID in 2016. At that time, only adults suffering from illnesses or disabilities who had reasonably foreseeable deaths could qualify for MAID.
The law that legalized MAID in 2016 said that a review into the law must begin five years after the law was passed.
But before Parliament reviewed the law, it removed the criterion that a patient’s death be reasonably foreseeable, creating two MAID tracks. Track 1 MAID is for people with reasonably foreseeable deaths; Track 2 is for those without reasonably foreseeable deaths.
But Alan was approved for MAID before Track 2 MAID was legalized in March 2021. His family still does not know why. They have testified at Parliamentary committees and contacted police, medical regulators and politicians. All to no avail.
“There’s no accountability,” said Gary Nichols, Alan’s brother.
As Canada marks 10 years of MAID legalization on June 17, some are calling for greater scrutiny of the law.
But others say there is no evidence that socially vulnerable people are more likely to access MAID, and that the current system prevents such deaths from occurring.
“We trust the professionalism of clinicians, the training and standards that guide MAID practice, the role of regulatory colleges and the oversight mechanisms designed to identify concerns and strengthen practice over time,” Dying With Dignity Canada, a charity that advocates for MAID, wrote in a statement to Canadian Affairs.
Quick uptake
As of Dec. 31, 2024, 76,475 Canadians had died by MAID.
MAID accounted for five per cent of all deaths that year.
The pace of MAID uptake in Canada exceeds the Netherlands, the first country to legalize euthanasia and assisted suicide in 2002.
In Canada, MAID accounted for four per cent of deaths by the end of 2022 — six years after legalization. In the Netherlands, euthanasia and assisted suicide accounted for four per cent of deaths 17 years after the practice was legalized.
Many do not find the quick uptake of MAID worrisome.
Only 35 per cent of respondents said they were worried about the high number of MAID deaths in a recent Angus Reid Institute poll. People who reported knowing someone who had died by MAID were less likely to be concerned.
But some are worried, particularly about how MAID may impact people with disabilities or people who are socially marginalized.
“Accessing medical assistance in dying cannot be the result of inequality, nor can it be the result of the state’s failure to fulfill its human rights obligations,” said Tabitha Tranquilla, director of strategic policy at the Canadian Human Rights Commission.
“As a national human rights institution, it is our responsibility to raise human rights concerns in Canada, regardless of jurisdictional boundaries,” she said.
“We feel it is our job to sound the alarm.”
For years, the commission has been calling for a national review into who receives MAID and why. In particular, the commission wants Track 2 MAID reviewed.
The commission monitors Canada’s compliance with the United Nations’ Conventions on the Rights of Persons with Disabilities, which Canada has ratified but not adopted into law domestically.
In March 2025, a UN committee that reviews countries’ compliance with that treaty told Canada to repeal Track 2 MAID, saying it violates the right to life guaranteed by the convention. The committee also told Canada to not further expand MAID eligibility. Parliament is set to legalize MAID for the sole purpose of mental illness in March.
Krista Carr, CEO of Inclusion Canada, says the organization would “vigorously” participate in a national review of how MAID impacts people with disabilities.
The organization, which supports Canadians with intellectual disabilities, launched a Charter challenge in 2024 arguing that Track 2 MAID violates people with disabilities’ right to life. The law makes them the only people in Canada eligible for a life-ending procedure when they are not dying.
Many people support MAID because they say it promotes individual autonomy. But laws often limit individual autonomy to protect others, says Carr, noting restrictions on driving drunk or carrying guns.
Restricting MAID to people whose deaths are reasonably foreseeable would be similar, because it would limit individual autonomy to protect others, she says.
“[MAID is] actually the greatest degree of possible harm, because it’s death,” she said. “You can’t reverse death.”
‘A distraction’
Others say a national review of MAID is not needed.
Dr. James Downar, a palliative care physician and head of palliative care at the University of Ottawa, says there is no evidence to suggest MAID patients in general and Track 2 patients in particular are more vulnerable.
“Every piece of data we have suggests that Track 2 MAID is a very, very rare practice,” he said.
“When it is practised, it is practised disproportionately on privileged populations, not marginalized populations.”
There were 732 Track 2 MAID deaths in 2024, the highest annual total on record.
People who died under Track 2 MAID were slightly more likely to live in the richest neighbourhoods, according to Health Canada data: 16 per cent versus 15 per cent of all deceased Canadians that year.
Instead of reviewing MAID, there needs to be a review of the lack of services available for people with disabilities, Downar says.
“We know that service gaps and poor supports cause numerous harms in terms of illness and natural death,” he said. “That clearly should be the focus of any review.”
“A review of MAID will, at best, be a distraction [from addressing those problems],” he said.
Dying With Dignity Canada agrees that socioeconomic factors are not driving MAID requests.
“No one can receive MAID only on the basis of lack of social support,” the organization said in an email to Canadian Affairs.
The current oversight of MAID is sufficient, the organization added.
Not always ethical
But Tim Christie, a bioethicist who studies MAID, says there needs to be more ethical oversight of MAID.
“There’s a difference between law and ethics,” said Christie, a professor at Dalhousie University.
The laws for MAID in the Criminal Code protect medical professionals from wrongful conviction, he says. These laws do not protect patients, particularly vulnerable ones.
“The decision to provide MAID … is an ethical decision, not a medical one,” he said.
Christie resigned from a working group producing curriculum to teach health-care professionals about assessing vulnerability in MAID cases. The curriculum, he says, did not distinguish between what is legal and what is ethical.
Every approved MAID request should have an ethics review before MAID is administered, says Christie. Reviews should consider if providing MAID is the least harmful option to relieve a patient’s suffering.
In Christie’s view, MAID may be the least harmful option for some patients, particularly those with advanced terminal illnesses or those at the end-of-life. But he does not think MAID is always ethical.
Christie was once asked to consult on a MAID case where a patient with a complex medical history wanted MAID because they feared what would happen to them after their primary caregiver, an older sibling, died. This sibling, while elderly, was not dying.
The Criminal Code says that to be eligible for MAID patients must be experiencing intolerable physical or psychological suffering that cannot be relieved in a way the patient thinks is appropriate. Christie agrees that living without an older sibling may cause “intolerable suffering.”
“But I do not think that by any stretch of the imagination that justifies a doctor in euthanizing [a patient].”
Despite Christie’s concerns, the patient received MAID.
A national review may help understand past MAID deaths, says Christie. But he wants there to be a consistent ethical framework to determine if MAID requests should be approved.
“What we need is something proactive going forward.”
In Edmonton, Gary and Trish Nichols are unsure whether anything will change with Canada’s MAID laws. They live in Alberta, the first province to pass legislation to restrict MAID to those with a 12-month prognosis or less. (That law has received Royal Assent but is not yet in force.)
The couple supports MAID for people who are suffering and dying from terminal illnesses. But they did not support Alan being approved for MAID, even though he was not dying and was in mental distress.
Their questions remain unanswered. The only thing they are certain about is that his death still makes them as angry now as it did nearly seven years ago.
“When does the running freight train stop? When it goes off the tracks?” said Trish. “Well, it went off the tracks with Alan.”
