This article originally appeared in BMJ.
By Ramona Coelho, October 2, 2025
Medical Assistance in Dying (MAiD), Canada’s assisted dying program—which includes both assisted suicide and euthanasia—was first introduced in 2016 for people whose natural death was reasonably foreseeable. Over time, it has expanded far beyond that original scope. Today, there are two eligibility pathways: the original, now Track 1, and Track 2, which applies to people with a ‘grievous and irremediable’ condition who are not nearing death. In 2027, people with mental illness as their sole medical condition will also qualify, and discussions are underway about further expansion. Quebec has already moved ahead, expanding eligibility through advance directives.
This week, the Ontario Chief Coroner’s MAiD Death Review Committee (MDRC) released its latest report. The MDRC reviews selected provincial cases, and the committee, whose members have diverse viewpoints, contributes expertise to help the Chief Coroner formulate recommendations to clinicians and public authorities. As a member of the MDRC and a physician who cares for marginalized patients, I have serious concerns. Social vulnerability—poverty, housing insecurity, insufficient accommodations, and, in my view, systemic discrimination—combined with a superficial approach to alleviating suffering, can lead to MAiD deaths. The MDRC cases illustrate what the disability community has highlighted from the beginning—that people can be driven to choose MAiD not by their medical conditions, but by system failures, leading to the conclusion that their suffering is unbearable. Barriers to palliative care, inadequate home supports, and discriminatory attitudes send patients the message that their lives are less valuable—and that MAiD may be their most accessible option.
The latest report focuses on dementia. While dementia cases comprise a small number of MAiD deaths, they elicit more family concerns. Consider these cases: one man with Alzheimer’s and delirium received MAiD during an acute illness while facing long-term care placement after losing his caregiver. In another case, family members raised MAiD requests on behalf of a patient with advanced dementia. These highlight the risks of coercion in an already vulnerable population. The patient with advanced dementia was assessed in a single meeting with family present, with only a limited evaluation of cognitive impairments documented. In general, informed consent is often impossible in such situations. Yet in this case, MAiD was administered.
In my view, similar patterns emerge across cases: capacity assessments can be inadequate, requests are sometimes accepted based on fear of future suffering rather than current suffering, and neglect—not medical decline—can drive both suffering and the administration of death. Clinician bias, where disability or cognitive decline is equated with diminished worth, creates an environment in which life-ending decisions can be made without sufficient scrutiny or attempts to address suffering. The MDRC report found that only 13.6 percent of dementia patients who died by MAiD received palliative care beforehand, meaning most never accessed treatments proven to ease suffering linked to fears that often fuel the wish to die.
Consider last month’s report: Mrs. A, isolated, severely obese, depressed, and disconnected from care, refused treatment and social support but requested MAiD; instead of re-engaging her with care, clinicians deemed her incurable because she refused all investigations, and her life was ended. Mr. B, a man with cerebral palsy in long-term care, voluntarily stopped eating and drinking, leading to renal failure and dehydration; he was deemed eligible for Track 1 because his death was considered “reasonably foreseeable.” No psychiatric expertise was consulted despite psychosocial distress. Mr. C, a man in his seventies with essential tremor, requested MAiD primarily due to emotional suffering and bereavement. In my view, Mrs. A’s case illustrates how assessors may deem suffering irremediable without an accurate prognosis or appropriate care; determinations of incurability must never be based on patient neglect. Mr. B highlights that clinicians can seemingly allow for broad interpretations of “reasonably foreseeable natural death,” while Mr. C demonstrates that essential tremor, though incurable, does not usually constitute a serious decline, and his suffering was largely due to bereavement. While Health Canada provides guidance on what constitutes a grievous and irremediable condition, incurable or irreversible decline in capability, and reasonably foreseeable natural death—including stating that someone cannot refuse all treatments to render themselves eligible for MAiD—there are no straightforward medical definitions, allowing MAiD clinicians broad interpretive leeway with seemingly no consequences to date.
In April 2025, MDRC reports highlighted how assessments can be rushed and MAiD given in place of palliative care. Mrs. B, in her 80s, preferred palliative care, but adequate support, such as hospice, was denied. Instead, she underwent MAiD the same night her spouse, overwhelmed by caregiver burnout, urgently contacted the MAiD coordination service. Similarly, Mr. B, a man with Alzheimer’s, was euthanized under a waiver of final consent after he no longer recognized the MAiD provider, yet no effort was made to re-engage him to determine if he was still suffering or wanted to die before the lethal infusion was administered. Another patient, Mr. C, deemed to have lost capacity by his treating team, was roused and nodded in response to questions; this was considered sufficient evidence of capacity, and MAiD was administered.
Cases from Track 2 MDRC reports, involving patients outside the end-of-life context, also reveal systemic failures, which I have previously written about in this forum. Individuals with complex medical, mental health, and social needs—including untreated psychiatric conditions, disabilities, trauma, and unsuitable housing—ended their lives through MAiD. Access to essential supports was limited. Patients were more likely to be poorer and women—groups already facing social injustice—and were less likely to name family as next of kin, often relying instead on friends, lawyers, or healthcare providers, highlighting isolation.
MAiD is often framed as a matter of individual choice. But autonomy is compromised when people lack housing, palliative care, disability supports, or protection from coercion. What appears as “choice” can be masked despair, shaped by systems that frequently fail. The United Nations Committee on the Rights of Persons with Disabilities, in March 2025, found Canada’s MAiD regime discriminatory and ableist. While MAiD was meant to relieve intolerable suffering when no alternatives remained, it instead puts vulnerable people at risk, becoming a path of least resistance when barriers to care exist, preying on fear of being a burden and often overlooking supports that could genuinely alleviate suffering.
Dr. Ramona Coelho, Family Physician; Senior Fellow of Domestic and Health Policy at the Macdonald-Laurier Institute; Member of Medical Assistance in Dying (MAiD) Death Review Committee; Ontario, Canada.
