#223: Examining MAiD in Canada with Dr. Ramona Coelho

I sit down with Dr. Ramona Coelho to revisit the complex and controversial topic of Medical Assistance in Dying (MAiD) in Canada. Dr. Coelho shares insights from recent Health Canada and Ontario coroner reports, revealing safety concerns, ethical dilemmas, and the societal failures that lead many to seek MAiD. We discuss cases driven by financial constraints, housing insecurity, and loneliness, and explore how Canada’s policies differ from other jurisdictions like California and Europe.

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Transcript

Christopher Balkaran (00:00.449)
Welcome to the Open Minds podcast. I'm your host Christopher Bulkman, folks. This is another special podcast with Dr. Coelho where we're revisiting medical assistance in dying here in Canada. So many of you have reached out wanting to see the second episode of this and here we go. Dr. Coelho, welcome again to the Open Minds podcast. Thank you for your time and thank you for all your work on Maid.

Rljc (00:23.746)
Thanks for having me, Christopher.

Christopher Balkaran (00:25.965)
So last we chatted, less than a year ago, what has changed in your world when it comes to maid?

Rljc (00:34.954)
So a lot has changed since we spoke. Since we've last spoke, the last Health Canada report has come out officially reporting findings from 2023, quite delayed, it came out in just December of this past month, as well as the Ontario coroner released his report on...

the May Death Review Committee findings. It is his report highlighting cases of concern to help improve May practice and highlight, in my view, some very important safety issues that we've known about for a long time on the ground, some of us who are practitioners, but are actually highlighted in this government report.

Christopher Balkaran (01:23.991)
What were some of the safety concerns brought forward?

Rljc (01:27.854)
Yeah, so just to be clear, these are my views. The committee, there are, I am on the MAiD death review committee and I think there are 16 of us, all of different backgrounds, different expertise that were invited to sit on this committee to lend our various voices and thoughts on MAiD cases that had already been flagged by his own MAiD review team.

They're a very specialized group that study and look into and monitor MAiD in Ontario. They're responsible. government, Ontario government legislated that it is the coroner's office that's in charge of that. And the two reports that came out in October and the coroner has said that there will be more, but in those two reports, they look at complex

chronic cases of people who receive MADE and vulnerable persons who receive MADE. Both reports highlighting cases of people who are not dying, who qualify for track two. So just to, just because people might be watching this podcast who don't know a lot about medical assistance in dying, medical assistance in dying is the Canadian term that covers both euthanasia and assisted suicide.

99.9 % of cases in Canada to date are euthanasia. think Health Canada's last report from 2023 that just came out said there were less than five, less than a handful, less than five cases of assisted suicide. primarily a euthanasia regime. And Quebec does not allow assisted suicide as the other provinces. But regardless, there are two tracks of to access euthanasia.

in Canada, one is called track one. Those are for people who have a reasonably foreseeable natural death. This is already a very broad term. it's people who are terminally ill, but more people who might have years left to live might still qualify under that track one where they can access MAiD under a certain set of safeguards if they're suffering. And then track two, which was legislated in 2021 opens up medical assistance in dying for people who are not dying.

Rljc (03:53.368)
who might be seeking to end their lives for life suffering and primary for people with disabilities. But as we're seeing in Ontario, so apart from the reports we were seeing in the media, many cases emerging of people who are choosing euthanasia for intolerable sufferings such as financial constraints, housing insecurity.

things that I don't think most Canadians understood that this was what the legislation would apply to. And so these reports actually touch on some cases that are very similar to the ones that we've seen in the media. So a gentleman, for example, who did have inflammatory bowel disease, but he also had mental health issues, untreated mental health issues, including addictions. His psychiatrist did raise

Christopher Balkaran (04:25.143)
Mm-hmm.

Christopher Balkaran (04:32.726)
Mm-hmm.

Rljc (04:50.254)
that maid could be an option or ask him if he knew about it. And in the end that started his maid journey. And I believe after his assessments, the maid provider drove him to the location where he received maid all without his family being aware and his family being the ones who were financially supporting him and who he was living with. So the reports highlight some cases. I think that we've been hearing a lot from the pro-maid lobby that our stories were false.

Christopher Balkaran (05:09.665)
Wow.

Christopher Balkaran (05:19.832)
Hmm.

Rljc (05:19.918)
that the stories in the media were fictionalized or anecdotal and that MAiD could not happen for psychosocial suffering. And this last year, what we're hearing more and more actually even from MAiD providers is that yes, MAiD for psychosocial suffering is allowed if someone has a disability. So your suffering doesn't have to be tied to your disability. And I think most people in Canada would have an issue with this that

I think Canadians understood that euthanasia was being legalized for intolerable suffering that we couldn't cure. And most people don't think of poverty or housing insecurity, loneliness as reasons that we should be allowing people to die. These are things that track very closely to suicidal risk factors. And that overlap is concerning to me.

Christopher Balkaran (06:14.168)
Mm-hmm.

Rljc (06:18.786)
So the May Death Review Committee reports the cases kind of expressed some of the concerns that I've already had that we discussed last year.

Christopher Balkaran (06:18.787)
you

Christopher Balkaran (06:28.951)
Doctor, just so that everyone is aware, can you explain the difference between euthanasia and assisted suicide?

Rljc (06:37.038)
Sure, both of these induce death. So someone is not dying, and you're giving them a lethal cocktail to die. In euthanasia, it is done usually intravenously. it's clinician or somebody else administered. Someone else ends your life. And that's why in the criminal code, this is an exemption to.

culpable homicide because you're ending someone else's life. Assisted suicide is when a doctor or whoever gives you a cocktail that you go and fill at the pharmacy and then you self ingest. many other jurisdictions in the world only allow assisted suicide like in the states. Most jurisdictions as far as I know only allow assisted suicide. I think it has to do with their federal laws, but I'm not 100 % sure.

versus Canada has chosen mainly the physician administered route.

Christopher Balkaran (07:41.411)
I did a really deep dive on MAiD comparing after the fifth annual report came out comparing our jurisdiction to California's So California does have MAiD but they have very very strict controls and I'm just amazed by the number of what the report calls MAiD Provisions not deaths and I find the lexicon quite interesting

Rljc (08:07.758)
Yeah.

Christopher Balkaran (08:09.577)
In California, from 2016 when they legalized maids same time as Canada to now, there's about four, almost 5,000, maid provisions in California compared to 64,000 in Canada. I'd love to get your thoughts on that because I feel like so many Canadians have questions as to why that is in Canada.

Rljc (08:23.768)
Yeah.

Rljc (08:32.942)
Yeah, there's a few things you ask good questions, Chris, but they have lots of answers. So actually, you know, because we're late in our reporting, like the Health Canada report is 2023, we're probably closer to 80,000 now, like 75 or 80,000 deaths in Canada compared to much smaller numbers in the States. And I think that that has a lot to do with our legislation.

Christopher Balkaran (08:36.158)
You

Rljc (09:00.318)
and with the way that maid plays out. So in Canada, as I demonstrated in that case, a physician can raise maid under the idea that it's letting people know their options. But there have been stories in the media of several times different doctors raising maid to the same patient, which can be quite distressing if you don't want to die and people think that maybe this is a good option for you.

Christopher Balkaran (09:27.363)
Yeah.

Rljc (09:27.926)
So that kind of suggestion can cause in my mind undue influence because if you are hopeless, if you are struggling as many of my patients are, so as a doctor who takes care of patients who often find themselves at the margins for different reasons, they often do have a lot of struggles and death wishes are something I'm used to dealing with.

But that is a time when they are vulnerable, right? So if someone suggests to you when you're hopeless that medical assistance in dying, could actually, in my opinion, actually increase their chance of getting it. And that is not just my opinion, like I'm speaking my opinion, but there is a lot of suicide prevention research that shows that our messaging affects our choices. And one of the most important societal and public health policies that we have for suicide prevention

Christopher Balkaran (10:08.767)
Mm-hmm. Yeah.

Rljc (10:22.528)
is promoting messages of hope. It is promoting messages that life matters and people matter and that there is a chance for recovery and healing. And that the opposite messaging does the opposite. So if you start to have advertisements of clinics that people can get MAiD here so people are learning about it, doctors are suggesting it to you.

I'm starting to hear from patients who are coming in saying, heard there's this injection, this needle you can give me when I don't feel like I want to live anymore. From my patients who are depressed now. So that kind of messaging, think, which is kind of becoming more more widespread is concerning to me in terms of what it can do to influence choices. Two, I'm very concerned about barriers to access to care.

Christopher Balkaran (10:58.061)
Wow.

Mm-hmm.

Rljc (11:16.91)
affecting Canadians' choices to access death has also been kind of told in many stories. A patient reached out to me saying that just through hearing my writings that, you know, it's very hard to access home care at his level of disease and disability.

And that a doctor had mentioned to him that he was the only patient at his level of function who had not chose maid. You can imagine that pressure to like, that this is not normal anymore. Maybe you should choose maid. So moving from, you know, a choice to being a burden and maybe you should be choosing maid. Also, our legislation is built in such a way that it is easier to access. And again, messaging affects choice. Access to lethal means affects choice, meaning that

Christopher Balkaran (11:51.191)
Hmm. Wow.

Christopher Balkaran (12:06.851)
Yeah.

Rljc (12:13.912)
When people are at their lowest, if they have access to pesticides or guns or other things, they could more likely self-harm or end their lives, which is why we try to, for example, prevent bridge jumping with barriers. We try to not report in media things that will increase that suicide contagion. But medical assistance in dying in its very essence offers access to death.

And the legislation is built in such a way that you need to know or you should know what you could be offered to help remediate your suffering. But in reality, people don't actually be able to, don't have to access it either because they can't afford it or the wait list is too long or they're ambivalent because they're not well in their mental health and wellbeing. And so they feel ambivalent and are more likely to choose death.

And that's built very differently from legislation and other jurisdictions where all, first of all, medical assistance in dying or euthanasia or assisted suicide, if we're talking about California, is limited to people who have terminal illness. Even our track one is not limited to people with terminal illness. It's open to the interpretation of the maid providers. And we're seeing cases of people who are being approved who have

Christopher Balkaran (13:26.423)
Yes.

Rljc (13:39.134)
years left to live. That is not what I would consider to be either reasonably foreseeable natural death. But there's very wide practice differences among maid providers. So you'll have some maid providers who are interpreting that legislation more strictly. But because it doesn't have a medical translation directly, you can have people who are much more relaxed about what they consider to be qualifying.

So the legislation being the way it is, and I think euthanasia has something to do with it too. I don't know this for a fact, but I think that if you had to go home and take a drug yourself versus the way that it's done in Canada, often people will have this party, it's kind of glorified. There's a lot of pressure to go through, right? If everyone shows up and the euthanasia provider shows up, even if you have to consent at that time.

Christopher Balkaran (14:34.029)
Mm-hmm.

Rljc (14:34.318)
I think there's just a lot of factors in our Canadian legislation and practice that have led to these increasing numbers. Made providers, not all MAiD providers, but a lot of those who have spoken out publicly about the numbers say numbers don't matter. This is autonomy. This is about choice. So if everyone wants to die this way, that's fine. Well, I don't believe that that's true. I don't believe this is just about autonomy. I think that's a skewing of the arguments here.

especially from the patients that I've seen from some of the cases that we're hearing in the media, there is definitely a subset of people who, even small or large, I'm not quantifying, but there is a subset of people who are choosing MAiD because they don't have any other options, which is the opposite of autonomy. It's a structural coercion to die. And if you look at the Health Canada report, if this is really about choice, why are so many people noting that the cause of their intolerable suffering

is loneliness or feeling a burden. Those are societal failures. I recently wrote an article that was published in McDonnell-Laurie Institute, I think it was like a week or two weeks ago, where, you know, that really struck me. we're talking about autonomy here. We're saying that this is about choice. But really, isn't this about a lack of other choices for some people? I mean, I'm hearing the stories that I hear, even if people feel like it's their choice, they're like, well,

I was talking to someone in my extended family and they chose maid for her, she chose maid for her spouse because she could no longer lift him. And that's not choice. That's not about choice. So a lot of the stories that I'm hearing do not sound to me like their choice. In the Health Canada report, they talk about cases that were stopped because coercion was clearly identified.

Christopher Balkaran (16:14.498)
Yeah.

Christopher Balkaran (16:18.189)
Mm-hmm.

Rljc (16:30.894)
So maybe that's a family member pressure. We know financial and elder abuse are big issues. But what about all the cases that might be missed? Those things can be very hard to detect in real time. We're talking about a procedure that once it gets started can happen extremely fast. In Canada, track one cases can technically happen the same day or the next day if they can get two assessments that day. And of course, we know that there are cases like that.

Christopher Balkaran (16:35.256)
Yes.

Christopher Balkaran (16:47.203)
Mm-hmm.

Christopher Balkaran (16:51.341)
same day.

Rljc (17:00.202)
And even cases that happen within 90 days, sometimes it's taken me more time than that to understand the family dynamics and what was happening. So I'm very happy that some cases were stopped for undue influence or coercion. But how many more cases are more subtle and that were missed? that's family member that I was that extended family member. Really, what I was hearing is that there was some caregiver burnout.

Christopher Balkaran (17:21.28)
Mm-hmm.

Christopher Balkaran (17:29.058)
Hmm.

Rljc (17:29.496)
Do I know if her spouse was truly fear, like not coercion, felt like felt bad for his wife, right? She's very petite compared to him. Maybe he felt a burden, maybe he didn't. It just even that family situation that I'm relating like without there being kind to any kind of like coercion, way you think of like holding someone down.

Could those things affect your freedom in a negative way and make you choose death even though you didn't really want to die?

Christopher Balkaran (18:02.647)
Doctor, I feel like every time you write an article, you should come on the podcast, because this is interesting. This is so interesting. There's so many interesting pieces I want to tease apart. But you're right, coercion isn't like overt. In many cases, it's, your state of mind could be in a vulnerable position and you go to a doctor, you go to, you know, like if you're worried about your taxes, you go to your tax accountant and whatever your tax accountant tells you.

Rljc (18:07.23)
Christopher Balkaran (18:28.875)
You just do because now your worries are, are assuaged. And so I can understand why if someone's in despair, they go to a medical practitioner who throws around the idea. Suddenly it's not even, it wasn't in their periphery and now it's front and center. And that's a form of some form of, of coercion. Doctor, I want to talk to you about some of the race based data that I was able to pull from California and Canada. We see a massive preponderance of.

white Canadians and white Americans opting for maid in comparison to their population. 95 % of maid cases are of white Canadians. They're making up 72 % of the population, disproportionate number. California, 85 % of cases are white Californians. They only make up 35 % of the population in California. And so I pose this question to...

to my followers and I asked them, why do you think that is? And the overwhelming response was lack of family connection, lack of spirituality, lack of meaningful like friendships to ground them. And we see an under-representation of under-represented groups, which is also interesting. So I'd love to know, has your research touched on that at all or have you seen that? And I'd love to tease that apart too with you.

Rljc (19:55.118)
I'm smiling and laughing because we're both brown people on the show. And I feel like any answer I give, could get in trouble for what I say. okay, so I have some thoughts. I don't have any specific research on maid and race. But there are actually a few things. One is that the Health Canada report, first of all,

Christopher Balkaran (19:56.843)
you

Rljc (20:23.69)
in its write-up says that some added reporting started late and the actual rollout of information, it might not be complete data. That's just the first caveat to say that the Health Canada report said because it took time for me, providers, to know that they had to report this and so it might not actually be complete representation. Two, the Ontario data, I believe, reflected the same.

Christopher Balkaran (20:35.171)
Mm.

Rljc (20:52.086)
as the health candidate reports. So regardless of what they said, I think that that is actually correct. Three, know, Rebecca Vachon from Cardus, I just think I watched her yesterday or the day before on TVO on the agenda. And actually she, they asked this question and what she said, I think it's a report and to repeat, cause I hadn't thought about it before, but she said, you know, regardless of race,

people who are Caucasian can still be very vulnerable. And that's because I think that a lot of people were saying, well, these are wealthy Caucasian people. This is a further evidence that that's autonomy. And she says very clearly, no, it's just because they're white and educated and well-off doesn't mean that at the end of their life or when they're choosing this, they're non-vulnerable. So very important point that she MAiD.

Christopher Balkaran (21:31.555)
the

Christopher Balkaran (21:44.875)
Hmm.

Mm-hmm.

Rljc (21:49.524)
Another thought that had come to me that has to do more with general with policy rollout is that first adopters do tend to be people with people who are educated and have more money as the maid providers have been saying. But I also think Christopher that you're

Christopher Balkaran (22:09.367)
Mm-hmm.

Rljc (22:17.944)
people who responded to your question are probably right, right? That a lot of us who come from immigrant populations are thankfully for now, our communities are well integrated, we tend to have more support for each other. And I take care of a lot of Middle Eastern refugee families like, and also Portuguese and other families too that are still very tight. And if something happens in the family,

Christopher Balkaran (22:21.346)
Hmm.

Christopher Balkaran (22:35.202)
Mm-hmm.

Rljc (22:45.998)
Even as I'm talking to you here, I have my five kids. I also take care of my father who lives with me with dementia. He's, and my mother, but my father has been in the hospital last week. He will have a surgery next week. And between me and my husband and my five kids and my mother, my dad is super happy. He doesn't really know who the grandkids are, but he's, because all of his needs are met.

Christopher Balkaran (22:52.12)
Wow.

Christopher Balkaran (23:06.305)
Hmm.

Mm-hmm.

Christopher Balkaran (23:15.211)
Mm-hmm.

Rljc (23:15.244)
You know, there might be other reasons. Maybe his temperament was one of being happy. Some of his friends who knew him as a child said, you know, this reminds us of Kevin as a child, but his needs being met by the family have decreased his stress. When they were trying to live alone, my parents, it was really hard. When they moved here, it was really easy. So I think that also speaks to

Christopher Balkaran (23:27.299)
Hmm.

Christopher Balkaran (23:36.365)
Hmm.

Mm-hmm.

Rljc (23:41.774)
choice, even that extended family member that I was mentioning, they are Caucasian, they're through my husband's family. Like in our communities, we tend to just pull people in when they're struggling. And I think that that's like a cultural positive. And I do think that I don't think that that's necessarily something about Caucasians. You can have Caucasians like I was saying, my Portuguese families who are really

Christopher Balkaran (23:59.469)
Yes.

Rljc (24:07.954)
well integrated, but I think it has to do with Canadian and American society. And that it's very like autonomy focused and it's sold as like the dream and like as soon as you can be independent, that's great. And so people create these lives for themselves where they're far away from everyone they love. And then it's really just not easy because I think our communities might even prioritize getting a job close to your family versus, you know,

Christopher Balkaran (24:20.93)
Yeah.

Christopher Balkaran (24:30.701)
Mm-hmm.

Christopher Balkaran (24:35.351)
Yep.

Rljc (24:37.422)
being independent. And being independent might be great, but at one point it really might not if you don't have a community to fall back on.

Christopher Balkaran (24:45.965)
It's totally true, doctor. That's why every Sunday, my family, Sunday lunch is happening at my parents' house. My sister and I have to crawl out of whatever rock we're under and we have to like stumble home and you know, you're totally right. So that sense of community and some white people tell me, some white friends of mine tell me that, you know, they went to school, they got a great job, very successful. They're financially set in their thirties, you know, top of their industry and they can't really talk about their success because, you know,

Rljc (24:53.29)
Yeah.

Christopher Balkaran (25:12.973)
they're a white man or they're a white woman with a privileged background and they feel that sense of shame almost reaching that stage that early and it leads them down a spiral of anxiety, stress and depression. And some are in fact suicidal or many have said, I'm okay with doing maid, like how do I qualify? And so that's such a foreign thought to me, but as they explain their familial relationships, it starts putting things into perspective a little bit.

Rljc (25:39.542)
It could also be like cultural values, right? Like for people who come from other cults, like I think not just culture, it's very like MAiD could be have tapped into something that I think is not that healthy about Canadian society, right? Yeah, but yeah.

Christopher Balkaran (25:41.997)
Yeah.

Christopher Balkaran (26:00.099)
Very good point. Yeah

Doctor, I'd be remiss if I didn't ask you about... Sure.

Rljc (26:06.958)
Wait, Christopher, Christopher, we need to watch this after and edit it, because I honestly could see people going after us for being brown, and being like, well, our white friends, don't have anybody in their life, and they suck, and I was like.

Christopher Balkaran (26:10.541)
OK.

I

Rljc (26:23.314)
Don't you think? So we'll just like, can we see together how that goes? And because I think that you're probably right. And I think that that's exactly what maid providers don't want it said, right? That not all cultures are created equal. And of course, some things about Eastern cultures are maybe not as good. But I think in terms of family cohesion, it's a very protective

Christopher Balkaran (26:25.307)
I'll send you this.

Yes.

Christopher Balkaran (26:40.322)
Yeah.

Rljc (26:53.208)
factor.

Christopher Balkaran (26:54.133)
It is. like, know, even when I talk to like, my brown friends, always like, know, spirituality to me is huge. And so I always think like, yeah, there's ups and downs with life, but that's life, you know, it is what it is. And I just kind of ride the waves, but I can understand how some really do delve into the downs and they want to get back up to that high. And if you don't have that grounding, whether family or spiritual, I can understand how you can spiral with those ups and downs quickly. So

Rljc (27:19.448)
Yes. You know, our North American society doesn't really delve well or talk about existential questions of life, right? And then the thing is when you're suffering, it's really important you can't kind of ignore those questions anymore. And if there's no belief that your life has meaning,

Christopher Balkaran (27:29.247)
Yes, 100%.

Christopher Balkaran (27:34.455)
Mm-hmm.

Christopher Balkaran (27:39.245)
one of them.

Rljc (27:49.538)
that you mean something to other people, it becomes very hard to keep going. And the thing is that it is a societal failure when people feel so bad that they want to die, right? It is, yeah.

Christopher Balkaran (28:00.547)
Yes.

Christopher Balkaran (28:04.387)
Doctor, I'd be remiss if I didn't ask you about the number of cases in Canada. When I look at the fifth annual report, 7.2 cases per practitioner in Canada were leading the world. It took the Netherlands 32 years to get 4.8 % of their entire deaths in their country to be as a result of MADE. It took Canada six years to get to that same level.

And there's a real concern that practitioners at seven cases per practitioner are overworked and are overlooking some of the details as you've alluded to with each case. Do you believe that there is really overworked practitioners in this field that aren't providing that level of care to each case as needed perhaps?

Rljc (28:56.96)
Well, I can only speak to what I know. I am not a maid assessor and practitioner. I do know from the Ontario reports as well that the providers, there are some maid providers doing the bulk of the cases in Ontario, just like in Canada. So you have most practitioners who are not involved at all. You have some practitioners that might see one person in their practice.

Christopher Balkaran (29:14.903)
Wow.

Rljc (29:26.67)
and emerging and I don't have the numbers in front of me Christopher is that you have some practitioners who have very high levels like it looks like it's become the bulk of their practice. And the question, know, I asked this question in my McDonnell-Laurie Institute article on the Health Canada report, two questions. One is that to me, MAiD euthanasia does not.

Christopher Balkaran (29:39.683)
Wow.

Rljc (29:53.976)
fundamentally is opposed to the principles of medicine. So medicine is about healing and recovery. It's about proportionality. So you should never give someone a cure that is gonna cause harms and that is not needed more than the effect that you need. For example, if someone has heart failure, you're not just gonna give them a huge dose of medicine like Lasix that will take care of their water.

Christopher Balkaran (29:58.636)
Hmm.

Rljc (30:20.918)
without making sure it doesn't affect their kidneys. You have to nuance the dose and make sure it is just proportional enough to help their heart and their function and not injure their kidneys, right? So it is proportional. It is supposed to be nuanced. It is supposed to be per person dealt out as needed. It should be evidence-based. And with the baseline of always trying to restore hope,

recovery and like accompaniment and healing. Even at the end of life, there can be healing. Palliative care medications for pain are meant to be nuanced and with expertise dealt out to not cause side effects and delirium, but to help someone with pain control and shortness of breath and other symptoms. And if it's done well, then that is what medicine is about. Medical assistance in dying is one set of doses that they use on everybody.

Christopher Balkaran (31:13.634)
Mm-hmm.

Rljc (31:19.286)
Of course, it's not been studied because you can't study. You can't really study because you're not looking for safety. You're just looking for efficacy. We do know that there are failed cases of Maid in Canada. are some articles about that have come out about poor IV access law. We know because emerged doctor surveys have shown that patients have come to the emerge by ambulance in a state of failed Maid because the IV access wasn't good. so people can have some symptoms.

Christopher Balkaran (31:22.421)
Yeah.

Christopher Balkaran (31:29.475)
you

Christopher Balkaran (31:47.031)
Wow.

Rljc (31:48.3)
So in my mind, MAiD is not congruent with the principles of medicine. And Harvey Chachanov and Joseph Fiennes wrote an excellent article on the principles, the ethical principles of medicine and how it's not seemingly congruent with assisted dying. And they published it in JAMA not too long ago. And I recommend that people look at that article. And so I think that that's a very important point. Like, can is MAiD?

Christopher Balkaran (31:56.141)
Mm-hmm.

Rljc (32:17.626)
Is someone able to do only MAiD and are they actually practicing medicine? I would say they're not. Two, my other concern is that medicine and healing, addressing suffering requires lots of expertise. And sometimes we need to consult, we need to work with allied healthcare givers.

We don't have all the solutions. If you look at the Ontario, the Maid Death Review Committee report, they have statistics that have been reported by the Ontario government. And you'll see that, for example, for the track two cases for 2024.3, the report on vulnerable people and maid, that's not actually the name of the title, but it's about vulnerable persons and maid in track two. They have statistics that show that like,

less than 50 % of those patients who accessed Maid had access to disability care or palliative care. Very, very low percentages had access to community solutions and other solutions. So what happened there? So this is all, I mean, I'm speculating on statistics, right? So this is just my opinion, but it looks like there were Maid providers to me that did not aggressively pursue all other options.

Christopher Balkaran (33:33.057)
Yeah.

Rljc (33:43.448)
Could that be because they didn't know there were other options because this is not their expertise? Their expertise is become ending life. which I, going back to the point where I feel like these are incongruent. And I'm very concerned that if people, if our society shifts to this incredibly high numbers of MAiD, like that patient who wrote to me saying that his doctor said that he has.

Christopher Balkaran (33:55.458)
Mm-hmm.

Rljc (34:08.92)
that that doctor has no one as sick in their practice because everyone's chose me before they got to his level of functioning. Will we lose our clinical skills? Will we lose our ability to improve symptoms and quality? Will we lose all of our clinical expertise or not develop them because we have MAiD that is concerning to me.

Christopher Balkaran (34:15.669)
Mm.

Christopher Balkaran (34:31.363)
Doctor, when we do a comparative analysis with Europe and California and other states in the United States with jurisdictions on MAiD, I can understand why folks would wonder why the case numbers are so astronomically high in Canada. In 2021, we removed that 10 day waiting period for track one. And now to your point earlier, you can get same day approval for MAiD. What's behind the thinking?

amongst the committees that are influencing the politicians because I don't, I imagine that similar conditions of poverty, isolation, loneliness exist in other G7 countries, but Canada seems to be more okay and liberal to the idea of assisted suicide, physician assisted or euthanasia. What's your sense of what makes Canada and our decision making so different?

Rljc (35:30.678)
Well, okay, again, this is my take on government decisions, which of course I don't know 100%. But I think MAiD in Canada and how the lobbying has kind of gone down has been pushed as like something compassionate, something about social justice, like, and trying to marginalize people as conservative.

if they think assisted dying is not the best option, when actually in reality assisted dying is being pushed by extremely wealthy people and lobby groups who want to have control over their lives. I cannot say, given the way that the lobbying has been done and the lack of consideration of all people, including vulnerable people, my take is that they clearly don't care enough about other people.

Which I know sounds very harsh and I'm not talking about every Canadian who supports assisted dying. I'm talking about the lobby groups who have spoken over the disability groups, spoken over the mental health associations, spoken over many disabled people. You know, they hold up a few disabled people, few persons' voices that kind of have their talking points. But forget about the fact that this is a public policy that will affect everybody.

Christopher Balkaran (36:42.232)
you

Rljc (36:57.986)
And so you have extremely clever and powerful lobbying at play here. I presume politicians were not fully aware of what they were getting into when they signed up and now they're in a terrible spot because it's becoming increasingly obvious. It's almost impossible. have our Ontario reports, the Health Canada reports.

Christopher Balkaran (37:15.939)
Mm-hmm.

Rljc (37:21.494)
you kind of like how much can you pull the wool over Canadians before they start to realize? And I think many Canadians are starting to realize that there is assisted dying that's happening not for cases that they think are okay, things that are actually human rights violations, right? And then you have like Associated Press had an article that came out also in this past year showing leaked private forums of MAiD assessors and providers themselves.

extremely concerned because they're trying to follow the law, but this means that they're ending the lives of people who they understand have things like housing insecurity or scared of long term care or financial constraints. So they themselves are having moral distress. And so I think our Canadian situation is a mess. I think it's been led by politicians who were in bed with dying with dignity.

Christopher Balkaran (38:06.817)
Hmm.

Rljc (38:17.92)
And now, you know, in terms of losing face, losing votes, popularity, which is, it's very sad to me, but it seems like politicians care about a lot, has kind of led to silence instead of like some reversal. And we have the disability community that has started their court challenge saying that track, track two challenge is an infringement on their right to life.

Christopher Balkaran (38:28.291)
Yeah.

Rljc (38:45.719)
and they're not dealing with track one. They do say that track one also poses a safety issues to persons with disabilities, but they decided to tackle track two in court. And so we'll see if perhaps there can be some stepping back. I think that the pushing back, the delay of MAiD for mental illness is a sign that the government is very aware that they may have overstepped on this one. But I think that they, I always presume goodwill. So I presume that they went in not really understanding and really thinking that this was about compassion.

and not understanding that this was mostly caving to very wealthy and smart lobbyists and stakeholders.

Christopher Balkaran (39:22.476)
That's a very important point, Doctor. In fact, even if I know some think that, the result of this increase in MAiD is due to track two, and I removed track two from the total numbers and even with track two removed, which is a small percentage, track one deaths are still 16 times higher than California, the state of California. And to our earlier discussion, they removed the 10 day waiting period on track one.

Rljc (39:44.549)
yeah.

Christopher Balkaran (39:51.235)
MAiD in California is very tightly regulated six months prior to foreseeable passing and there has to be palliative care mandatory, I believe, as something that has been provided or hospice care provided before the person has selected MAiD as well.

Rljc (40:09.228)
You know, I don't know California as well. Christopher, I'll just take your word on it. I do know that there was a recent article. So I 100 % agree that other jurisdictions can do it better than Canada. I think Canada is an example to the world of what you don't want to do. And we are really in trouble. I do think that there's some worrisome evidence coming even from places that I think had better legislation that actually I thought were better models like

Christopher Balkaran (40:22.392)
Yeah.

Yeah. Yeah.

Rljc (40:38.026)
Oregon for sure I know is the older one or Oregon like there were some studies that have shown that initially it was people who it looks anyways like they were exercising choice they were more wealthy but now it's most people who who are on government supports who are choosing assisted death and there was a recent article in the British Medical Journal showing that there have been increased numbers of young people accessing death for eating disorders.

Christopher Balkaran (40:39.189)
Yeah.

Christopher Balkaran (41:07.276)
off.

Rljc (41:07.658)
Like, so you have the legislation hasn't changed, but you have a certain laxity, again, in the assisted death providers and saying, well, maybe you're making yourself ill enough to die, which is extremely dangerous. So I agree that American jurisdictions are better than Canada, but I think that there's still loopholes there. And I think as time goes on, California might degrade like Oregon has. In Canada, highly worrisome to me.

is that you can, at least, maid providers, some of them are switching tracks. Meaning that someone, so the numbers look like they're soup, so a lot of maid providers are saying, look, our track two numbers are going down. You can go home and live your life. There's nothing to worry about. Everyone here is dying. But actually, a lot of the cases that I'm hearing about are patients who have disabilities and again, are being informed.

Christopher Balkaran (41:44.482)
Hmm.

Rljc (42:03.712)
So you're not allowed to counsel for suicide, but apparently if you're informing people medically how things work, that's different. So you have practitioners telling patients, well, if you don't accept antibiotic treatments, if you state that you're gonna refuse care, then I can say that actually your death is reasonably foreseeable. We can end your life now. And there is one case in the May Death Review Committee

Christopher Balkaran (42:12.909)
Bye.

Christopher Balkaran (42:28.193)
Wow.

Rljc (42:34.033)
2024.3 where the maid assessor documented that possibility if the patient declined care, he could get MAiD faster than 90 days. And there are other cases that I know of in the community where patients are being told that there is a Chem-up. So Chem-up is tied to dying with dignity. It started off as an advocacy group and the government has given it funding to do education for maid assessors and providers.

and to the tune of $3.3 million. And they have a document, a guidance document called Interpreting Reasonably Forseeable Death, where they instruct, make assessors and providers that actually, if a patient states that they're gonna refuse care like antibiotics or whatever, they can make themselves sick enough to become track one. And so the thing is, I...

Christopher Balkaran (43:27.863)
Wow. Wow.

Rljc (43:30.378)
I am, first of all, I'm concerned about track one too, right? Just in general, even if someone is close to death, if they don't have access to mental health care, if they don't have access to palliative care, I'm sorry, that's still a wrongful death and that's not a free choice. But I'm not even 100 % sure that all the track one cases are really track one. In fact, I know just on the ground from cases I hear from different clinicians who call me in distress, that that is not the case. And we're not even tracking that.

Christopher Balkaran (43:33.591)
Mm-hmm. Mm-hmm.

Christopher Balkaran (43:42.925)
Mm-hmm. Mm-hmm.

Rljc (44:00.247)
We do not know how many cases clinicians are interpreting as track one when they actually should have been tracked to.

Christopher Balkaran (44:07.991)
That is so, so upsetting because you think again, like, you know, you're at a crossroads in your life. You go to your doctor, you go to someone, you know, who you trust and that type of advice can be so dangerous. You know, it's so interesting again, back to the lexicon that we look at MAiD as provisions and not death and the WHO does not classify MAiD as a cause of death. So Canada does not call.

it a cause of death, but if it were, it would be, think, the fifth leading cause of death in Canada. And that's just like what you've just said. It really is emblematic of the very strong lobbying efforts that you've mentioned. Doctor, I wanted to play a bit of like a role call game with you, which is I struggle with what to do if either of us were in a position of leadership where we could affect

change like broadly across the country, I find these committees are very much, their minds are MAiD up on increased access to MAiD the more I read their reports. Do you agree with that assessment? And what can our politicians and leaders do to rein that in talk about poverty, equitable access, things like that?

Rljc (45:29.87)
Sure. Which committees are you talking about Christopher, just so I understand?

Christopher Balkaran (45:33.493)
Yeah, so I remember reading reports from the Quebec College of Physicians and others on MADE. I remember reading a MADE committee to the federal government was in Quebec.

Rljc (45:44.14)
Made for Mental Illness, probably, Monogupta's panel. Yeah, very good. Okay, sorry. Okay, I'll start now. So yeah, that's very interesting, Christopher. There have been many groups that seem very ideologically stacked. The Made for Mental Illness expert committee that was put together by the Liberal government had many known MAiD expansion activists to the point where two people who were pro-Made for Mental Illness had to step down.

Christopher Balkaran (45:46.955)
Yes.

Christopher Balkaran (45:59.533)
Mm-hmm.

Rljc (46:13.664)
And one of them cited the chair's activism as a conflict and why they didn't feel comfortable staying on that committee. have, in fact, I have a book, this is not a plug for the book, but it's because one of the authors, Trudeau Lemons, who wrote a chapter with me, who was involved with assisted dying long before I was. I got involved late in the game compared to him. But he documents in the book,

how MAiD expansionists kind of populated our Royal College. They found their ways into like the regulatory colleges. They found their places of power to be able to make this role happen to the extent that it did without balance. And all I can say is that

I think that Canadians care. There was a recent study that was done by Scott Kim, I think at the NIH, a survey that showed that most Canadians don't actually understand what's happening in Canada. And I do believe that the more they do, the more they will be holding politicians accountable, the more that colleges will kind of pull back when they realize the dangers. We have in BC, I think three court cases now involving Ellen Weep.

Christopher Balkaran (47:26.998)
Mm-hmm.

Rljc (47:37.634)
So today is January 17th, the Globe and Mail had an article on how Willow Clinic, so that's Ellen Wiebe, who's a maid practitioner's clinic, has agreed not to let her do, their workers will not be witnesses to her maid cases anymore, like assigned witnesses on her maid cases. And also that there was a case, this filing happened because there was an injunction where a woman from Alberta

Christopher Balkaran (47:48.472)
Right.

Rljc (48:07.704)
who her own clinicians did not think she qualified for MAID, did a virtual consult allegedly with Wiebe in BC. Wiebe approves her, Wiebe contacts her friend, Whynot, Dr. Whynot, who also approves her virtually without seeing the whole chart allegedly. This is all public knowledge. The judge did not put a publication ban on the doctor's names. And there was an injunction to protect this woman's life.

And so Willow Clinic has come forward and filed that they will not let this happen on their premises. So it is possible that these court cases, these media stories of these court cases will make people realize like, our loved ones can potentially be in danger when they're not well. You know, the fact that you can get MAiD without your family knowing, the fact that you can get MAiD through virtual assessments without your whole chart or your

Christopher Balkaran (48:37.571)
Wow.

Christopher Balkaran (48:43.416)
Wow.

Christopher Balkaran (48:56.513)
Mm-hmm.

Rljc (49:07.052)
your own doctors being involved in a different province, the risks that pose to the people that we love. I mean, all Canadians matter, but maybe Canadians need to understand that their people are going to be affected, right? You think about it as somebody else that you don't know and you're like, it's all about choice. Imagine it's your 21-year-old daughter. Maybe then it's not all about choice, right? When you understand all, because then you can actually say, well, no, it's because she's stressed and she's in university.

Christopher Balkaran (49:20.961)
Yes, yes, of course. Yeah.

Yes.

Rljc (49:35.63)
And oh, she just, I'm thinking about my own daughter who doesn't want me, thankfully. But I'm, know, just, oh, she's in university and she doesn't get to stay home. And yes, she's coming home every weekend, but it's still hard on her. And oh, she has to get a co-op because of her program. And oh, maybe I don't think she's, maybe just because she has a disability, maybe her maid is coming, her maid request is being driven by other things. When you know somebody and you start to understand how complicated people's stories are,

Christopher Balkaran (49:42.893)
Mm-hmm.

Yeah.

Christopher Balkaran (49:50.583)
Yeah, yeah.

Rljc (50:02.606)
all the different layers that need to be unraveled, like, or helped in decreasing suffering, which is a whole experience. It is all the factors of your life, right? Your relationships, physical pain, lonely, all these things create pain, suffering, right? And so when people know people who want...

Christopher Balkaran (50:12.887)
Mm-hmm.

Rljc (50:29.674)
MAiD or understand that this could be their family member who actually needs care, they can understand that this is actually a miscarriage of justice. And then I think is when we'll start having the government change. think more doctors will feel more brave to try to get onto those bodies and fight because it's right now quite toxic, I understand, for many people, including my understanding is many MAiD assessors and providers.

because actually many of them would not do a lot of these cases that are happening. You can have a few people doing these kind of out there cases and doing a lot of them. And you can have other meet assessors and providers who are kind of following more California model. And even they, I shouldn't speak for them, but I have heard from several of them personally that some of them feel that they don't have a voice. And so I think that we have to change that as a society.

Christopher Balkaran (50:56.227)
Mm-hmm.

Christopher Balkaran (51:09.122)
Mm-hmm.

Christopher Balkaran (51:17.345)
Wow.

Christopher Balkaran (51:22.977)
Doctor, I just want to say, you know, it's one I'm glad that you come back on these podcasts because your voice is so important. But I recognize it's also not easy for you in your role as well. And, you know, as a podcaster, I explore all these different topics. But, you know, I don't have technically skin in the game, whereas you do. And you've written extensively about this. And I think that that shows the level of maturity, the level of courage that our policymakers need to embody.

They don't have to agree with every single recommendation. The reality is, is that I don't find the policy to be emblematic of a moderate approach. It's clearly very influenced by one particular side. And that to me is dangerous because our policy should be evidence-based and I'm worried that they're not looking at enough evidence.

Rljc (52:00.588)
No. Yeah. Yeah.

Rljc (52:13.25)
You're like it is beyond it is like 100 % proof. Like it's so sad that we had to live this to understand that our MAiD regime doesn't protect vulnerable persons, that our safeguards are too lax. You cannot rely on the good faith of providers, even if you have many good providers, because you could just have a few. Like and then you can call in virtually from a different province who can end many lively Ellen, we've

I'm not speaking about her as a provider, but she announced herself that she has ended the lives, I think, of 450 people in May of 2022. That's almost three years ago. So now she's not saying how many people's lives she's ended, but it gives you a sense of how many one person could do, who clearly we know given the injunction has, it seems,

Christopher Balkaran (52:43.489)
Mm-hmm.

Christopher Balkaran (52:52.141)
Wow.

Rljc (53:07.316)
a very liberal approach to who she approves. And in other videos that have been released to the public of her, there's a video that was released in Alex Rakin's article, No Other Options, where she's teaching maid providers and assessors, and she says, kind of candidly, family anger is the biggest thing you're up against. Right?

Christopher Balkaran (53:27.672)
Wow.

And that's the real issue we should be talking about more in Canada. You know, it's so interesting. know both of us have to go, but so many aspects of our lives are so tightly regulated. think about like, if you want to buy a pack of cigarettes, it is so tightly regulated. They don't even put it on display anymore. And yet when it comes to MAiD, seems like we're suddenly okay with it. And I have these ethical

Rljc (53:46.915)
Yeah.

Christopher Balkaran (53:57.581)
conversations with friends all the time and they themselves are totally stumped when I start going down these rabbit holes. It's like it's not uniform and that tells us that there are lobby groups, there are interest groups at play that are making our policy so one-sided in some cases and one-sided in other cases. I mean, there's no rhyme or reason and we need voices like yours to correct

when policy goes too far. whatever, however I can do to amplify your voice, I will. But I just can't thank you enough for being on and sharing your perspectives again, doctor.

Rljc (54:33.932)
My pleasure. It's always fun to actually chat with you.

Christopher Balkaran (54:36.931)
This won't be the last time because your research is so important, but thanks again.

Rljc (54:39.054)
Okay, you take care.

Christopher Balkaran (54:43.191)
You too.