Healthcare serial murder and MAiD

How does Canada's MAiD system stack up against the conditions that enable medical murderers?

Healthcare serial murder is back in the news this week. In the UK, a former nurse is convicted of murdering babies and jailed for life. In Canada, a doctor is charged with murdering more elderly patients in Ontario. At least the UK case has elements common to many medical serial murder cases, including warnings from colleagues and dismissed complaints.

The past week has also seen warnings from medical officials in Quebec that MAiD providers, at least in that province, may be skirting the law in killing patients.

“We see, more and more, that the cases receiving medical aid in dying are approaching the limits of the law,” Bureau said. “It’s no longer just terminal cancer, there are all kinds of illnesses _ and that’s very good, but it requires a lot of rigour from doctors to ensure they stay within the limits of the law.”

A while ago, I looked at some of the literature on healthcare serial murder to compare the features [1-5], which often allow medical murderers to remain undetected and kill for extended periods, to Canada’s MAID system. I wanted to assess Canada’s MAiD safeguards against these enabling conditions. I came up with the following list, which I also included in a paper now under peer review.

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Characteristics specific to healthcare serial killing and the MAiD comparison
(adapted from Lyon, C. Under review.)

1. IV or injection to administer lethal doses of routine medical substances

MAiD typically involves the IV or syringe injection of lethal overdoses of common medical substances.

2. Employment history may involve unusual job changes, complaints, sanctions or restrictions, and similar anomalies

Unknown.  Clinicians are not known to be vetted for MAiD. The only legal requirement needed to practise MAiD is being a licensed nurse practitioner or medical doctor.

3. Personal history may involve substance abuse  or interpersonal difficulties, mental illness, or disorders, especially personality related

Unknown. Clinicians are not known to be vetted for MAiD. The only legal requirement to practise MAiD is being a licensed nurse practitioner or medical doctor.

4. Attention craving, arrogant, or enthusiastic about skills

Uncertain, but some MAiD clinicians have expressed self-promotional accounts in books and media and made strong claims about the arguable sufficiency of existing safeguards.

5. Suspicious or alarmed colleagues

Some providers and other clinicians have publicly stated concerns [6–9]. Alarming reports of MAiD assessments and provisions provided for ‘loneliness’, to prisoners shackled and under guard [10], to people who seek it for poverty or lack of support.

6. Gratification from killing

Positive reactions from MAiD providers after taking lives through lethal injection include feelings of gratification or adrenaline highs [11].

7. Rationalisations to end suffering by killing

Some MAiD providers express a similar rationalisation, and ending suffering through death is a broad rationalisation for MAiD (in addition to self-determination).

8. Nicknames like ‘angel of death’

Unknown and likely requires access to complaint records or interviews with colleagues.

9. Predictions of patient deaths or prognosis

Assumption of prognostic power inherent in the MAiD legal criterion of irremediable, and especially uncertain in MAiD for mental illness. Mistakes are legally permitted if ‘reasonable’ [12]. CAMAP advises providers that threats to kill oneself amount to irremediability and render patients eligible for track 1 MAiD:
“A person may meet the “reasonably foreseeable” criterion if they have demonstrated a clear and serious intent to take steps to make their natural death happen soon or to cause their death to be predictable. Examples might include stated declarations to refuse antibiotic treatment of current or future serious infection, to stop use of oxygen therapy, to refuse turning if they have quadriplegia, or to voluntarily cease eating and drinking.” [13]

10. Inconsistencies in accounts of deaths

Accounts of divergent understanding of patient health and character voiced by clinicians and families. Some assessors find rejected patients eligible after assessor shopping [14-17].

11. Secrets medicines at work and home

Legitimate access to medicines for MAiD means that providers do not need to possess them illicitly. Any other unauthorised possession is unknown.

12. Higher instances of death on a shift

Wide variation in the to-date distribution of deaths per provider (1 - >400). Some providers acknowledged to have killed over 400 people by 2021 and assessed up to 1000 [18,19]. A small number of providers appear to be responsible for most MAiD deaths.

13. Victims are ill or disabled, some lack mental or physical capacity

Patients eligible MAiD match common victim profiles of medical serial killers, e.g., elderly, incapacitated, women, mentally or physically ill.

14. Seeking opportunities where they won’t be easily observed

MAiD assessments tend to occur privately, and what is said is only recorded by the clinician and records are confidential.

15. Poor clinic and system level surveillance to detect anomalies in the number of types of deaths or other adverse medical events

Poor surveillance of MAiD deaths and practitioners due to lack of national standards, local variation in health administration, coroner reporting requirements, and data collection. Poorly presented report data from Health Canada reports, and limited data collection can conceal anomalies, such as clusters of deaths or disproportionate approval rates.

16. Reports or complaints from patients, colleagues, family members, or other observers about problems

MAiD recipients do not survive, meaning there are no ‘escaped’ victims beyond people who feel they were inappropriately offered MAiD. Reported witness accounts in the news media and academic literature question assessment and provision standards. Any internal complaints against providers are unknown to the public.

17. Poor record keeping

Reporting requirements for MAiD deaths vary by province and territory in terms of documentation, recordkeeping, Medical Certificates of Death, and coroner involvement. Oversight is inconsistent and assessors and providers themselves are responsible for the contents of such documentation.

MAiD specific issues

18. Health Canada MAiD reports conceals deaths per provider

The current federal government method of presenting deaths per provider conceals per provider deaths, preventing the detection of anomalies that could signal malfeasance. 

19. Variations in reporting deaths

Reporting requirements to coroners vary by province and territory, meaning there is no consistent review of deaths, and some MAiD deaths are not reported to coroners. This is a gap a serial murderer could exploit.

20. Broad criminal exemptions for MAiD clinicians

MAiD provides exemptions to criminal culpability for assessors, providers, and other clinical staff, making identification and prosecution of criminal homicide more challenging compared to non-MAiD healthcare serial murder.

21. Power for clinicians to independently define and apply MAiD

Diverse personal views and biases mean there are inconsistent understandings of MAID, which may influence and shape how MAiD is explained to a patient and the conduct of the assessor.

22. Rights and autonomy ideology

Ideological views about the nature of autonomy may take priority over clinical judgement of the suitability of death as a ‘treatment’. This might translate to approvals and provisions for non-medical or minor reasons and/or allow a provider’s personal ethics to justify safeguard or law-breaking.

23. Assessor shopping

Patients deemed ineligible by other providers may seek unlimited further assessments increasing the likelihood they will intersect with a clinician more willing to find ways to approve and kill.

24. Financial gain

The billable nature of MAiD is a financial incentive to maximise assessments and provisions. Financial or material gain is a motive in serial murder.

25. Unmonitored or unassessed capacity to consent

Capacity to consent may be assumed. Without ongoing capacity checks, patients may be provided death lacking capacity. 

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I do not know or presume healthcare serial murderers function as MAiD assessors or providers. Yet, I find it very hard to argue that the system could reliably filter or catch them if they did.

Imagine how a Wettlaufer, Shipman, or other healthcare serial murderers would see Canada’s MAiD regime?

There are ample warnings now of problems coming inside and outside the house such that we should not be surprised if or when something truly horrifying turns up.

References

1          Crofts P. Gosport Hospital, euthanasia and serial killing. In: Fleming DJ, Carter DJ, eds. Voluntary assisted dying: law? health? justice? Canberra, ACT, Australia: : Australian National University Press 2022. 155–78.

2          Frank C. Health care serial murder: What can we learn from the Wettlaufer story? Can Fam Physician2020;66:719–22.

3          Tilley E, Devion C, Coghlan AL, et al. A Regulatory Response to Healthcare Serial Killing. J Nurs Regul2019;10:4–14. doi:10.1016/S2155-8256(19)30077-8

4          Yardley E, Wilson D. In Search of the ‘Angels of Death’: Conceptualising the Contemporary Nurse Healthcare Serial Killer. J Investig Psychol Offender Profiling 2016;13:39–55. doi:10.1002/jip.1434

5          Yorker BC, Kizer KW, Lampe P, et al. Serial Murder by Healthcare Professionals. J Forensic Sci 2006;51:1362–71. doi:10.1111/j.1556-4029.2006.00273.x

6          Coelho R, Lemmens T, Gaind KS, et al. Normalizing death as “treatment” in Canada: Whose suicides do we prevent, and whose do we abet? World Med J 2022;70:27–35.

7          Evidence. 2022.https://parl.ca/DocumentViewer/en/44-1/AMAD/meeting-20/evidence (accessed 19 Mar 2023).

8          Li M, Agrba L. I am a MAID provider. It’s the most meaningful—and maddening—work I do. Here’s why. Macleans.ca 2023.https://macleans.ca/society/i-am-a-maid-provider-its-the-most-meaningful-and-maddening-work-i-do-heres-why/ (accessed 18 Mar 2023).

9          Sonja B. Sonja B on Twitter. @Sonjalovesbikes. 2023. https://twitter.com/Sonjalovesbikes/status/1642519335284494336

(accessed 2 Apr 2023).

10        Driftmier P, Shaw J. Medical Assistance in Dying (MAiD) for Canadian Prisoners: A Case Series of Barriers to Care in Completed MAiD Deaths. Health Equity 2021;5:847–53. doi:10.1089/heq.2021.0117

11        Green S. This Is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life. Toronto: : Scribner Book Company 2022.

12        Criminal Code. 1985.

13        CAMAP. The Interpretation and Role of “Reasonably Foreseeable” in MAiD Practice. 2022.https://camapcanada.ca/wp-content/uploads/2022/03/The-Interpretation-and-Role-of-22Reasonably-Foreseeable22-in-MAiD-Practice-Feb-2022.pdf

14        Anderssen E. A complicated grief: Living in the aftermath of a family member’s death by MAID. Globe Mail. 2023.https://www.theglobeandmail.com/canada/article-maid-death-family-members-privacy/ (accessed 20 Mar 2023).

15        Green S. ‘I let him down.’ A doctor providing medical assistance in dying reflects on a tough case. Tor. Star. 2022.https://www.thestar.com/news/canada/2022/03/27/i-let-him-down-a-doctor-providing-medical-assistance-in-dying-reflects-on-a-tough-case.html

16        Raikin A. ‘I don’t want to die’ — New revelations on how Canada ushers the vulnerable to medically aided death. New Atlantis 2022;71:3–24.

17        Reyes R. Canadian doctor who’s euthanized 400 says she helped kill man deemed incapable of choosing suicide. Dly. Mail Online. 2023.https://www.dailymail.co.uk/news/article-11611095/Canadian-doctor-whos-euthanized-400-says-helped-kill-man-deemed-incapable-choosing-suicide.html (accessed 22 Mar 2023).

18        Wiebe ER, Kelly M, Spiegel L, et al. Are unmet needs driving requests for Medical Assistance in Dying (MAiD)? A qualitative study of Canadian MAiD providers. Death Stud 2023;47:204–10. doi:10.1080/07481187.2022.2042754