Canada's Summer of Discontent
Euthanasia practitioners warn of nationwide "crisis"
Shortage of euthanasia practitioners "a real problem"
13 October, 2017
There were 803 euthanasia/assisted suicide (EAS) deaths
in Canada during the first six months after the procedures
were legalized. In the second half of the first year (ending
in June, 2017) there were 1,1791
— a 46.8% increase. EAS deaths amounted to about 0.9% of all deaths
in the first year. Health
Canada correctly states that this falls within
the range found in other jurisdictions where
euthanasia/assisted suicide are legal,2
but the Canadian EAS death rate in the first year was not
reached by Belgium for seven to eight years.3
The dramatic increase of EAS deaths in the last half of the
first year would have had a direct impact on EAS
practitioners, and this may be why, in July, they sounded the alarm about access to the service.
Physicians refusing euthanasia: a nationwide "crisis"
"Recent changes to the MSP Physician Fee Schedule have
made MAID economically untenable and I unfortunately can no
longer justify including it in my practice."4
Dr. Jesse Pewarchuk of Victoria, British Columbia, had
provided euthanasia or assisted suicide for more than 20
patients.5 However, in July, 2017, having concluded there
was "no conceivable way" that providing euthanasia or
assisted suicide ("MAID") made "economic sense" for any
physician, he made public a letter announcing that he would
no longer provide the services. He explained that the fee
cap set by the province for the procedures ($200.00) worked
out to about $25.00 per hour after overhead, and
practitioners were not paid for time and travel involved in
service delivery. Dr. Pewarchuk complained that fees
approved for some physician specialties provided "7 figure
annual incomes," but funding for euthanasia/assisted suicide
was "grossly inadequate."4
Billing issues and euthanasia/assisted suicide advocacy
had been among the topics discussed at a conference held the
previous month in Victoria by the Canadian Association of
MAID Assessors and Providers (CAMAP). Dr. Pewarchuk and
other conference participants — Shanaaz Gokool, Dr. Stefanie
Green, and Dr. Chantal Perrot6 — featured in several
Canadian media articles that appeared in early July. Their
common theme was that patient access to euthanasia and
assisted suicide was in danger because inadequate
compensation and burdensome bureaucracy were discouraging
physicians from providing the services.
"It's a real problem, the shortage in the number of
physicians," said, Shanaaz Gokool, CEO of Dying With Dignity
Canada (DWD).7 Dr. James Downar, a member of DWD’s Physician
Advisory Council,8 had complained four months earlier that
the "scarcity of doctors" providing euthanasia/assisted
suicide was "putting serious pressure" on the few who were.9
According to Dr. Green, president of CAMAP, by July the
situation had become "a crisis."5
Attempts to compel unwilling practitioners and
institutions to provide or facilitate euthanasia and
assisted suicide are frequently based on the claim that
compulsion is necessary to ensure patient access to the
procedures, even at the expense of fundamental freedoms.
Allegations of a nationwide "crisis" caused by a shortage of
euthanasia/assisted suicide (EAS) practitioners thus warrant
Providing euthanasia/assisted suicide can be "financial
Dr. Green, an EAS practitioner in British Columbia,
agreed that the province’s fee schedule was unsatisfactory,
even, perhaps, a "planned disincentive" to discourage
practitioners from providing the service. Noting that fees
in some other provinces were based on time actually spent in
consultation and delivery, she insisted EAS practitioners
were looking only for "reasonable compensation" based upon
"what the work actually entails."10 She had restricted her
travelling to deliver the service.11
Rates for euthanasia/assisted suicide in British Columbia
had risen to $40.00 per 15 minutes consultation to a maximum
of 90 minutes, plus $200.00 for administering the drugs: an
overall maximum of $440.00. However, EAS practitioners still
considered this to be "woefully inadequate." Dr. Tanja Daws
a self-described "hard core" euthanasia/assisted suicide
advocate, reported that she had refused three requests
because continuing to provide the service was "financial
Euthanasia/assisted suicide fees in Canada were said to
compare unfavourably with those offered in the Netherlands,
which are about five times higher: 1,500.00 euros per case
($2,200.00 Canadian dollars).11 Compensation arrangements for
Canadian physicians vary from province to province, and
euthanasia/assisted suicide fees were still being worked out
in Canada in the summer of 2017. Fees in Alberta,
Saskatchewan and Manitoba were said to be satisfactory,11 but,
in Nova Scotia, Dr. Tim Holland said he had not yet been
paid for services provided over the preceding year, and that
the significant delay in payment was discouraging physician
participation.12 EAS practitioner fees there were capped at
Ontario physician Dr. James Downar observed that
fees there were low and that "a physician could make more
money doing almost anything else," but he conceded that,
though the situation was not "ideal", it was not
"problematic." However, he argued that EAS practitioners
should not have to take a "financial hit" in addition to
suffering from the stigma still associated with providing
Other "barriers" to physician participation
Dr. Downar was more concerned about barriers to physician
participation caused by "administrative duties" ancillary to
providing euthanasia or assisted suicide. Arranging for a
patient to see specialists like psychiatrists or social
workers and obtaining and returning supplies needed for
lethal infusion could be "quite the deterrent," he
explained, noting that these responsibilities often have to
be fulfilled in addition to full-time practice.13 According to
Downar, many EAS practitioners were refusing to sign up for
the coordination service launched by Ontario at the end of
May, 2017 because, unlike Alberta’s system, it did not
provide EAS practitioners with administrative support.
Ontario physician Dr. Chantal Perrot dismissed the new
scheme as a mere "matchmaking service" that connected
patients with practitioners but did nothing to help the
Another Ontario EAS practitioner, Dr. Scott Anderson,
identified the legal criterion that death be "reasonably
foreseeable" as a problematic barrier.14 Downar, with Dr.
Jonathan Reggler of British Columbia, had previously
criticized the criterion, as well as the legal requirement
that euthanasia/assisted suicide be provided only to
patients who have a "grievous and irremediable" medical
condition. They said the terminology was uncomfortably vague
and unfamiliar to physicians, causing them to "pull back"
from providing the service. Downar, referring to Quebec’s
euthanasia oversight panel, seemed particularly annoyed that
people who had never performed euthanasia and were mainly
non-physicians were second-guessing the professional
judgment of euthanasia practitioners.9
Other time-consuming or taxing barriers or disincentives
identified by Canadian EAS practitioners included meeting
with patients (perhaps more than once), reviewing their
often "lengthy and complicated" medical histories,
counselling family members (especially those opposed to or
doubtful the procedures),11 finding two independent witnesses
to verify the voluntariness of a patient’s request,14 and
"paperwork and bureaucracy involved,"9 such as having to
complete forms and fax reports to the coroner.4,14 Dr. Anderson
noted the inconvenience of having to respond to "urgent"
calls for euthanasia or assisted suicide in the evenings and
on weekends, adding that he had once even had to see a
patient in "a filthy apartment filled with cat feces.14
The most striking assertion was that physicians and
hospitals refusing to kill patients for moral or religious
reasons were creating a barrier for patients wanting the
service.15 Against the backdrop of withdrawal or restriction
of services by EAS practitioners, this implies that refusing
to kill patients for financial reasons is acceptable, but
refusing to kill patients for reasons of conscience or
religion is not. Whether this accurately reflects Canadian
values remains to be seen.
Preliminaries to "crisis" intervention
Coercion is legally and pragmatically problematic
In any case, it is unlikely that lightening the caseloads
of euthanasia practitioners by forcing unwilling physicians
to participate in killing patients could be legally
justified. The Charter of Rights guarantees freedom of
conscience and religion, not easily manageable euthanasia
Nor is it likely that coercive policies would actually
increase patient access to the procedures. In 2008, American
bioethicist Holly Fernandez Lynch considered the case of
conscientious refusal by "the last doctor in town." She
concluded that coercion would be ineffective in securing
patient access to services. Objecting physicians would
probably face discipline rather than do what they believe to
be wrong, she said, leaving patients "in precisely the same
situation that they would have been had that doctor
originally been permitted to refuse." She warned that a
policy of coercion would cause objectors to relocate, change
specialties or quit medical practice, making it more
difficult for all patients to obtain even "morally
Events in Canada have since demonstrated that Fernandez
Lynch's pragmatic assessment is sound. Objecting physicians,
threatened with discipline by the College of Physicians and
Surgeons of Ontario (CPSO) if they refuse to do what they
believe to be wrong, have responded as she predicted. Some
have announced retirement from medicine.17 Some may leave
specialties where they are badly needed;18 in one city, every
palliative care physician has reportedly stopped accepting
The Protection of Conscience Project believes that, with
some good will and imagination, Canadian authorities can
address concerns about patient access to euthanasia and
assisted suicide without suppressing fundamental freedoms
and punishing those who refuse to have any part in the
procedures. Canadian EAS practitioners argue that more
physicians will participate if incentives are provided and
disincentives are reduced or eliminated. The two positions
are not in conflict. To begin with, however, it is important
to avoid unrealistic expectations about levels of physician
Avoiding unrealistic expectations
Even where euthanasia or assisted suicide has been legal
for years, only a minority of physicians — sometimes a small
minority — personally provides the service. In Belgium, the
nearest jurisdictional exemplar, the proportion of
physicians practising euthanasia in the first year was only
about 1%; for the next three years only about 2% of
physicians were involved. 13 years after legalization less
than 14% of Belgian physicians were providing the service.3
The Netherlands began with much higher rates once
euthanasia was formally legalized, but twelve years later
the proportion of all physicians providing euthanasia was
still less than 10%.20 Less than 1% of all physicians
prescribe assisted suicide drugs in Oregon21 and Washington
state,22 though assisted suicide has been legal in those
jurisdictions for nine and almost 20 years respectively.
These are maximum estimates; actual numbers could be much
lower, because one practitioner may be responsible for a
number of cases.23 Yet, as Dr. Jeff Blackmer of the Canadian
Medical Association told parliamentarians, access to
euthanasia/assisted suicide is not a problem in any of these
Four or five euthanasia cases per year is apparently
considered a responsible maximum for a euthanasia
practitioner in the Netherlands.25 Applying the Netherlands
rule of thumb, the 551 Ontario patients who died by
euthanasia or assisted suicide in the first year of practice26
could have been adequately serviced by roughly 110 to 137
practitioners willing to personally administer the lethal
drugs — or about 0.4% of active Ontario physicians.27
Unsystematic news reports suggest that the number of Ontario
physicians willing to personally administer lethal drugs
fluctuated between 74 and 106 in 2017,28 — about 0.3% of all
The difference between 0.4% (with an
annual caseload of about four patients) and 0.3% (with an
annual caseload of about six) is insignificant. If we
suppose that the EAS death rate in Ontario in the second
half of the first year of legalization continues, without
escalation, there will be 724 EAS deaths in the second year.
These could be provided by 145 EAS practitioners with 5 cases
each — about 0.5% of active physicians.
Finally, three Ontario practitioners were responsible
for almost 13%29 of the euthanasia/assisted suicide deaths
reported to have occurred in the province,26
that the demand for the service province wide could have
been met by about 23 physicians working at the same rate. Of
course, that does not mean that an annual euthanasia
caseload of almost 24 patients per practitioner would have
been desirable, or that the travel involved would have been
practicable. It only confirms what the preceding
calculations demonstrate: that panic about the rate of
physician non-participation in euthanasia/assisted suicide
in Ontario was quite unwarranted.
Nor was panic justified in British Columbia, especially
on Vancouver Island, notwithstanding Dr. Pewarchuk’s concern
that the pay was so bad that euthanasia/assisted suicide
might become completely unavailable.4 Between March and the
end of June, 2017, when he announced his withdrawal of
services, the number of Vancouver Island EAS practitioners
had actually increased from 14 to 21:30 to about 1% of Island
physicians,31 the same proportion as in Belgium during its
first year of legalization.
Moreover, it was reported that Vancouver Island had one
of the highest euthanasia/assisted suicide rates in Canada:
77 in 2016.30 Yet over half of these appear to have been
provided by just two physicians: Dr. Pewarchuk (more than
20)5 and Dr. Daws (25).30 Even if the number of Vancouver
Island euthanasia deaths increases to 100 in 2017 and the
number of EAS practitioners remains constant, the average
individual caseload of 21 practitioners will not exceed the
number recommended as a rule of thumb in the Netherlands.
None of the jurisdictions where euthanasia or assisted
suicide is legal provide adequate statistics about actual
physician participation. Given the controversy about
"access" to the services in Canada — inflamed by unrealistic
expectations and unwarranted allegations of a "crisis" — one
would hope that Canadian authorities will do better than
their counterparts in other jurisdictions in tracking actual
rates of practitioner participation. The Project has
encouraged provincial and federal Ministers of Health to
demonstrate leadership in this regard.32
Interim Report on Medical Assistance in Dying in Canada. Ottawa:
Health Canada, October, 2017: p 5. Accessed 2017-10-09 [Health Canada
2. Health Canada Rpt 2, supra
note 1, p. 8.
3. Murphy S.
Euthanasia reported in Belgium: statistics
compiled from the Commission Fédérale de Contrôle et d' Évaluation de
l'Euthanasie Bi-annual Reports. Protection of Conscience Project.
Letter from Jesse A Pewarchuk, MD, FRCPC [Undated] "Dear referring
physician." Accessed 2017-09-12.
5. Grant K.
Canadian doctors turn away from assisted dying over fees. The
Globe and Mail. 3 July, 2017. Accessed 2017-09-12 [Grant, 3 July].
6. Canadian Association of MAID Assessors
and Providers. National Conference on Medical Assistance in Dying Program. 2-3
June, 2017. Accessed 2017-10-08.
7. Grant K.
Ontario clinicians raise concerns over assisted-dying co-ordination
service. The Globe and Mail. 5 July 2017. Accessed
2017-10-03 [Grant-5 July].
8. Dying With Dignity Canada,
Physician Advisory Council, (Accessed 2017-10-09).
9. Kirkey S.
"Take my name
off the list, I can't do any more": Some doctors backing out of assisted
death. National Post. 26 February, 2017. Accessed
10. Larsen K.
Low fees have B.C. doctors thinking twice about providing assisted
dying. CBC News. 4 July, 2017. Accessed 2017-09-12.
11. McIntyre C.
Should doctors be paid a premium for assisting deaths? Macleans. 12 July, 2017. Accessed 2017-09-12.
12. Davie E.
Doctors raise alarm about long delays in getting paid for medically
assisted deaths. CBC News. 4 July, 2017. Accessed
13. Dunn T.
Why don't more Ontario doctors provide medically assisted dying? It's
not the money. CBC News. 10 July, 2017. Accessed
14. Lupton A.
1 of only 2 London doctors willing to help their patients die.
CBC News. 4 July, 2017. Accessed 2017-09-14 [Lupton].
15. Whether the claim was made by the CBC
or by Dr. Scott Anderson is not clear. The article appears to attribute
it to Dr. Anderson, but it may have been interpolated it into the
account of the interview by the writer. See Lupton, supra note
16. Fernandez-Lynch H. Conflicts of
Conscience in Health Care: An Institutional Compromise. Cambridge,
Mass.: The MIT Press, 2008: p. 206.
17. Naylor NL.
Response to Dr. Genuis Article, April 2016 (eLetter). Can Family Physician
April 2016 62:4. Accessed 2016-09-22.
18. "Scarborough's palliative care system
is grossly under serviced," wrote Dr. Mark D’Souza, but "half of our
group is considering leaving the field" because of the coercive policy
of the College of Physicians and Surgeons of Ontario. See D’Souza M.
Fatal flaw in Ontario euthanasia bill. Toronto Sun. 7 April, 2017. Accessed 2017-10-04.
19. Swan M.
Health care workers bring case for conscience rights to Ontario
legislature. The Catholic Register. 18 May, 2017. Accessed 2017-10-05.
20. Murphy S.
Euthanasia reported in Netherlands: statistics
compiled from the Regional Euthanasia Review Committees' Annual Reports. Protection of Conscience Project.
21. Murphy S.
Assisted suicide reported in Oregon, U.S.A.:
statistics compiled from the Oregon Public Health Division annual Death
with Dignity Act reports. Protection of Conscience Project. August, 2017.
22. Murphy S.
Assisted suicide reported in Washington
State, U.S.A.: statistics compiled from the Washington State Dept. of
Health annual Death with Dignity Act reports. Protection of
Conscience Project. August, 2017.
23. For example, by August, 2017, Dr. Lonny
Shavelson of California was responsible for the deaths of 48 patients
pursuant to the state’s assisted suicide statute. See Nutik Zitter J.
Should I Help My Patients Die? The New York Times. 5
August, 2017. Accessed 2017-08-23.
24. Canadian Medical Association.
Oral submission to the Special
Joint Committee on Physician Assisted Dying, Parliament of Canada. 27
January, 2016. Protection of Conscience Project.
25. Hune-Brown N.
How to End a Life. Toronto Life. 23 May, 2017. Accessed
26. First and second half year totals
=189+362=551. See Health Canada,
Interim update on medical assistance in dying in Canada June 17 to
December 31, 2016. Ottawa: Health Canada, 2017: Table 3.2: Profile of Medical Assistance in
Dying by Jurisdiction/Region. Accessed 2017-10-09; Health Canada
Rpt 2, supra
note 1, p. 13.
27. There were about 29,500 MDs in active
practice in the province. See College of Physicians and Surgeons of
2016 Annual Report.
p. 7. Accessed 2017-10-03.
28. Number reported to be willing to
personally provide euthanasia in 2017 ranged from a high of 146 in May
(see Grant-5 July,
supra note 7) to a low of 74 in July (see Lupton, supra note
29. Dr. Scott Anderson of London – 40 (see Lupton, supra note
14 ); Dr. Gerald Ashe of Brockville – 10 by May, 2017
(See Hune-Brown, supra note 25 ); Dr. Chantal Perrot of Toronto – 20
(See Grant-5 July, supra note 7).
30. Derosa K.
Island MD, citing low fee, halts assisted dying. Victoria
Times Colonist. 6 July, 2017. Accessed 2017-08-10.
31. Based on 2015 census information
compiled by the Canadian Medical Association. See Canadian Medical
Number of physicians by census metropolitan area or census
agglomeration: Canada, 2015. Accessed 2017-10-09.
Sean Murphy, Administrator, Protection of Conscience Project, to
Canadian federal and provincial ministers of health. 5 September,
2017. Protection of Conscience Project.