Canada's MAID Debate w/ Dr. Ramona Coelho

This week on The Caregivers Podcast, host Dr. Mark Ropeleski sits down with Dr. Ramona Coelho, a family physician and leading voice in Canada’s MAID (Medical Assistance in Dying) debate. Together, they take a deep dive into the clinical and moral shifts occurring within Canada’s healthcare system. Dr. Coelho shares harrowing insights into "Track 2" cases—where patients who are not terminally ill are being approved for MAID—and discusses how social vulnerabilities like poverty, housing insecurity, and loneliness are increasingly becoming drivers for assisted death. Dr. Coelho argues for a return to a medical culture that prioritizes accompaniment and community support, ensuring that care is always the first and primary response to human suffering.

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What is The Caregivers Podcast?

The cost & courage of caring - stories that spark resilience.

Welcome to this week's episode of

the Caregiver's Podcast.

I'm your host, Dr.

Mark Ropolesky, and you can call

me Dr.

Mark.

Our guest today is Dr.

Ramona Coelho, a family physician

who works closely with

marginalized and medically

vulnerable patients

and one of the most visible

physician voices in Canada's MAID

debate.

She has testified before a

parliamentary committee studying

MAID, written extensively on the

issue,

and serves as an adjunct research

professor of family medicine at

Western University

and is a senior fellow at the

MacDonald-Laurier Institute.

In today's conversation, we

examine what she's saying is

happening inside Canada's MAID

system,

how vulnerable patients may be

affected, and what kind of medical

and moral culture this country is

building.

Dr.

Ramona Coelho, welcome.

So glad you're here with us today.

Let's jump right in.

So you're a family physician, and

you care for disabled, poor, and

very medically complex patients.

And before we get into things like

policy debates and some of the

politics around that,

I'd really like to know, what were

you seeing with MAID around the

time with your patients' lives and

their care

that sort of made you feel like

you started to need to speak out

about this?

Well, thank you, Mark, for having

me.

I, like you said, I've been taking

care of people with complex issues

for many years.

For almost 20 years now, I've been

in practice.

And I've been dealing with, in my

regular care, death wishes, my

whole career,

trying to help people have

solutions to mitigate that

suffering.

And when MAID came along,

initially I wasn't too active on

the political front.

I was concerned that I'd be able

to continue taking care of my

patients, like in terms of

conscience rights.

But otherwise, I was pretty not

involved in the debate.

And then I started to see that

this issue was going to touch my

patients more than I had

anticipated.

I read the legislation for the

2021 expansion to people with

disabilities who are not dying.

And in the legislation, I could

already read that there were

certain things I considered to be

issues,

that you had to offer people

options, but they didn't have to

be accessible or tried.

That suffering was deemed

intolerable, but was totally

subjective.

There didn't seem to be an

objective scale or a time to kind

of try to mitigate it.

90 days, I was concerned because

for my patients, it takes a lot

longer than that to sometimes to

deal with very intense suffering.

But we do deal with their

suffering, you know, wait times to

see a specialist can be long.

Then there has to be trials of

care.

So I was concerned about that

timeline.

And then patients started to get

offers of MAID, my own patients.

So some patients already, if they

had gone to the emergency room,

could sometimes, you know, in a

rushed emergency room,

can sometimes be sent home even if

they are sick and you have to kind

of like advocate for them and send

them back,

especially some of the patients

that I take care of.

But it turned out that some of my

patients were being offered MAID

immediately when they found out

they had a new diagnosis.

I had a cluster of patients who

had new dementia.

You know, they had still had a

prognosis of seven years or more.

They had very mild findings.

This is really the beginning of

their journey and they were

terrified.

And the, you know, the

geriatrician had written in the

consult, well, Dr.

Coelho, I, I think they said that

they're not sure they can live

like this.

So I have connected them to the

MAID team.

And I'll share, as I've shared

many places that I've also cared

for my father who has dementia,

who lived with me, who died a year

ago, last March.

And also I used to do dementia

care at the CLSC in Montreal.

And so even just with being able

to work with them and explain to

them how we could cope and how

people can live well with dementia

and how I would be there for them.

They decided they didn't want

MAID, but they were already

approved for MAID within two

weeks, both of them.

Both under track one, even though

they would have, they're both

alive today.

And this is like six years ago, I

think.

And, and they were not offered

options by, like, they were no

concrete options in place.

This is like first diagnosis.

I had another family that, where

this lady had a liver cancer and I

have a lot of palliative care

skills.

I had done home care in Montreal.

So actually the palliative care

team was not actively involved.

I was taking care of her.

We were managing her pain and her

shortness of breath.

Those were her two main symptoms

that she was doing quite well.

Her family had taken time off for

their last days to go through

photos and spend time together.

And home care booked a half day to

talk to her about MAID.

And they all called me after.

And they were like, well, we've

booked the MAID assessment in the

morning because you apparently

wanted it and you sent this team

to the house.

And I said, I didn't do that.

And what do you mean?

They were pretty angry.

They were angry and they thought

that I wanted this for them when

they were actually enjoying the

little time they had with their

mom and they wanted that time.

And actually she died two days

later.

So they felt like we were robbed

of half a day.

And they had felt pressured

because the power imbalance of

being offered this to have that

MAID assessment.

And I had told them, you can

cancel that.

And I didn't set that up for you.

How did you offer to arrange that

MAID assessment?

I guess it was home care that was

wanting to inform her of her

options.

And so I don't know if it was a

social worker who went to the

house to talk to them.

And I started, I had a patient who

had a relatively new spinal cord

injury, no time for adjustment,

was told by a MAID provider.

She could come back whenever she

wanted that she would qualify.

And anyways, I started speaking

about these things.

And then doctors started

connecting with me about cases of

concern.

And that's what I ended up

speaking in Parliament to share

these cases.

And it really hasn't stopped since

then.

So, you know, I think that you've

witnessed the introduction of MAID

as a physician in practice.

And if we consider Track 1, which

is the original legislation that

was offered to Canadians as an

exceptional measure for, you know,

exceptional cases of suffering.

But that's now kind of rapidly

shifting.

In your view, what is MAID

becoming?

I think, you know, I was just

involved, I've written an article

in BMJ about safety in MAID.

That's the British Medical

Journal?

Yeah, the British Medical Journal

of Supportive and Palliative Care.

I wrote an article with the

coroner of Ontario's cases that he

released.

And in that, I talk about the

drift that I think is happening.

And part of, you know, I think

that we've had very little kind of

corrective measures in terms of

how MAID is implemented.

So, you have certain MAID

professionals, clinicians who do

an excellent job.

They self-regulate themselves.

They will look for other options.

And then you have a very, I think,

a very small group of MAID

providers who potentially have a

very lax interpretation of the

law.

And no one is really correcting

that drift.

And so, patients can shop until

they find those few MAID

providers.

And I think that there are, in my

opinion, there are proving cases

that the rest of Canadians, the

rest of their own MAID community,

the rest of our medical community,

would not consider to be in

keeping with the spirit of the

law.

So, we hear so much these days

about quality assurance in

medicine and medical care.

What are the quality assurance

measures looking at this whole

process and reassessment and, you

know, re-evaluation using real

live data in terms of where and

how the process is evolving?

Are those measures in place?

I would say they're not.

So, the government did not

legislate that any special

training happened to happen for

MAID assessors and providers.

So, any physician and nurse

practitioner can be a MAID

provider in Canada.

They do not have to do any special

training.

Alberta has just tabled a bill

that would enforce training before

becoming a MAID provider.

But otherwise, no.

So, you had a lot of people

joining on who wanted to help this

along but might not have had

chronic care skills.

But aren't assessors?

I've heard that assessors go

through some training to become

assessors.

But by that, you mean they have no

experience in the field of

palliative or other rehabilitative

care?

No, they have no training,

actually.

No, they have no training.

Really?

No.

So, I'll tell you.

So, basically, the government did

give a certain amount of money to

CAMEP, which is the Canadian

Association of MAID assessors and

providers.

And they have developed or are in

the process of optimizing their

curriculum that can be offered.

It's not mandatory.

It's CMEs.

And you have people like David

Henderson, Nova Scotia Health

Authority, who has shared in

parliamentary hearings when he was

called that he's very concerned

that a lot of MAID assessors in

his area do not have an

understanding.

So, he's a palliative care doctor

by training that a lot of them

don't necessarily have that kind

of palliative approach,

evidence-based approach to chronic

care or symptomology, like

managing symptomology.

And a lot of them, he offered to

create a curriculum.

This is just a local story, but

just to explain.

And it was declined because he was

told it would be too

time-consuming to do that.

So, you have some people who are

very motivated, who want to learn,

who will learn the best evidence

to how to mitigate suffering.

But then, actually, you don't have

a standardized training program

across Canada.

So, that can lead to potential,

like I said, drift of certain lax

providers.

And you have Alberta that's moving

towards enforcing training to

have, to be a MAID provider.

So, I remember hearing about how

there's sort of very firm belief

among leadership nationally that

standards are in place and this is

all going to be covered by

standards.

Is that the case on the street?

No, it's not.

And I think that that's been,

like, I try not to be political,

but it's been very difficult

because the government, even in

the parliamentary hearings that

are ongoing, what they want to

hear is that we are professionals.

We will get this right every time.

Trust us to do the best job.

You have CAMAP and Pursuit & Al

publishing in CMAJ saying, yeah,

there's wide variation in how we

practice MAID and what we believe,

but let us figure it out with MAID

consensus internally.

You have the disability community.

I know that you had Krista Carr on

on a previous episode who have

been trying to share their

experiences, even under track one

of people getting MAID because of

long-term care, forced separation

from their families, lack of

resources.

And you have the government, I

suspect, that doesn't want to lose

face, who just keeps saying, like,

we have standards, there's no

issue.

The thing that we hear often is,

like, there's no police charges,

there's been no college issues, so

there's no issue.

And for me, I understand, I have

friends who are MAID assessors who

are doing a good job, like,

according to the legislation,

whether I agree with the

legislation or not.

But there are others who are not.

And trying to pretend that there

are no issues because of the

polarization of this debate really

leaves the disability community in

a bad position, in my opinion.

So that when you have people who

have transient suicidal crisis,

just like me or you would have,

you have people looking at them

saying, yeah, I totally agree.

If I were you, I think it would be

totally compassionate to end your

life.

And so in very short order, ending

their lives.

In terms of quality insurance, in

terms of that question you asked,

every province has different

legislation.

So even though MAID is a criminal

framework, it's an exemption to

homicide and assisted suicide,

it's carved out federally, you

have each province enacting

medical legislation in terms of

how MAID will happen in each

province.

And Ontario, I would say, has the

best oversight.

Our chief coroner of Ontario was

legislated, mandated to have

oversight of MAID.

And he has a team of specialized

nurses called the MAID review

team.

And they review all cases of MAID

in Ontario.

And they give feedback to MAID

providers if they think there were

some medical issues.

There were some complaints, like

in the media, about how, you know,

feedback is great, but if it's not

changing their practice and

there's no enforcement, that's

problematic.

That's not the coroner's fault.

He doesn't have the ability to

sanction them.

I think he could refer them on to

the police or the college if he

wanted to, but he does a lot of

great teaching.

And so I think Ontario has the

best model, but it still doesn't

have sanctions.

And so I would say that we have

the best quality assurance, but

whether that leads to correction

will remain to be seen.

You know, part of this is

generating some conversation

around an issue that, you know,

people think about all the time.

I think it's on the topic agenda

of things that people consider

when they're sick, when they're

unwell.

And it's not surprising that there

are lots of opinions out there.

But getting back to track two,

which has been the expansion from

the original indication where

death was imminent,

are we seeing an increase in the

growth trajectory of the number of

track two cases?

Yeah.

So actually, I just want to say

for track one, just so that people

understand, it was never about

imminent death.

So Canada already had a very broad

legislation from 2016.

We had reasonably foreseeable

natural death.

And that has been interpreted, as

I said, like, because it's not

easily medically translatable.

It has been interpreted as weeks

to months by some made assessors

and providers and some up to five

years prognosis.

And track one allows for same day

death.

And we can talk about that.

But in terms of track two and in

terms of growth in general, there

has been astronomical growth in

Canada.

I would say, you know, Health

Canada would probably frame it

differently than me.

But, you know, year after year, we

were seeing like 36 percent

increase in made totals.

The last year's, our last report

is the sixth annual report on

made, which came out in 4-2024.

So it came out in December 2025,

reporting on the 2024 year.

And I think it showed a 7 percent

growth increase of all made.

And I think the numbers for track

two went from 450 to 750.

You have to look those up for

sure.

But I would say that the increase

is quite substantial.

And already in track two, like I

said, some made providers are

calling that five years.

It's actually in Pursuit and Al's

made assessors and providers'

scientific research that she

published in CMAJ last month, I

think.

So that is from the made community

themselves.

But for track two, you don't have

to be anywhere near the end of

your life.

So you can have people in their

20s or 30s with fibromyalgia.

You can have people who have

social vulnerabilities.

So in terms of the MAID Death

Review Committee, which again, is

what the, so like I said, the

chief coroner has been doing

oversight of MAID.

But he decided in the beginning of

2024 to enact a MAID Death Review

Committee on top of his MAID

Review Team.

And I'm one of his members.

There are 16 of us on a panel.

And his team selects cases that we

look at, look at the cases, review

them, and then lend our expertise

in terms of public safety for him

to make reports that he's

published.

They're out there with the cases.

And in the track two reports that

came out in October 2024, you can

see that track two cases had more

women than men, tended to be

poorer people, tended to not have

as many have a next of kin.

So like for me, already we know

from the Health Canada reports

that loneliness and being a

burden, what are those?

For me, those are societal

neglect, right?

The people we have failed to make

them feel included in community.

But in the track two reports, like

in terms of looking at statistical

evidence, many of them could not

name a family member as their next

of kin.

Some of them naming their doctor

or their lawyer.

To me, that speaks of social

isolation.

If you look at the treatments they

were offered before they got MAID,

99, I think, percent of them, 99

percent of them got medicines,

drugs.

But only 50 percent of them had

been offered disability or mental

health supports, and less than 10

percent had been offered community

solutions.

As somebody who has done chronic

care of vulnerable people, often

housebound in my life, most of

them have benefited most from

mental health supports, disability

supports, and community solutions.

And so I find that very worrisome.

So, you know, as we approach the

100,000 number for MAID in about a

decade, you've certainly said that

that marks a quiet but very

profound transformation in how

medicine understands suffering and

autonomy and its own purpose in

this.

What has changed here, or is

changing in real time, that

Canadians are just not realizing

that we need to acknowledge?

Well, you know, there was a very

interesting study done by Choi et

al.

It was published in BMJ Open.

It was an NIH, like a National

Institute of Health study, of

Canadians.

From the States, yeah.

Yeah.

But it was a survey of Canadians

to see what they knew about

medical assistance in dying.

And what it showed is that the

majority of Canadians in that

survey strongly support medical

assistance in dying.

But the survey followed up with

cases that are actually happening

in Canada, that there are

legislatively allowed by our

framework.

And actually support for medical

assistance in dying in those cases

fell a lot.

So it means that I think that most

Canadians, even though they

strongly support medical

assistance in dying, like they

think of it as, as you mentioned,

eminent death.

First of all, it was never about

eminent death.

They think about it for people

that we have tried everything,

that we care about, and we have

really failed.

And so we're offering this option.

And that's not actually the case.

That has never been the case.

Our legislation is much broader

than any American jurisdiction's

approach to MAID.

Or they say assisted suicide

because they self-ingest their

meds.

They have a much tighter

prognosis.

You know, in the Netherlands and

Belgium, even though they have

problems.

And actually, it's Carter.

The judges said we would never be

like them.

They actually discounted evidence

from Belgium because they said we

would never have such a kind of

open approach.

They still have to, in most cases,

say that everything has been tried

and the patient has not responded.

So tried, not just suggested.

Yeah.

But tried.

And as you said, like as I pointed

out in the track two cases, what

are we offering people before we

offer them death?

We have another report, a dementia

report.

And again, my father died for

dementia, so this one.

And he died, he was dying as that

dementia report was coming out.

It was very sad for me that of the

people who received MAID for

dementia, they were citing fear of

decline in the future, fear of

being burdened.

Things that, you know, we should

be comforting people with.

We should be offering them

existential psychotherapy.

We have Harvey Chachanov has, you

know, he is like a pioneer in the

world in creating dignity therapy

and letting people understand that

they still have value, even as

their lives change, to help them

adjust to illness and injury.

Yet, people received MAID, only

13% of them had been connected

with palliative care before they

died.

That, to me, is a human rights

failure.

That we're not offering care

first.

That this is not really an

exception.

And I am disappointed that

Canadians don't know.

It's not their responsibility.

But it's not been very high in the

public interest either, I would

say.

And there's a lot, and because

there's a lot of polarization, you

can have unkind players on both

ends of the spectrum.

That can make it more difficult to

have what is a very complex

debate.

But I do think that people are

allowed to have their opinions on

both ends of the spectrum.

I'm just, I'm talking about unkind

players.

I think people are allowed to have

their positions.

But then we have to bridge.

And we have to bridge with reality

and what's actually happening.

And these cases are actually

happening.

It's not helpful to anyone to have

certain groups saying that, to the

disability community, basically

they're saying they're all liars.

Not, not okay.

Not okay.

This is the community that the UN

has said is marginalized.

We don't meet their needs.

We don't meet their health care

needs.

We don't include them in society.

We don't have the accommodations

they need to get into most places

to actually be able to connect

with people.

And then that is the one group

that we offer, death.

And then we say, no, your stories

are fake.

That's basically why I got

involved.

Because, you know, it's very sad.

But in terms of discrimination,

people have a harder time when

medical experts get involved.

Even though I'm only saying what

the Indigenous and disability

community has been saying from the

beginning.

So are we at risk or is there this

looming risk of heading towards

euthanizing the poor and

disadvantaged in Canada in the

name of compassion?

Well, like I said, I think it's

pockets of providers.

You know, there was actually an

Associated Press investigative

journalist article that came out

by Maria Chang and Angie Wang in

2024, where they were given access

to MAID providers' private forum,

where MAID physicians were talking

about how distressed they were but

felt compelled to do these cases

because they fit the legislative

criteria and patients really

wanted them.

So I'm not blaming those doctors,

but I don't think that that's what

the legislation intended.

Like, I understand that there's no

definition of suffering, but

really, like, poverty?

That's not irremediable.

If we cared to fix that, we could.

Housing insecurity, loneliness,

going into long-term care.

What does that say about the state

of our long-term care?

And is MAID not, because MAID is

lending a life, is that not

further neglect?

When we're saying that we can't

offer them a better situation, so

we will offer them death.

There was a case in the MAID Death

Review Committee of a woman who is

in her 60s, I believe, and she's

obese.

And that was also part of what was

leaked in the Associated Press

article through the forum of MAID

providers.

And this lady was disconnected

from care for years.

She was housebound, and she had a

history of depression, but she had

been off her meds for several

years.

She requests MAID, and she refuses

any workup, any workup, to figure

out what her actual prognosis is,

how she would do.

And the MAID providers approved

her.

And this is a MAID Death Review

Committee case that's been

published.

The MAID providers deemed her as

having a grievous and irremediable

suffering with a reasonably

foreseeable natural death because

she would refuse any treatment

anyways if she got sick.

And a reporter asked me about this

case.

Well, it's her choice.

People are allowed to decline

care, so wasn't it compassionate

to offer her MAID?

And, you know, this is where I

feel like there's, like, a little

bit of disconnect.

I'm not talking about the

reporter.

I'm talking about everybody, like,

in general.

And, like, some of us have had

these life experiences that are

changing for us.

But when I did home care, I was

called several times into homes of

people, like, where they had gone

to do work in the apartment and

realized this person was in a

total state of neglect.

You know, there'd be, like, feces

on the floor.

There could be papers.

There could be hoarding.

There could be lots of things.

Total social isolation, not

malnutrition.

And sometimes these patients

wanted to die or they wanted me to

go away.

Either way, right?

So now it sounds like they found a

similar patient in the time of

MAID and they offered the MAID.

So what would I have done if I had

met this lady when I did CLSC

Metro Home Care or, like, the

other patients that I met?

I would say, please, let me be

your friend.

Please let me come back.

Let me get to know you.

And actually, I would like to send

other people from my team.

They're really nice people and

they'd like to just have tea with

you, right?

And we would send in the social

worker and we would send in other

people.

And I would keep going back and

we'd be building that relationship

as long as they would let us in.

That is what I consider good care,

right?

You build up that trust and then

eventually you get them reengaged

with care.

You reconnect them with community.

That is the appropriate response

to someone in that state.

But saying, well, you're not going

to get treatment anyways, I'm

going to give you MAID, to me is

just a worsening of the neglect

that they have found themselves in

for whatever reason.

You know, people say, and that's

what really concerns me, people

say this is autonomy.

You know, autonomy is a fragile

concept.

And some of us have more choices

and therefore more freedom in our

autonomy to make choices than

other people.

Some people have been dealt a

really, a really shitty card, like

a really shitty hand.

And it's our job to help them

repair that.

It's, it's not, I think that when

we say like, I care about what I

hear and what I'm, what, how I

interpret this is, I care about

you so little that I'll help you

end your life.

I know that's not their approach,

but this is how I see it because I

have accompanied so many people

and you can't help it when you do

chronic care and you follow people

for years yet, you, you learn to

love them, right?

You know them, they know you.

They're like, it's, to me, it's

very personal.

This is not, this is not true love

to end someone's life when they're

like suicidal and in a state of

neglect.

I mean, Health Canada's own data

shows that loneliness, fear of

being a burden like you alluded

to, and existential suffering are

major drivers in the emergence of

more and more track two cases.

I mean, why is the answer here to

those conditions increasingly

death instead of care?

And when those are exactly the

kinds of suffering that, you know,

medicine and community are

actually supposed to respond to.

You know, I can share a personal

story about that.

Yeah, well, first, first, it

shouldn't be so easy.

I think that the government has

had a failure here, a major

failure.

I'm not talking about the main

clinicians.

I'm talking about the government

in terms of the lack of, of

willing to correct or willing to

mandate teaching or other kinds of

things.

But, you know, what I think is, is

I said, like I said, it's very

personal to me, but it's also

personal to me because I could see

myself in a different time having

made very different choices if I

hadn't, if I hadn't accompanied

those patients for a long time.

So when I started practicing and I

shared this on a different

podcast, I was given the care of

people who with very severe

disabilities and I felt scared.

My, I personally, I felt scared

and I started to project my own

fears, uncertainty of what would

happen to them and about their

death.

Those fears created what I call,

or what has been called in

evidence, therapeutic nihilism,

right?

This understanding that I can't

fix anything here, nothing's going

to get better, and maybe it would

be better if all of this just went

away for all of us.

And I shared that I probably had a

major depression or existential

crisis, it's hard to know now, but

part of that, that therapeutic

nihilism, which can, which I think

is a very natural response.

And I think a lot of Canadians are

scared of disability as well.

And so the thing is, it can feel

like a compassionate response if

you don't have the learnings and

potentially don't have the

psychological maturity, like you

haven't actually lived through

that, to understand the evidence

that people largely recover,

right?

If you look at the evidence on

major illness and injury, most

people by two years rate their

quality of life as the same as

age-matched, healthy individuals.

But now, in that time of crisis,

we can end their lives with MAID.

And so we absolutely need a

correction here.

Who it comes from, I don't care.

If it comes from the MAID

community and the clinicians who

are evidence-based, helping their

confers, great.

But I do think that for the

protection of Canada, there needs

to be some sort of external group

also providing oversight and

making sure.

This is not just any program.

This is a program to end life.

And it's been, for better or for

worse, it's been inserted in

medicine.

You know, my husband's a surgeon.

And can you imagine if, he's not,

he's a kidney cancer surgeon, but

anyways.

But imagine that he was doing

amputations and he was offering

them for things that could be

treated otherwise.

That would be unacceptable.

He'd probably have lost his

license.

And rightfully so.

We would all understand that.

But there seems to be a hard

disconnect.

And I think it's because of that

nihilism or people who call it

discrimination, call it what you

want.

But you see people who are with

disabilities and that fear that

you think you never want to be

there.

You would just be compassionate to

offer them death.

That needs to be corrected.

I wanted to switch gears a little

bit and sort of talk a little bit

about some of the illustrative

cases so people can understand a

little bit better what you've seen

and what the reviews have shown.

Some of your research has flagged

track two deaths among people with

no fixed address.

Now, how is it possible that

homeless people could be dying

under a system that actually

claims to have safeguards?

So actually, that stat was pulled

from the Health Canada report

itself.

And so I don't have a lot of data

on that.

But the Associated Press article

did speak about MAID for also in

that leaked document about MAID

for people with housing

insecurity.

So we do know that those cases are

happening.

We do know that there are cases of

people who are, their needs, their

suffering is not from their

disability.

In fact, the previous president of

CAMAP said in an interview with

Megan Gilmore for the Canadian

Affairs that the legislation

doesn't tie the suffering to the

disability.

And so you have some people

interpreting that as it could be

any suffering.

And we know that homelessness,

financial insecurity, loneliness,

all of these things, they are real

suffering.

I mean, no one's going to deny

that they're real suffering.

But I don't think the intended

legislation was that we would end

lives for that kind of suffering.

So in the theme of safeguards

then, identifying individuals in

this predicament,

shouldn't there be built into this

whole system provisions for

something like a crisis team for

these types of track 2 requests so

that there's expedited access to

the care that's truly needed to

help start the process of turning

things around for these

individuals who are otherwise at

risk of death, potentially?

Yeah, I couldn't agree with you

more, Mark.

Actually, I'm friends with David

Shannon.

David Shannon is a gentleman with

disabilities.

He's also won the Order of Canada,

Order of Ontario.

He's a human rights lawyer.

And we have written an article

about needed legislative

safeguards that could potentially

make this regime safer.

You know, I personally, I'm with

the United Nations that track 2

needs to be repealed.

That if you look at the stats,

like, the question is, like, it's

a public policy, right?

So one has to decide how many

wrongful deaths one thinks is okay

before they stop a program.

This is not about suicide.

Suicide is a right.

We've decriminalized suicide.

People commit suicide.

It sounds very harsh.

I don't want people committing

suicide.

But this is our society helping

people end lives.

And I, from the stats, from the

stories that I've seen, I find

track 2 very dangerous.

I actually think there have to be

a lot of safeguards put into track

1.

You know, that people can have

same-day death, again, with rushed

assessments, without having access

to palliative care,

when they have clearly, in my

opinion, and from the

documentation, lacked capacity.

And these are also really

problematic.

And I think also, you know,

there's two levels of things that

we're dealing here with this MAID

program.

You have a group of people who

want compassionate access to

death.

But we have to balance it with the

safety of vulnerable Canadians.

And a lot of people say, well,

these are white, elderly, wealthy

people getting MAID.

Therefore, they're not vulnerable.

You know, I'm so sorry.

I used to do part of my CLSU home

care in Westmount.

When you're near the end of death,

it doesn't matter how rich you

are.

You can still have

vulnerabilities.

You can still have

vulnerabilities.

You can still have, unfortunately,

family and elder abuse is very

high in Canada in general.

You know, in the MAID Death Review

Committee, you have cases of

families raising MAID repeatedly

to the clinical team,

not the patient, patients who have

documented pretty severe cognitive

changes who under the current law

shouldn't be getting MAID.

The family is saying they want

MAID and they're getting MAID.

You have patients where there's

caregiver burnout involved and the

family is calling the care

coordination service for MAID

assessments when the patient has

clearly documented the day before

that they didn't want MAID.

So everyone's allowed to have

their own opinion.

But just to be very honest, I

think we need to get rid of track

two and we need to fix track one.

It sounds like just a deeper lens

looking at those situations when

it comes to talking about

safeguards and sort of

prophetically saying that the

safeguards are there, they will do

their job.

And you hear more and more stories

where, you know, acknowledging the

reality and that these things have

happened.

The safeguards need to be better

developed or, as we alluded to

earlier, the quality assurance and

reassessing and taking the time to

reassess where are we at now?

You know, is there a problem?

What do we do about it?

And how do we reassess for being

successful at implementing those

changes?

You described, maybe you alluded

to it a little bit earlier, where

a patient was vigorously roused

from a state of sedation and sort

of getting rough ideas with

nodding and sort of mouthing yes

and blinking that they were

willing.

And that was sort of considered

consent for maid.

Can you take us through like what

happened in that case and how, in

terms of the principles of

consent, how that could be

considered valid in Canada?

I don't think it's valid.

I just have to be very clear.

But this is a documented case from

the coroner.

So the chief coroner actually in

2020, it's not public at the time,

but he gave a presentation to maid

providers saying that there were

documentation problems with

capacity, that patients, that

there were patients who had

clearly documented incapacity by

the treating team or were

delirious from the notes, and that

somehow the maid provision

happened anyways.

The maid assessments happened

during those times, and there was

no standard capacity assessment

done.

You know, to do a capacity

assessment, it has to be

issue-specific.

You have to show that the patient

understands and appreciates what

this choice is and what the other

options are, and that they can

reiterate to you their reasoning

and understand.

You have to make sure that their

insight and judgment is intact.

You know, there's lots of things

that go into a rigorous capacity

assessment.

And in terms of capacity, there is

usually a presumption of capacity

in everyday life, except that as

the stakes get higher for a

medical decision, as you and I

know, it's really important that

capacity is assessed.

So I will share that when my

father had dementia,

unfortunately, was not making a

financial decision.

Like, my father was very

high-functioning in terms of

presenting himself for two

minutes, even though he thought we

were still in India now and lived

on a cruise boat.

Like, it was pretty amazing how –

anyways, we had to get him

declared incapacitated for his

finances.

And we had – Ontario has – you

have to hire a capacity assessor

who's been trained and certified

by Ontario.

They have to come to the house.

They had to meet my dad separately

and then us and actually look at

the finances and find out what was

real.

And all of this to protect my dad,

which I appreciate.

But the standard of financial

capacity assessments is very high,

right?

And they decided my dad did not

have financial capacity.

And so the POA for my mom was

enacted.

For a maid, one could say that the

stakes are just as high or higher,

right?

We're talking about life and

death.

And so in this case that you're

talking about that was published

by the coroner, and I wrote an

analysis of it in an article, I

think, called Rushing to Die.

This gentleman had made maid

inquiries.

So it's not that he had actually

had maid assessments.

It's not that he had met an

assessor and talked about his

suffering and been approved.

He had made maid inquiries.

And then he became delirious, as

according to the documentation of

the treating team.

And actually, he was made

comfortable.

His POA was enacted.

His substitute decision maker was

enacted, meaning that everyone had

acknowledged that this patient

didn't have capacity.

And he was being prepared for a

transfer to hospice.

A maid assessor shows up and says,

well, I think he wants maid.

I'm paraphrasing now because I

don't have the case in front of

me.

He holds medication to try to make

him more alert, shakes him, like

rouses him to try to get him to

open his eyes, accepts nods,

mouthing yes, as confirmation that

he has capacity and that the

assessment is good enough to do

under those conditions.

Facilitates a second virtual

assessment that way.

And then the patient's life is

ended through maid.

I don't think in any way that that

fits the capacity standard in

Canada.

I do not know if the chief coroner

put the case forward.

We don't know those kinds of—we're

not entitled.

Like, as the May Death Review

Committee, we're not entitled to

that kind of information.

Like, if there was an inquest or

if he was reported to the college,

I don't know.

But I think it's very clear

for—I'm sure you understand, too,

as a physician, that doesn't meet

the standard of capacity and

currently maid is supposed to be a

voluntary decision where there is

capacity.

You know, you also describe or

speak of a patient saying that she

would rather die than live in

poverty.

But by definition, that's not a

medical crisis.

And it's a social crisis.

And when a patient says that to

you and hearing it as a physician

or as a citizen, like, what does

that reveal about what the system

has become or is at risk of

becoming?

Yeah.

You know, this is—I'm concerned

about social messaging in general,

Mark.

So in terms of suicide prevention

principles, the strongest one that

we have is that messaging affects

our choices, which is why the

Indigenous leaders are so

concerned, right?

They have a suicide crisis amongst

their youth.

And what is the strongest

prevention tool that we have?

It is the message that death is

not the answer, suicide is not the

answer to our life suffering, that

we can overcome life suffering,

that there can be hope.

So when we start to introduce very

broadly into society that actually

for a certain group of people,

death could be the answer, we are

potentially doing what we know is

suicide—the opposite of what

suicide prevention does is suicide

and inducement to suicide.

So when Robin Williams committed

suicide, suicide rates went up in

America.

When a youth commits suicide on an

Indigenous reserve, the community

has to be really careful and try

to really attend to their other

young because the rates of suicide

after that, they go up

transiently.

When people have access to

pesticides or guns or bridges,

there is increased suicide rate.

And these are—these are—these

are—like, if you put up

guardrails, we know that suicide

rates go down.

It's not like someone walks over

to the next bridge and jumps.

But here we have a program that

offers a compassionate, lethal

means, like, embedded in medicine,

very attractive, and is being

given to patients.

So that patient of mine had a

spinal cord—I mentioned to her

earlier, actually.

You know, she can't—she has a

spinal cord injury, and she let me

share her story.

I shared it in Parliament.

She can walk, but she's lost some

of her other functions.

She can't lift.

She used to be—do more manual

labor.

She would rather die than not be

able to afford to live well.

And her—and I'll just step back

from her because I don't want this

to become all about her.

But what I'm seeing is patients

who are saying, well, MAID is

legitimate.

I don't want to go see a mental

health expert.

And it's very difficult when MAID

providers are telling some of my

patients that they don't need to,

that it's their right.

Like, that is not—the

legislation—if you actually read

the Legislative Health Canada's,

like, write-up, not in the

legislation,

the intention is not to refuse all

treatments to automatically render

yourself eligible for MAID, right?

That is—that is suicide.

And yet, you have some MAID

assessors telling my patients,

yeah, you don't have to do that.

And, like, as in the case of this

lady.

And it becomes very difficult to

offer care when you have these

competing principles.

You have someone else kind of

saying, like, hey, come here.

I'll take care of you.

I really care about you.

I'll end your life.

Don't worry about that treatment.

It can be very difficult, then, to

do the hard work—it is hard work,

right?

It's not hard—I don't know if

you've—I have personally, like I

shared, had a depression myself.

I've been suicidal myself.

Very ambivalent.

I would have been very happy if a

bus had hit me when I was doing

home care those years ago, for

many years, actually.

And the idea that someone would be

there offering death to a certain

group of people when they have

their down,

that it's not understanding, that

it can still be mitigated, that it

can still be treated, is very

worrisome to me.

You've talked of some cases where

a disabled patient in hospital was

feeling medically neglected

and sort of even felt humiliated

and being left hungry, just in a

state of decay and still moving

through the MAID process.

Now, who's supposed to protect the

patient in those scenarios where

the care provided by an

institution in itself

is actually wearing them down,

making them see MAID as being more

appealing?

So in that case, that's one of the

cases where I gave a talk and the

doctor involved in this case

called me.

Not the MAID provider, but

somebody who is associated.

And he said, Dr.

Coelho, I have to say, I thought

you were a bit over the top.

He's like, I heard you give a talk

of what you're worried about in

the legislation, but we're all

professionals here.

He said, except that there's this

case, and I have taken care of one

of the family members for years,

and I know this family.

And this patient was also

delirious, and he had his MAID

provision booked before he had his

assessments,

and he was separated from his

family during COVID.

And could you help?

That's how I got involved in this

case, unfortunately, after he had

died.

And I offered kind of support to

the family, who basically have a

lot of PTSD from what happened.

But, you know, a lot of the cases

I spoke about in Parliament since

it became public were also during

the time of COVID.

So add on that layer mark of them

being separated from their family.

They're not allowed to have that

many visits.

So this gentleman was eventually,

initially, he came in, I think he

had a fall,

and then they put him on the COVID

floor in case he had COVID.

He caught C.

difficile while he was there.

So these are all acute things,

right?

You know what?

I don't think we should be

offering MAID for someone when

there are things that are acute.

It also affects our voluntariness.

So, like, when we talk about,

someone could have capacity,

but if you are in a state of acute

suffering, that might not be the

best time to talk about death.

And yet someone, when they

mentioned to him that he wouldn't

be able to go back home,

that he'd have to have a longer

rehab admission, they said, or he

could have MAID.

And so all of these things affect

voluntariness.

And then our system failing people

also adds on to that in terms of

affecting our choice.

Again, it comes back to, like, is

this really just about autonomy?

Or can we understand that life is

a bit more complex than that?

And that there are different

constraints.

You know, if no one had offered

him MAID during that time, it

would still be a horrible memory,

but at least he would have come

home.

Maybe he would have still chosen

MAID when he was stable and later,

but we will never know.

And also I strongly question

whether he had capacity.

I do not believe he did.

Like, he was so sick during that

time that there was, from what I

understand, he was delirious.

Many failures there.

You mentioned something that sort

of really struck me, and that's

the distress the families

sometimes experience,

and even to the point of having a

PTSD-like reaction.

Can you comment further about

family and caregivers of patients

pursuing different avenues,

respect to, you know, track to and

MAID?

Sure.

What is the impact on families and

caregivers?

I'm sure it's very diverse.

You know, I am sure it depends on

how the family is, what their

values and preferences are,

and how they perceive MAID went

for them.

There was an article that came out

of the Joint Center of Bioethics,

and they had used CAMAP, so like a

pro-MAID, like scientific group,

to acquire the families.

So, you know, you wouldn't think

that these are people who all hate

MAID.

And they interviewed these 12

families, and then they wrote up

their findings.

And one-third, so I guess that's

four families, thought that MAID

was amazing,

that it was a dignified death, and

they were so happy their family

had access to that death.

But one-fourth found the,

the procedure in itself traumatic,

that it didn't go, it wasn't

peaceful,

it was either rushed, or the

person was in pain,

and they weren't comfortable,

and there were other things going

on.

And then one-thirds, the last

four,

found it was undignified because

it was driven by socially unjust

reasons.

That's very hard.

And actually, that's an older

study,

but a newer study just came out,

literally, I think, 15 days ago,

so like at the beginning of March,

from a group of University of

Alberta researchers

on family perspectives of MAID.

And Sharon Kirkey published an

article,

the reason I know about this is

because she interviewed me for her

article

and sent me the link to the study,

so I read the study.

And, you know, again, diverse

responses,

but a significant amount found

that there was a rushed assessment

where, you know,

the patient didn't necessarily

have like a deep dive of their

suffering.

They weren't sure that all options

had really been covered.

There was virtual assessments that

they felt were inadequate,

and some reported in that study

only finding out about MAID of

their loved one after the fact.

And the reporter had asked me what

I thought about that.

Like, should families,

I think the question to me was,

should families be able to veto

MAID deaths?

And I said, you know,

I don't think it's that families

want to be able to veto MAID

deaths.

We have certain laws about

autonomy.

But I think families want to be

involved

because they are a necessary

safeguard.

They can offer information, for

example,

about past suicidal things,

about options that have not been

explored,

about ambivalence.

They can add a certain layer.

I mean, not all families,

but a lot of families could do

that.

And a lot of families would just

want to know

that really this was actually a

good medical choice for the

family.

It is going to affect them.

And so I ended up accompanying,

after I spoke in Parliament in

2020,

I ended up accompanying not a

small group of families.

I have been connected by lots of

reporters

of distressed families

and lots of physicians with

distressed families.

And so part of all of this

is also becoming a support for

families

who have an incredible level of

trauma.

And what I'm really concerned

about

is like how many people,

because all of these people were

very pro-made

and potentially in principle are

pro-made,

but now do not feel like it's a

safe law

because of what's happened to

their family member.

And so the question is like

when I circle back to the Choi et

al.

study

which showed that most Canadians

don't understand

what can happen in our MAID

program,

how many people will it take for

there to be changes,

for there to be the will

to really change this program and

make it safer?

One of the things I noticed

when I was researching this story,

particularly for the episode with

Krista Carr

and yourself,

is how the language has shifted.

There seems to be a control

around the language we're using,

which seems to align with sort of

the pro-made agenda.

You know, initially we were

talking about

doctor-assisted suicide.

Now we're using the acronym MAID,

which is much cleaner.

It's avoiding all the trigger

words.

Suicide isn't in there.

We're not referring to death

directly.

So we've got this sort of clean

use,

a shift from some of the more sort

of

triggery or difficult language.

Also, I noticed this with mature

minors.

And I read that.

I was like, we're talking about

children.

Why are they calling them mature

minors?

What does that even mean?

But it seems to me there's a shift

away

from some of the more challenging

and problematic language

that might actually stop people

and get them to sort of reconsider

this.

Have you noticed a shift in the

language

or a shift around the control of

the language

that's being used to describe

what's happening?

Yeah, it's a very good

observation.

And it's one, like, for example,

the palliative care community,

so Balfour Mount, who pioneered

palliative care.

You went to England, learned from

Dame Cicely Saunders,

came back.

He was a urologist in Montreal,

who became one of the first

palliative care doctors in Canada,

had said, we've always had medical

aid in dying.

Because that's what they called it

in Quebec.

They called it medical aid in

dying.

That's what palliative care people

do.

And I remember that my parents

didn't even understand

the difference between palliative

care and MAID.

And that was largely part of the

debate.

And I don't know if you have ever

seen the article.

It's by Miranda Schreiber in The

Walrus.

It's called The Lobby Group That

Owns the Conversation.

And it talks about how certain

very wealthy lobbyists

have funded, well-funded

lobbyists,

have employed PR companies to come

up with these terms.

You know, even in terms of forced

transfers right now,

they're having a court case about

everyone has to do MAID

everywhere,

otherwise it's cruel.

And we have forced transfers.

We do transfers all the time.

But that was a coined term

that you could read about in a

Policy Options article

by Gabrielle Peters

about this kind of language

discussion

and how we can create arguments

and how we can reach people in

society.

And that's part of what I think is

different

in the UK debate.

They didn't have so much a

monopolization

on the media and the language.

You know, so they're doing,

though,

what we did here 10 years ago.

So, you know, they talk about

initially,

like what they're talking about

here,

it was the same discussion that we

had here,

that this would be an exceptional

measure.

they said, you know,

Gaetan Barré predicted 100 cases

in Quebec,

requests per year in Quebec.

Now it makes up 7% of their deaths

and they're doing research as to

why.

And they had said it would be

first and foremost

a policy of excellent palliative

care.

I was still at McGill.

I was still in Montreal when this

happened in 2010,

when this discussion happened.

And they said that, you know,

it would be,

there would be incredible

safeguards

to prevent wrongful deaths.

And then when it passed,

the language quickly shifted.

Like, safeguards have become

barriers to access.

You know, we almost lost the

language of safeguards.

You are discriminating against

certain groups

by not allowing them access.

So instead of protecting

populations,

the language has largely shifted

to ones of discrimination

and barriers to access.

And if you look at the articles

that are coming out after Alberta,

even though, for example,

the National Post and the Globe

and Mail,

both their,

even the Globe and Mail editorial

board,

they all welcome Daniel Smith's

bill

for safeguards.

The initial articles that were

coming out

was that Alberta was restricting

rights.

I think that was,

I was actually at the press

conference.

A lot of the reporters

who were framing their questions

were like,

why are you trying to restrict

people's rights?

They couldn't even understand

that there's an intersection here

about safety.

And part of that has to do

with very smart lobbying.

Right.

We're back from the break, folks,

with our guest today,

Dr.

Ramona Coelho

on the Caregivers Podcast.

Ramona,

I'd like to speak

a little bit more broadly

about some terms.

And certainly,

you know,

there are many proponents of MAID

and MAID has its place

and it's evolving.

A lot of the conversation these

days

speaks of autonomy and choice.

But if people aren't being offered

housing,

income support,

proper mental health care first,

is that really autonomy in choice

or is this what you kind of mean

when you say

when death is given

because systems fail to offer

support,

that is not autonomy.

It's actually abandonment.

Yeah.

I say abandonment,

patient neglect,

coercive influences to die.

That is exactly how I read it.

And suicide.

You know,

the International Association

of Suicide Prevention

just released a statement

in December of 2025

reminding the world,

so they're the biggest group

of suicide prevention experts

that are coupled

with the World Health

Organization,

that,

first of all,

that MAID for mental illness

cannot be done safely,

that we don't have any evidence,

first of all,

to be able,

it's guesswork

about who will never get better.

So we're,

when we say it's grievous

and irremediable,

we're actually guessing

and we'll be wrong

more than 50% of the time.

But even for psychosocial

suffering

for people with disabilities,

we must not forget

the principles

of suicide prevention.

And so,

when someone is

wanting to die

because they have

a transient life crisis,

and by transient,

I could mean

a longer transient life crisis.

Like,

some people suffer

for a few years.

I've had patients

with disabilities

who,

you know,

I let medical students

come to my clinic

to see and meet

my patients

and to learn.

And,

I introduced them

to a lady

who had been

in the hospital

in and out

for years.

And she does have disabilities.

She would have

qualified for MAID.

And she would qualify

for MAID now.

But,

but then,

though,

some things

change.

they change

without necessarily

systems getting better.

And actually,

sometimes

even without treatment.

Just with accompaniment

and something

external of medicine

helps them.

Because community life,

meaning,

these things

can often

change

our perspectives

on whether,

on our will to live.

And so,

100%,

I see this as

patient neglect.

I also see it as,

like,

ignoring evidence-based

medicine,

suicide prevention,

medicine,

and how we actually

can best help

the patient.

Should,

well,

I mean,

you've said that

MAID

is now shifting

medicine

from treatment

of suffering

to the elimination

of the suffering

of the suffering

patient.

And what does that

do to our

medical culture today

and what impact

does that actually

have on the next

generation of physicians?

In your discussions

with medical students,

what is,

how is this

affecting their vision?

You know,

just because I have

been labeled

as extremely biased,

I'm so careful

about talking

about medical students.

And it's unfortunate,

right?

like,

it's like,

okay,

I don't feel

I've been labeled

a certain way,

so probably

that's not something

I should bring

into the discussion.

But I definitely

try to focus

on vulnerability,

on recovery,

on understanding,

not flattening

the patient

just to their suffering,

to try to understand

holistically

what is,

like,

the total pain,

what are all

the aspects,

the things that

we can offer them

outside the gamut

of traditional,

like,

medications.

So I would say

that that's my focus

with medical students.

In terms of rewriting

the ethics of medicine,

I am really concerned.

I did co-edit a book

with Shruda Lemmons,

who's the bioethics chair

at the University of Toronto

for the law faculty,

and Dr.

Sana Gained,

who is a professor

of psychiatry

in Toronto,

called Unraveling

Made in Canada.

And in that book,

we have

different chapters

from different experts

across Canada

talking about the problems

with the maid regime.

And in one of my

chapters that I wrote,

I ended

saying,

I am so worried

that,

you know,

young students

who haven't had

the,

I would say,

the,

haven't had the benefit

of long

accompaniment

of patients

with chronic

issues,

not learning

that resilience

and patience,

not learning

that we can

target suffering.

if they see

that less

than they see

made,

and we have

an incredibly

high rate

of made

in Canada

right now,

we're at

one in twenty

deaths,

our made

deaths.

And for example,

with ALS,

I wrote an article,

a gentleman

contacted me

that his

neurologist

told him

that he was

the only

person

in his

practice

who was

still alive

at his

state of

disease

that everybody

else had

had made.

and the

Health Canada

report

mentions that

as well,

that we have

much higher

made deaths

for ALS

than natural

deaths anymore.

And so the

question is

when we

no longer

have that

mentorship

or we're

not seeing

and not

having that

time to

understand

how beautiful

it can be,

how much

closure there

can be,

that there

can be

beauty

on the

other side,

will this

become like

the fastest

solution?

and I

can't say

that this

is my

own idea.

Harvey

Chachnoff,

I mentioned

him before

as the

gentleman

who pioneered

existential

therapy in

Canada,

he's also

one of my

life mentors

and friends,

but he

wrote an

article in

JAMA

about is

medical

assistance

in dying

really

palliative

care?

And he

goes through

the basis

of what

medicine

has always

traditionally

been,

and I

would say

that his

article speaks

not just

to whether

medicine,

a maid

belongs in

palliative

care,

which he

concludes

it doesn't,

but is it

actually congruent

with the

principles of

medicine,

right?

Medicine is

proportional.

We try to

really target

the suffering

and the

disease process

without hurting

the patient.

It tends

to try to

not do

harm.

Here we're

rewriting the

whole plan,

right?

We're ending

the person's

life because

we're saying

we can't

target the

suffering,

but actually

we're offering

missing the

suffering.

Anyways,

this article

goes on

principle by

principle.

It's a

brilliant

article written

by Harvey

Chachnov and

Joseph Fiennes,

F-I-N-S in

JAMA, and I

suggest everybody

reads it.

We were all

trained in the

biopsychosocial

model of

medicine, and

you alluded to

palliative care,

and that's

probably late

phase biopsychosocial

in terms of just

the whole journey

with the patient,

right?

And if you have a

patient for a long

time in your

practice, it's the

natural continuation

of the

biopsychosocial

model, but

as you sort

of start talking

about therapeutic

nihilism and

all these other

things, what

strikes me in

this conversation

is that it

seems like

there's a

halt to the

whole biopsychosocial

model, and this

is going to be

the fix.

Yes, Mark,

that's exactly it.

The biopsychosocial

model is something

that we've held

dear, it's been

rooted in our

training, it

continues to be,

yet.

I think it's

almost jeopardized

to some extent,

unless someone

would argue that

MAID falls within

the spectrum of

adapting the

biopsychosocial

model to the

patient in front

of you, but I

think that's a

difficult argument

to make, or

certainly one that

needs to be very

carefully made.

Yeah, I couldn't

agree with you

more.

You do chronic

care as well,

am I correct?

Well, I look

after patients

with chronic GI

disease.

but I

don't do,

and I have a

large patient

population of

chronic patients

in that specialty

setting, yes.

Yeah.

So, when we

think about sort

of track two

and how patients

are becoming

cognizant of

their options as

they're facing

certain situations,

and the question

is, does the

patient bring up

MAID, or is

should healthcare

workers even

be allowed to

raise MAID

first in a

vulnerable patient

as an option

amongst the list

of other things,

or sometimes

maybe even at

the forefront?

I could

understand where

nihilism and

bias could

definitely say,

well, there is

MAID early on

as opposed to

feeling somewhat

defeated at the

prospect of

everything that

needs to be

done to take

a vulnerable

patient out of

loneliness, out

of that feeling

of lack of

community.

I mean, it

takes time, and

it's a process to

bring people back

from those states,

but it is

achievable, as

you've pointed

out, and it is

something that we

can hold in our

sights.

So, before the

patients ask for

it, should it be in

the scope of what a

healthcare worker of

any kind should be

proposing to a

patient?

Yeah, I

absolutely think

it should not

be.

In some

jurisdictions, it

is, so in other

jurisdictions, it is

often illegal, like

patients must

initiate the MAID

discussion and say

that they want to

talk about it, and

in other jurisdictions

where it's not

illegal, it is

really frowned upon

to raise MAID.

CAMAP came up

with a policy called

Bringing Up

MAID, suggesting

that it was very

important that

Canadians be

informed about

this if they

could qualify, and

that has been

adopted by the

model standard by

Health Canada for

MAID.

I've considered that

to be very

concerning, and

these are just

professional standards.

Alberta has, in

their legislation

that they've

tabled, turned it

back to being a

patient-initiated

approach.

And the reason

you've touched

on it, you

know, when we're

talking about

vulnerability, we

talk about

medicine and

evidence-based

medicine about

discrimination, and

we have a lot of

evidence about

that doctors and

clinicians, unfortunately

we carry the same

biases, sometimes

consciously, and

sometimes very

dangerously

unconsciously, you

know, about, you

know, racism,

sexism, we have

lots of

disability, ageism,

you have a, there's

no shortage of

medical literature

that show that

doctors tend to

just naturally rate

the quality of life

people with

disabilities much

lower than they

rate their own

quality of life.

And so, when you

think that certain

people might be

seen as having a

life intolerable, and

that it might be a

mercy to end their

life, and so we

suggest it, you know,

that's problematic.

And the fact that,

like, the fact that

some patients get

offered MAID many

times.

I have been

contacted by

pro-MAID doctors

doctors in certain

cultures who are

really concerned, you

know, they're like,

I'm pro-MAID, like, I

have no problem with

MAID, they tell me, but

you know, I will

approach a patient and

they will say, like, if

you talk to me about

MAID again, I'm going

home, because you'll be

the third person during

the submission who

decided that somehow I

was MAID-able.

And, I mean, and

that's a very

sensitive doctor who's

concerned about it,

right?

They feel that they

have an obligation to

raise it, but they're

feeling that certain

patients are having it

raised way too many

times.

And the thing is,

there's a power

imbalance in our

relationship with

patients.

We have to

acknowledge that.

When I tell my

patients sometimes,

like, okay, these are

your options, you know,

in terms of your

values and preferences,

whatever, they're often

like, what would you

do?

Tell me, what would

you do?

Just tell me.

And I'm like, okay,

look, can we just get

back to, no, no,

what would you do?

I'll do whatever you

want.

What would you do for

your mother?

I'm like, okay.

So, like, there's a

lot of respect, there's a

lot of power imbalance.

And so, the thing is,

when someone goes to the

maid, which has

happened, what

signaling does that

sense?

That's a message of,

like, this is going to

be pretty shitty for you.

Right?

I'm terrified for you, and

I think maid might be a

good option for you.

And I think that's

incredibly dangerous.

That almost sounds like

it sets up a coercive

dynamic for the

elderly or the

disabled or the

marginalized as well.

Do you think that's a

slippery slope?

I think we're there.

I think we've, you

know, the idea that

people would say, like,

there's no slippery

slope.

This is exactly what

Carter intended.

I find that denialism.

We have enough cases.

Now we have, you know,

people saying that all

the media cases are

fake.

We have the coroner's

cases.

But, you know, not

everybody in the

disability community can

be lying.

And we have

research, emerging

research.

I can't see how people

cannot say that this is

a slippery slope.

there's definitely

been drift.

Like, you even have

some providers saying

in the media that

when they hear about

a case being approved,

well, that changes

their approach and

they open up their

approach more.

So what does that

mean?

That's what I consider

a slippery slope,

right?

When we don't keep

the safeguards tight,

there's no way to

enforce them.

We kind of, like,

open up and let more

people in, people who

are unintended, people

that we wanted to

protect from wrongful

deaths.

That's what I consider

to be the slippery slope.

Canada is now

preparing to expand

made, and I know

it's been tabled

to 2027, but to

people with mental

illness, and beyond

that, Parliament's

also even discussing

future expansion to

children deemed

capable of consenting

on their own,

even when, you know,

parents may not be

consented, or may not

be providing consent,

but rather just

simply consulted on.

Once a country or

population accepts the

principles that

suffering in itself,

just suffering alone,

can justify an

assisted death, where

does that logic stop?

Like, where are the

breaks for that kind

of thinking, and what

concerns you the most

about where this could

go next?

Yeah, it's very

interesting.

You know, Scotland has

just, I did testify in

Scotland, I was called

as an expert there, and

they did just vote

down their assisted

suicide law that had

been before them.

And it was very

interesting to see the

complexity and the

interest in a true

debate over in the

UK about safeties and

where this would stop,

and can you stop it

once you say that

death is an acceptable

answering to life

suffering?

Well, who's

suffering?

Who's suffering?

You know, they're

framing it as, like,

it's discrimination

now.

You think that people

with, this is what

we're hearing over and

over again from

people who want made

for mental illness.

You are discriminating

against people with

mental illness.

They are also

suffering.

This is stigma leading

to them being

excluded.

Well, actually, it's

the opposite.

Mental illness is not

like cancer.

We cannot predict who

will not, the few

people who will not

get better, we can't

even know who they

are.

If you put a hundred

people with severe

mental illness in a

room and asked a hundred

psychiatrists, they

would all guess wrongly

who that person was.

We have no way

prospectively...

No biomarkers or

nothing.

clinical tools

that can predict

that level of

granularity.

In fact, we have all

the meta-analyses

showing that all of

our top evidence

shows that, and yet

some doctors in

Canada and some

lobbyists have said

we can do it by

consensus.

We can just decide

that if someone meets

these 13 criteria,

apparently the CPA is

going to come out with

a consensus statement

based on people's

expert opinions.

You know, we talk

about eminence

versus evidence-based

medicine, and we're

trying to move away

from evidence-based

medicine because we

understand that there

are higher levels of

evidence.

And yet, because

ideologically people

want this to happen,

they are willing to

throw away evidence-based

medicine and say we can

just do this by

consensus.

Let's forget about the

fact that evidence says

we'll get it wrong

half the time.

But really, we're

talking about people's

lives.

People's lives who

would recover and want

to live.

And if it is a

medical, if MADE is a

medical tool, like if

it's been inserted in

medicine, then it should

obey the same kind of

checks and balances that

other things have, right?

We need to look at the

risks and harms to the

population, whether this is

something safe to

implement.

And yet, all that has been

thrown away by a certain

small group of people.

Like, the majority of

psychiatrists do not want

MADE for mental illness

in Canada.

The consensus among, like,

the chairs and other

statements have all been

that we are not able to

do this.

Like, we're not able to

actually guess who will

not get better, so we'll

be killing people

incorrectly.

Like, if the legislation

is supposed to really

help people who are never

going to get better by

ending their lives, we

won't be doing that.

Carter was actually put

forth for people who

were so physically

disabled, they couldn't

commit suicide.

That was the logic of

Carter.

We're going to help end

people's lives as an

exception because they

can't commit suicide so

they can live longer and

have someone commit

suicide for them when

they cannot.

How does that logic

even extend to someone

who is able-bodied and

commits suicide?

And we don't want people

committing suicide.

So that's what I'd say

about MADE for mental

illness.

About MADE for mature

minors, our consent

laws and capacity laws

for children are very

different than in other

countries that have MADE

for minors.

I'm not saying I agree

with those either there,

but there there's a lot

of, like, family

consultation.

The parents have to be

okay with it.

The child is usually

older.

In Canada, we have no

younger age and it's a

sliding scale and it would

be the maid assessor who

decides if the child has

capacity.

So in Canada, for example,

we have certain laws

restricting smoking or

alcohol because we're

trying to prevent future

harms for our children.

But here we're saying that

we are going to let

children, potentially

without their parents'

consent, be judged to

have capacity on something

that is life-ending.

And when we talk

about, like, they'll

say, oh, no, it's just

for track one, Ramona.

This is whatever.

It's just for track one.

Well, we know that some

maid assessors think that

track one is okay for

people who have five years

left to live.

And the psychological

brain maturation is not

there for children.

It happens much later.

So I have a lot of

concerns.

I've written an article

that was published a few

years ago in Al Jazeera

about the, and I wrote a

chapter for the book.

This is why I know a lot

about MADE for Children.

I wrote a chapter in that

book that I co-edited

about MADE for Mature

Minors.

And I could also get into

advanced requests, but I'm

not sure how much time you

have.

You know, I really like how

you said there's a

difference between

eminence-based medicine

and evidence-based

medicine.

And, you know, good

quality consensus

guidelines revolve around

breaking things down

into some parcels.

One is, is there

consensus and how strong

is the recommendation?

That needs to always be

tempered by the quality of

the clinical evidence

that those recommendations

are being made from.

And, you know, a

moderate recommendation

with very poor quality

evidence doesn't change

my practice.

It's something to think

about, but it's certainly

not written in stone that

that's how that guideline

needs to be implemented.

So I think it's an

important caveat that you

bring up.

If you could change

three things tomorrow

to sort of stop

Canada from offering

deaths where care

should come first,

what would they be?

Well, I said this in a

press conference in Alberta.

They asked me,

the reporters,

one of the reporters

asked during the press

conference,

what would you do

that's not on this bill?

And I said,

well, that's very rude

to ask me in front of

my guests.

Like, they've invited me

to do this press

conference.

But what I shared

is that the prognosis

of the disease

needs to be clear

and has to be the driver.

So the idea that we are

letting people

into this

made regime

for, as you mentioned,

like housing

or financial

insecurity

for people who have

these kinds of

sufferings,

I think the

one legislative

safeguard that I have

mentioned publicly

and written about

is having a disease

prognosis

that is

the driver,

like some sort of

timeline like they do

in the States, right?

They say like six months

or 12 months

with the disease

prognosis

causing the death,

not making oneself

having a natural death

by refusing food

or refusing antibiotics,

but really like having

a disease

that is going to

take you out,

unfortunately,

in a certain timeline

as being the largest

safety

that you can add

to such a bill,

to have to such

a legislation.

And I think that we need

to focus

as a separate issue.

You know,

my providers always say

this is a separate issue

and I guess it is

a separate issue,

but it does touch

on people's choices.

We need to help people

with our chronic care.

Our chronic care

needs to be better

funded,

needs to be more

timely,

needs to be more

long-standing.

I will share that

my sister is a psychiatrist

and she was the head

of public health psychiatry

for New York City

and then she came

and was the lead

at one of the

psychiatric hospitals

here in London

and I eventually

convinced her

to leave all that

and to do

OHIP-covered

psychotherapy

with my patients

because they just

could not get care.

I take care of a lot

of refugees,

a lot of men

out of prison,

people who just

do not have

the financial means

to have psychology

that is not covered

for them.

And so she does

do medication

and she does stuff,

but she also does

OHIP-covered

psychotherapy.

It's not fair

that I can harass

my sister

so that I could have

that thing

for my patients,

but that is

what all Canadians

need.

We need to fund

mental health care

better.

We need to fund

disability care

better.

My father,

I shared that

we got two days

of palliative care

before he died

because dementia's

prognosis is not

so clear.

So in January,

I was telling people

like,

my dad's not

eating anymore,

he's starting to

become way weaker,

his PPS score

was too high

to qualify for

having palliative

care services.

So it took

multiple hospital

visits,

stabilizations,

bringing home,

my husband

carrying him

around the house

and then finally

they gave us

palliative care

for the two days

before he died.

Now,

me and my husband,

my sisters,

my five children,

we got that.

Most people

don't have that.

I consider that

to be coercive

influences to die

and so I think

all of that

needs to be

heavily looked into.

And the third thing

is community life.

So if you look

at mental health

outcomes,

and I do believe

that it is

mental health

that is driving

a lot of people's

made requests,

even in track

one,

even in track

two,

and obviously

will be in

track three,

there is a person

named Thomas

Insel who was

the head of

the NIMH

of the National

Institute of

Mental Health.

He wrote a book

called Healing.

And he talks

about, you know,

with or without

medications,

what leads

to a good

prognosis,

right?

It is like

feeling included

in society.

It is feeling

like you bring

other people

meaning.

Not that you

can do things

like our

society is like

very metric

focused and

we do this

and we do

that, but

that we

belong and

that if we

weren't there,

it would bother

people because we

mean something to

people, that we

mean, like that

kind of relational

society, relational

autonomy.

And I think

partly COVID, I

think partly like

this kind of weird

politics that makes

people feel like

they can't talk

or connect

because they're

different.

Guess what?

We're very

pluralistic, we're

a very diverse

society, but I

think that we

all have a lot

more in common

than we don't

and we need to

start reaching

out to our

neighbors and

our communities

and rebuilding

community life

after COVID

because otherwise,

regardless of

MAID, we are

going to have an

increasing mental

health crisis for

our young people.

Those are the

three things I

think we need

to change.

I think we're

going to end it

there and with

that message

that community

is so strong

and it

permeates so

many elements

of suffering,

it permeates

elements of

caregiver burnout,

it permeates

medical training,

all of these

things, a sense

of community

and belonging,

contributing and

receiving contributions

from your

community

partners, if you

will.

bring so much

to the human

experience and

I just want

to take the

time to thank

you for

speaking to us

today, coming

from your

recent travels

and with your

busy schedule

and I think

what we've

created today

is just an

ability to just

put it on the

table and talk

about it and I

really appreciate

just being able

to talk and

listen and hear

what you have

to say and I

invite everyone

to do the same.

Thank you, Mark.

And thank you

for having me

as a guest and

what I know

can be a very

polarizing topic

and just to

reiterate that I

think a lot of

people who do

may do it

well and it's

not meant to be

about a personal

attack but it's

about how we can

protect vulnerable

people in our

society.

That wraps up

this week's

episode of the

Caregivers Podcast.

See you again

next week.

I'm your host

Dr.

Mark.

Dr.

Coelho, thank

you for joining

us today.

This is one of

the most difficult

and divisive

conversations in

Canadian public

life today.

We appreciate

your willingness

to bring both

clinical experience

and moral

clarity to it.

Whatever people

think about

MAID, this

discussion forces

a deeper question

that no country

should be able

to avoid.

When someone's

suffering, are

we meeting that

suffering with

care, protection

and support?

Are we allowing

some lives to

become easier

to end than

to help?

Before we wrap

up, I wanted to

remind you of

something important.

The conversations

you hear on this

podcast are here

to inform, to

support, to

spark reflection.

We're not a

substitute for

professional medical

advice, care,

therapy or crisis

services.

Listening to this

podcast does not

create a doctor

patient or caregiver

client relationship

between us.

If you're facing

a medical concern,

health challenge,

a mental health

challenge or a

caregiving situation

that needs guidance,

I encourage you to

reach out to a

qualified professional

who knows your

story.

If you're ever in

crisis, please

don't wait.

Call your local

emergency number or

recognize crisis

hotline right away.

You deserve real

time help and

support.

The views you hear

on this show,

whether from me or

my guests, are our

own.

They don't necessarily

reflect any

organizations we

work with, are

part of, or have

worked with or been

part of in the past.

This podcast is an

independent production

and it's not tied to

any hospital, university

or healthcare system.

Thank you for being

here, for listening,

and most of all for

taking the time to

care for yourself

while you continue to

care for others.

I look forward to

hearing from you.