Canadian doctors who provide euthanasia struggle with the ethics of killing vulnerable patients

TORONTO (AP) — A homeless man refusing long-term care, a woman with severe obesity, an injured worker given meager government assistance, and grieving new widows. All of them requested to be killed under Canada’s euthanasia system, and each sparked private debate among doctors and nurses struggling with the ethics of one of the world’s most permissive laws on the practice, according to an Associated Press investigation.

As Canada pushes to expand euthanasia and more countries move to legalize it, health care workers here are grappling with requests from people whose pain might be alleviated by money, adequate housing or social connections. And internal data obtained exclusively by AP from Canada’s most populous province suggest a significant number of people euthanized when they are in unmanageable pain but not about to die live in Ontario's poorest and most deprived areas.

Some doctors fear moving forward even with cases that meet Canada’s legal requirements, which allow euthanasia for people with “irremediable suffering” from serious but nonfatal medical conditions and disabilities. On private forums, doctors and nurses have expressed deep discomfort with ending the lives of vulnerable people whose deaths were avoidable, according to messages provided to AP by a participant on condition of anonymity due to their confidentiality.

Some of the requests from the forums were approved and acted upon. Others were denied. But the discourse about patients who are poor, disabled or lonely shows a fraught process where medical professionals test the limits of what conditions warrant euthanasia. The controversial cases in the forums have never been disclosed through Canada’s oversight system, even in an anonymized manner.

When Canada legalized assisted dying in 2016, officials said they wanted to reduce suffering and support individual autonomy and freedom of choice — and polls have consistently shown public approval. Prime Minister Justin Trudeau promised then that safeguards would prevent vulnerable people from being euthanized “because you’re not getting the support and care you actually need.”

But experts tasked with delivering euthanasia to people who aren't dying have called it “morally distressing” and say the legal provisions are too vague to be protective, obliging doctors and nurses to at times end the lives of people they believe might otherwise be saved.

“I don’t want (euthanasia) to become the solution to every kind of suffering out there,” a physician wrote to colleagues on one of the private forums.

Canada has the world’s fastest-growing program for euthanasia, the practice of doctors and nurse practitioners killing patients with an injection of drugs at their request. Medically assisted suicide — patients themselves taking prescribed, lethal medication — also is legal.

But virtually all of Canada’s MAiD cases — as it’s widely known here, for medical assistance in dying – are euthanasia, with a doctor or nurse practitioner giving the fatal injection.

Unlike many other countries, Canada doesn't require that patients exhaust all medical treatments before seeking death.

After legalizing euthanasia in 2016, Canada broadened its law in 2021 to allow people with incurable, but not terminal, conditions – including disability alone – to seek a way to die. This vastly expanded the number of people eligible, and medical groups in some territories and provinces require doctors to inform, offer or help provide euthanasia to any patients who might qualify.

Adults with serious, incurable conditions must have a written request approved by two independent doctors or nurse practitioners. Those with nonterminal cases must be informed of other ways to relieve their suffering, among other requirements, and there’s a minimum 90-day assessment period.

As the eligibility pool has grown, so has criticism among academics, disability advocacy groups and religious communities.

Doctors and nurses “do not treat MAiD as an option of last resort,” said an August report published by the Christian think tank Cardus.

The nonprofit organization Inclusion Canada regularly hears from people with disabilities who are offered euthanasia, including one disabled woman whose physiotherapist suggested it when she sought help for a bruised hip, said executive vice president Krista Carr.

“Our response to the intolerable suffering of people with disabilities is: 'Your life is not worth living,’” she said. “We'll just offer them the lethal injection, and we'll offer it readily.”

When euthanasia was legalized, doctors and nurse practitioners set up email discussion groups as confidential forums to discuss potentially troubling cases, with limited patient details for privacy. They're now run by the Canadian Association of MAiD Assessors and Providers.

Association President Dr. Konia Trouton told AP via email that providing euthanasia for vulnerability or financial reasons alone is “completely forbidden." Trouton said doctors and nurse practitioners consult with one another on the forums “to gain insights and learn from the experiences of others.”

The participant who shared some of the email discussions with AP provided dozens of messages raising questions about the medical and ethical complexities of euthanasia requests from people nationwide who weren't terminally ill.

A middle-aged worker whose ankle and back injuries made him unable to resume his previous job told his doctor that the government’s measly support was “leaving (him) with no choice but to pursue MAiD.” His doctor told forum participants the patient met legal criteria, with severe pain, strained social relationships and inability to work. Others agreed and assured the doctor the man was clearly in pain. But the doctor was hesitant because the man cited reduced government payments as a key factor.

Cases of homelessness appear regularly and spark some of the most heated debate.

One doctor wrote that although his patient had a serious lung disease, his suffering was “mostly because he is homeless, in debt and cannot tolerate the idea of (long-term care) of any kind.” A respondent questioned whether the fear of living in the nursing home was truly intolerable. Another said the prospect of “looking at the wall or ceiling waiting to be fed … to have diapers changed” was sufficiently painful.

The man was eventually euthanized.

One provider said any suggestion they should provide patients with better housing options before offering euthanasia “seems simply unrealistic and hence, cruel,” amid a national housing crisis.

Physicians said keeping their opinions out of assessments was difficult — and painful, given patients' emotions and desperation.

Experts not linked to the forums said that while doctors and nurses need private space for discussion, the lack of transparency about controversial cases is alarming.

“The question about who gets euthanasia is a societal question,” said Kasper Raus, a researcher at Ghent University’s Bioethics Institute in Belgium. “This is a procedure that ends people’s lives, so we need to be closely monitoring any changes in who is getting it.

“If not, the entire practice could change and veer away from the reasons that we legalized euthanasia.”

Critics have long warned that Canada’s policies have led to euthanasia among disadvantaged people whose deaths weren't imminent. Despite publicized cases of people asking to be killed because of insufficient support, government officials have largely refuted the idea that socially disadvantaged people are being euthanized.

But in Ontario, more than three quarters of people euthanized when their death wasn't imminent required disability support before their death in 2023, according to data from a slideshow presentation by the province’s chief coroner, shared with AP by both a researcher and a doctor on condition of anonymity due to its sensitive nature.

Of people killed when they weren’t terminally ill, nearly 29% lived in the poorest parts of Ontario, compared with 20% of the province's general population living in the most deprived communities, the data show.

People euthanized with nonterminal conditions were “more likely to live in neighborhoods where there’s higher levels of residential instability, higher material deprivation and greater dependency on government support,” Ontario Chief Coroner Dr. Dirk Huyer said during his May presentation.

The figures suggest poverty may be a factor in Canada’s nonterminal euthanasia cases.

But Huyer told AP that the data was only an early analysis and “it’s tough to know exactly what it means,” saying that his job was only to present the statistics.

Poverty doesn't appear to disproportionately affect patients with terminal diseases who are euthanized, according to the leaked data. And experts say no other country that has legalized euthanasia has seen a marked number of deaths in impoverished people.

Overall for Ontario, the data show, nonterminal patients account for a small portion of all euthanasia cases: 116 of 4,528 deaths last year. But the presentation and discussion among Ontario officials and medical professionals show rising awareness of euthanasia deaths for social reasons.

Health Canada, the government agency responsible for national health policy, publishes yearly reports of euthanasia trends but hasn’t released any review of cases that triggered ethical concerns.

Marie-Pier Burelle, a spokeswoman for Health Canada, said in an email that “lack of access to social supports or to health services is not and would never be part of eligibility criteria” for euthanasia. Burelle cited “stringent safeguards to affirm and protect the inherent and equal value of every person’s life.”

In private, though, Canadian officials have examined worrisome cases.

A document from the Ministry of the Solicitor General in Ontario sent to all euthanasia providers in the province in May noted two cases of “lessons learned” in nonterminal cases. The document was shared with AP by a doctor on condition of anonymity because it wasn’t authorized for release.

In one, a 74-year-old patient who’d suffered high blood pressure, a stroke and blindness, among other difficulties, was increasingly dependent on their spouse and “expressed their interest in MAiD to their family physician, due to their vision impairment and loss of hope for improvement of their vision and quality of life.”

The report cited three instances where legally mandated safeguards were not met. Among them: No assessor or expert versed in the nonterminal condition was involved, and efforts to discuss alternatives to death were “limited.”

The report also said the procedure was scheduled “based on the spouse’s preference of timing." Officials questioned whether “the patient’s death was genuinely voluntary and free of coercion." Independent legal experts said those breaches could constitute violations of criminal law.

Polls show that expanding access to euthanasia has long been supported across Canada. But the country appears to be pushing the boundaries of what’s socially acceptable, experts say, and that could have global implications, as countries including Britain and France move towards legalization.

“Canada seems to be providing euthanasia for social reasons, when people don't have the financial means, which would be a big taboo in Europe,” said Theo Boer, professor of health care ethics at Groningen University in the Netherlands. “That may be what Canadians want, but they would still benefit from some honest self-reflection about what is going on.”

Some of that reflection is happening in the confidential providers’ forums.

They’ve debated whether it’s valid to euthanize people for obesity in several cases. One woman with severe obesity described herself as a “useless body taking up space” — she'd lost interest in activities, became socially withdrawn and said she had “no purpose,” according to the doctor who reviewed her case. Another physician reasoned that euthanasia was warranted because obesity is “a medical condition which is indeed grievous and irremediable.”

When a health worker inquired whether anyone had euthanized patients for blindness, one provider reported four such cases. In one, they said, an elderly man who saw “only shadows” was his wife’s caregiver when he requested euthanasia; he wanted her to die with him. The couple had several appointments with an assessor before the wife “finally agreed” to be killed, the provider said. She died unexpectedly just days before the scheduled euthanasia.

Providers on the forum were divided over ending the lives of people in mourning. One case involved a woman in her 80s who required dialysis and lost her husband, sibling and cat in a six-week period. Her assessor said her suffering and request to die were tied to her husband’s death rather than any medical conditions.

Some doctors said because she lost her husband — the protective factor that would make the other losses and suffering bearable — she qualified. Others recommended grief counseling instead.

A provider referenced a similar case, in which a widow requested euthanasia within weeks of her husband’s death: “Her whole life system crashed. I felt much ease in providing for her and had no pushback from the coroner.”

Dr. Ellen Wiebe, who has euthanized more than 400 people in Canada, told AP that while poverty inevitably exacerbates suffering, improved housing and social situations have never changed a patient’s mind.

“The idea that because I’m disabled, I should lose my rights that undisabled people have is outrageous,” said Wiebe, who suffers from heart disease and uses a wheelchair.

She predicted legal consequences if officials introduce more safeguards for euthanasia: “We’ll just be back in court with somebody saying, ‘You interfered with my basic human rights.’”

The government already faces challenges to its euthanasia laws on all sides. The advocacy group Dying with Dignity filed an August lawsuit in Ontario, alleging it's “discriminatory” to exclude mentally ill people from euthanasia. A coalition of disability-rights organizations in a lawsuit last month argued that euthanasia legislation has resulted in premature deaths of people with disabilities.

On euthanasia forums, doctors and nurses continue to struggle with cases of patients who aren’t fatally ill, lamenting that Canada’s health and social services can seem woefully inadequate.

“I have great discomfort with the idea of MAiD being driven by social circumstances,” one provider said. “I don’t have a good solution to social deprivation either, so I feel pretty useless when I receive requests like this.”

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. This story also was supported by funding from a Pulitzer Traveling Fellowship grant. The AP is solely responsible for all content.

The CN Tower is seen from Trinity Bellwoods Park in Toronto on Wednesday, Sept. 18, 2024. (AP Photo/Angie Wang)

The Office of the Chief Coroner: Ontario is seen in Toronto on Thursday, Sept. 19, 2024. (AP Photo/Angie Wang)

The Toronto skyline is seen from Wards Island in Toronto on Thursday, Sept. 19, 2024. (AP Photo/Angie Wang)

The Canadian flag is blown by wind on Centre Island in Toronto on Thursday, Sept. 19, 2024. (AP Photo/Angie Wang)

The Toronto skyline is seen from Wards Island in Toronto on Thursday, Sept. 19, 2024. (AP Photo/Angie Wang)

GRAND RAPIDS, Mich. (AP) — Vice President Kamala Harris rallies in Michigan’s union halls, standing alongside the state’s most powerful labor leader, while former President Donald Trump fires back from rural steel factories, urging middle-class workers to trust him as the true champion of their interests.

As they compete for blue wall states with deep union roots, the presidential candidates are making their case to workers in starkly different terms. And nowhere is that contrast more significant than in Michigan, where both candidates are vying for workers’ support in a race that could mark a pivotal moment for organized labor.

“The American dream was really born here in Michigan,” United Auto Workers President Shawn Fain told a crowd of several hundred while campaigning for Harris in Grand Rapids. Fain, who described Michigan as “sacred ground” for his union at the early October rally, warned that the dream was on “life support" and that unions like his were key to protecting it for American workers.

Harris, who is planning to meet with union workers again in Michigan on Friday, hopes her message — amplified by supporters such as Fain — will resonate beyond the union families that once formed a rock-solid base for the Democratic Party. Her campaign has grown increasingly concerned about her standing with men in the blue wall states of Michigan, Wisconsin and Pennsylvania, where they are looking to union leaders to help mobilize voters in a political landscape that has shifted in the winds of a rapidly changing economy.

These concerns intensified recently when Harris failed to secure two key union endorsements that in 2020 went to President Joe Biden, who has touted himself as the most labor-friendly president in U.S. history. The International Association of Firefighters and the International Brotherhood of Teamsters both declined to endorse anyone, with the Teamsters citing a lack of majority support for Harris among their million-plus members.

The Teamsters have traditionally been less reliably Democratic than other unions, having endorsed Republican Presidents Richard Nixon and Ronald Reagan in the past. Some state-level unions have also diverged from their national leadership, with Michigan’s Teamsters and California’s main firefighters’ union backing Harris.

Still, any break in unity within the labor movement could strike a blow against a party that has worked hard to restore unions as a central source of its power at the ballot box.

“When you talk about unions, you’re addressing more than just unionized workers. Most people in states like Michigan have a family member or close friend in a union,” said Adrian Hemond, a longtime political strategist in Michigan. “Unions are just a vessel to get that messaging out to workers.”

Trump has seized on the union non-endorsements, claiming they prove rank-and-file workers support his vision for the country.

Many Midwestern communities once core to the labor movement have shifted to the right in recent decades, often in response to economic concerns such as deindustrialization and the removal of trade barriers. In that same span, non-college-educated white voters across the country began voting more conservatively for a number of reasons, including concern about cultural issues involving race and gender.

In Michigan, home to the Big Three automakers and the largest concentration of UAW workers, Trump seeks to capture an even larger share of these votes by framing Harris as a supporter of electric vehicle mandates and trade policies that he says send jobs overseas.

Attempting to separate union workers from their leaders, he labeled Fain a “stupid idiot" and praised Tesla CEO Elon Musk for firing workers who went on strike. The UAW says that could intimidate people who work for the Trump campaign or at Tesla who might want to join a union.

In 2020, Biden narrowly carried the blue wall states that had broken with Democrats in 2016 for the first time in decades on his way to winning the White House. That election win was built on a foundation of strong support from unionized voters, who have traditionally formed a turnout machine for Democrats in the Midwest. But it stood apart from past Democratic victories in a number of significant ways.

While Trump narrowly won white voters in Michigan in 2020, the former president’s vote margin was highly polarized along educational, professional and income lines; Trump won nearly two-thirds of non-college-educated white voters in the state, while Biden and Trump were drawn to a near tie among college-educated white voters, according to AP VoteCast, a comprehensive survey of the electorate.

Among Michigan’s nonwhite voters, who make up 16% of the state’s electorate, Biden won a resounding 80% of the vote. But signs of that coalition fracturing have emerged more recently, particularly among Arab Americans in metro Detroit, many of whom are expected to turn away from Democrats due to the Biden administration’s handling of the Israel-Hamas conflict.

As Trump again seeks the presidency, his campaign hopes to boost GOP support among the state’s non-college-educated white and nonwhite workers to unprecedented levels, partly to offset expected losses Trump will face with white college-educated voters, where he has hemorrhaged support since his 2020 loss and subsequent efforts to overturn the results in Michigan, Pennsylvania and other swing states.

“I think that part of the problem that Democrats are having with some of the white male, blue collar voters is not within the union itself,” said Brian Rothenberg, a former UAW spokesman. “It’s those folks that are children or relatives of union members that just aren’t doing as well."

Harris has aimed to win over these voters by emphasizing how unions benefit all workers. At a Labor Day rally in Detroit, she said “you better thank a union member” for the five-day work week, for sick and paid leave and for vacation time.

“When union wages go up, everybody’s wages go up,” said Harris.

Just over a year after securing new contracts for UAW workers at Ford, General Motors and Stellantis, Fain has staked much of his political capital — and potentially his future — on supporting Harris. He argues that UAW backing for Democrats has remained steady over recent elections, with approximately 60% of members voting for the Democratic presidential nominee.

Biden became the first president to walk the picket line when he visited Michigan in late 2023 amidst the autoworker strike. A day later, Trump traveled to Michigan and appeared at a non-union plant, where he railed against Biden's electric vehicle push and told workers to “get your union leaders to endorse me, and I’ll take care of the rest.”

Union leaders have said his first term was far from worker-friendly, citing unfavorable rulings from the nation’s top labor board and the U.S. Supreme Court, as well as unfulfilled promises of automotive jobs. They emphasize Democratic achievements in states like Michigan, including the recent repeal of a union-restricting right-to-work law enacted over a decade ago by a Republican-controlled legislature.

With membership dwindling in states like Michigan, Fain will need to attract more than just union workers to secure a victory for Harris, who has campaigned in the state alongside him. If the union president cannot deliver Michigan after all these efforts, it could raise questions about his union's political influence in future elections.

“This is a generation-defining moment, where we are right now,” Fain told Michigan voters. “This election is going to determine where we go.”

Cappelletti reported from Lansing, Michigan. Associated Press writer Tom Krisher in Detroit contributed to this report.

FILE - Republican presidential nominee former President Donald Trump attends a campaign event, Sept. 27, 2024 in Walker, Mich. (AP Photo/Carlos Osorio, File)

FILE - People arrive before Republican presidential nominee former President Donald Trump speaks at a campaign event, Sept. 27, 2024 in Walker, Mich. (AP Photo/Carlos Osorio, File)

FILE - United Auto Workers President Shawn Fain speaks at a campaign rally for Democratic presidential nominee Vice President Kamala Harris at the Dort Financial Center in Flint, Mich., Oct. 4, 2024. (AP Photo/Carolyn Kaster, File)

FILE - Republican presidential nominee former President Donald Trump arrives at a town hall campaign event at Macomb Community College, Sept. 27, 2024, in Warren, Mich. (AP Photo/Alex Brandon, File)

FILE - Democratic presidential nominee Vice President Kamala Harris, with Democratic vice presidential nominee Minnesota Gov. Tim Walz, left, and UAW President Shawn Fain, speaks at a campaign rally at UAW Local 900, Aug. 8, 2024, in Wayne, Mich. (AP Photo/Julia Nikhinson, File)