Ontario Panel Questions MAID Eligibility as Report Says Some Recipients Refused Health Care

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Members of Ontario’s government-appointed medical assistance in dying (MAID) review panel are raising concerns about doctors’ eligibility determinations under the expanded rules, noting that in some cases, patients qualified for assisted death after refusing available health care.

The review of three recent MAID cases has prompted “significant” discussion among members of Ontario’s MAID Death Review Committee, as some of the patients involved had conditions that could have improved if they had accepted care, according to the committee’s latest report, titled “Evaluating Incurability, Advanced State of Irreversible Decline in Capability, and Reasonably Foreseeable Natural Death.”

In three cases that are cited in the report, the patients were experiencing profound psychological suffering alongside physical conditions such as chronic illness or disability. This led them to decline care, despite being offered various medical and support options by MAID assessors, the report noted.

“The review of three MAiD deaths prompted significant discussion among [committee] members regarding whether current MAiD practices and legislative interpretations remain sufficient in light of evolving clinical and social complexities,” reads the report.

It adds that some members “advocated for a re-evaluation of current practices to ensure they remain aligned with the intent of the legislation and the principles of safe and person-centered MAiD care.”

Euthanasia became legal in Canada in 2016, and in 2021, the federal government passed legislation that eliminated the requirement that a person’s death must be “reasonably foreseeable” to qualify for MAID.

This established two safeguard pathways for applicants: Track 1 for individuals whose natural death is reasonably foreseeable, and Track 2 for those whose death is not. Track 2 involves additional safeguards, including consultation with a specialist in the patient’s condition and providing information on options to alleviate suffering.

Ramona Coelho, one of the MAID committee members, said the three cases discussed in the report raise concerns about “broad” interpretations of the reasonably foreseeable death requirement, allowing some Track 2 patients to qualify under Track 1 by refusing interventions that would otherwise prevent their health from deteriorating.

Health Canada guidelines state that a patient “cannot refuse all or most interventions and automatically render themselves incurable for the purposes of accessing MAID.”

“In my view, determinations of incurability must never be based on patient neglect,” she said in a Sept. 10 opinion piece published by National Newswatch.

Ontario recorded 4,958 MAID deaths in 2024, of which 97.6 percent corresponded to Track 1 and 2.4 percent to Track 2, according to the report. While the majority of the cases reviewed by the committee met all legislative requirements, 602 cases required further in-depth review or required an investigation, the report said.

An Obese Woman Chose Not to Access Health Care

The first case discussed in the report involved a woman in her 60s, referred to as Mrs. A, who suffered from obesity and related conditions, such as hypertension, diabetes, and chronic pain. Over a period of three to four years, she chose not to access health care and decided to discontinue her medications due to her “no longer having a will to live,” says the document.

She reported “severe chronic pain” as well as “profound psychological and existential suffering.”

The report says she requested MAID primarily due to her physical and functional decline. MAID assessors determined her conditions could improve with medical management and that her decline could be reversed through enhanced care, and although the two assessors offered “extensive” medical and care options, the patient declined.

The assessors determined her death to be reasonably foreseeable due to her decision to not pursue additional treatment. They also documented she did not present with depressive symptoms nor suicidal ideations that could impair her decision-making capacity. The assessors did not document seeking additional expertise to inform their determinations of eligibility, the report says.

Some committee members raised concerns about the patient’s access to MAID, saying that discussions about assisted death should not proceed until a patient has a re-established relationship with health care. They said this would ensure patients make informed decisions, rather than resort to MAID “as a result of unmet medical or social needs.”

Meanwhile, a few committee members disagreed with the need to re-engage the patient with health care before considering MAID, saying that the provider’s approach respected the patient’s autonomy and their decision to decline treatment.

A Man Stops Eating and Drinking

The second case involved a man, referred to as Mr. B, in his 60s who lived with cerebral palsy, a neurological disorder that affects movement and posture. He received long-term care for many years, and due to “profound suffering,” he decided to stop eating and drinking six to eight weeks before his first MAID assessment.

Dependent on a wheelchair but still able to operate it independently, Mr. B expressed psychosocial suffering and loneliness due to limited social relationships and isolation. The report notes his suffering “was mainly psychosocial and existentially oriented.”

The MAID provider offered the option to try medication and also consulted with another MAID practitioner who had experience with patients who voluntarily stop eating and drinking to help determine the patient’s eligibility. The provider documented Mr. B had no historical or clinical evidence of depression.

Mr. B was ultimately found eligible for MAID under Track 1, with the provider concluding he had an incurable condition, mainly cerebral palsy, and that he had an advanced state of decline due to his decision to voluntarily stop eating and drinking.

“His death was determined to be reasonably foreseeable due to clinical signs of renal failure and his terminal trajectory of physical decline, both resulting from inanition and dehydration,” reads the report.

Some committee members raised concerns that Mr. B’s voluntary stopping of eating and drinking could be indicative of “suicidal ideation.”

They said a psychiatric consultation could have helped determine whether his decision-making capacity was influenced by mental health factors, or whether those mental health needs could have been addressed through alternate interventions.

Grieving Widower Declines Care

The case of a widower in his 70s who suffered from essential tremor—involuntary shaking—was the third MAID death reviewed in the report.

The patient, referred to as Mr. C, suffered from “profound psychosocial and emotional suffering,” as his condition prevented him from engaging fully with life and his wife had died in recent years. His profound hopelessness and loneliness led him to request MAID, the report says.

MAID assessors determined that Mr. C suffered from an incurable condition—essential tremor—and was experiencing functional decline due to his inability to engage in activities, such as meaningful hobbies and occupations. He also experienced reduced hand-eye coordination, impaired fine motor skills, and increasing difficulty maintaining daily independence.

While a neurologist confirmed his tremor was incurable, assessors determined his death was not reasonably foreseeable and followed Track 2 safeguards.

Mr. C was offered “multiple additional treatments” but declined them for various reasons. Due to his history of depression and psychological trauma, a secondary MAID assessor offered a referral to psychiatric and counselling services, which Mr. C also declined.

Two assessors found Mr. C eligible for MAID, and all required safeguards were documented as met.

Some committee members expressed concern that Mr. C’s request appeared to be primarily driven by factors such as grief. They noted that Canada’s legislation prohibits MAID solely on the basis of mental illness, and that Mr. C’s eligibility was determined based on his underlying physical condition, namely, essential tremor.

“These members raised concerns that when psychosocial suffering is the primary motivation for a MAiD request, current approaches to implementing legislation and safeguards may be insufficient to ensure quality and safe practice.”