A B.C. Catholic investigation has uncovered systemic failures in British Columbia’s euthanasia program, including thousands of paperwork errors among the 2,767 MAiD (medical assistance in dying) deaths recorded in 2023, a lack of public reporting of violations and an oversight unit led by the same health official responsible for delivering MAiD in the province.

Leading critics of Canada’s permissive legalized-euthanasia regime call the findings “staggering” and “stunning,” saying the newly disclosed British Columbia government documents show a lack of effective oversight of MAiD in the province.

“It’s an actual life-and-death issue,” says Alex Schadenberg, a Catholic and head of the Euthanasia Prevention Coalition. “And what we’re seeing in B.C. is evidence that the scales have been tipped in favour of death.”

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The documents, received July 10 by The B.C. Catholic in response to a freedom-of-information application, reveal the inner workings of the B.C. Ministry of Health’s secretive MAiD Oversight Unit. The unit has not published a public report since it took responsibility for MAiD oversight from the province’s chief coroner in 2018.

The unit is led by social worker Sara Bergen, whose biography states that she also heads the overall administration of MAiD in British Columbia. This dual role is, in itself, cause for concern, says Trudo Lemmens, professor and Scholl Chair in Health Law and Policy at the University of Toronto. Lemmens also serves on Ontario’s independent MAiD-oversight body, which operates under the auspices of the province’s chief coroner.

“Somebody combining the organization of a practice with the oversight of a practice is unhealthy,” Lemmens said in reference to Bergen’s two jobs.

The Ministry of Health said in an email reply that the province’s MAiD Oversight Unit does not investigate wrongdoing but reviews documentation submitted by practitioners to ensure compliance with federal and provincial safeguards. While the unit may follow up to clarify missing or incomplete information, it does not determine misconduct or impose disciplinary action.

In rare cases, the ministry said, the unit may refer concerns to a health professional’s regulatory college or to law enforcement. Such referrals, it emphasized, “do not represent allegations of misconduct.” Police referrals are reserved for “the most serious compliance issues,” including significant deviations from eligibility or safeguard requirements, or cases where a deliberate breach of statutory obligations is suspected. Practitioners are not notified of referrals to police to protect the integrity of potential investigations.

The ministry also confirmed that Bergen, who leads the MAiD Oversight Unit, serves concurrently as the provincial director of MAiD. In that role, she oversees the strategic direction of MAiD policy and its implementation across the health system, including coordination with regulators, care providers and service delivery agencies.

Remaining questions about the outcome of past referrals and details of disciplinary action, the ministry said, would need to be submitted as Freedom of Information requests.

Among the problematic information contained in the 28-page FOI release is a “briefing decision note,” written by an unidentified bureaucrat, which argues that the oversight unit should not be overly strict in reporting infractions of MAiD-delivery protocols to professional colleges or the police.

“… Overly strict or severe use of referrals … may discourage physicians or nurse practitioners from providing MAiD despite high demand,” states the November 2023 memo, addressed to Stephen Brown, deputy minister of health.

Brown approved the note’s concluding recommendation to establish a new “weighted criteria model” for judging practitioner infractions.

“This is staggering,” said Dr. Christopher Lyon of the UK’s University of York in an email statement. An environmental social scientist with graduate degrees from Canada, Lyon has written extensively about problems with this country’s MAiD law.

He said the memo essentially gives permission to “unlawfully kill someone, but we won’t enforce it because it might discourage practitioners from playing loose with the law.”

Lyon said the province should be “very concerned” about what’s driving an apparent high demand for euthanasia rather than working out ways to address it.

Lemmens too was shocked by the bureaucrat’s reasoning that MAiD is too popular to worry about rules. “Indeed, (it’s) stunning to state that so explicitly.”

The FOI document also contains a spreadsheet showing that, in 2023 alone, the oversight unit found 2,833 “reporting issues” and “completion errors” in the paperwork for 2,767 MAiD deaths and for 1,041 cases in which MAiD was applied for but not completed.

Nevertheless, since 2018, the unit has made only 22 referrals to regulatory bodies for possible disciplinary action and just two referrals to law enforcement for potential criminal charges, according to an unattributed declaration appended to the end of the FOI document. The statement concludes by saying the referrals “represent less than 0.2 per cent of the total number of cases of MAiD reviewed by the unit.”

Such limited action in the face of so many infractions concerns Isabel Grant, a law professor at the University of British Columbia. 

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“It was alarming to read about the error rate in MAiD assessments in B.C.,” Grant said in an emailed statement. “Looking at only one indicator — errors around the eligibility requirements — we see an error rate of 4.9 per cent. When we are talking about close to 3,000 deaths, that is a very high number.”

The B.C. government’s MAiD reporting is about a year behind when the deaths took place, but if numbers for the first half of 2024 continue, the number of euthanasia deaths for last year is on track to surpass 3,000, up nearly 10 per cent from 2023.

Grant said that when the cost of a mistake is a potential wrongful death, society should not tolerate such a high error rate.

“Couple this with the concern raised in the report that we cannot have an ‘overly strict’ referral to law enforcement or professional colleges … (and) we can see the approach of the British Columbia government to MAiD deaths — err on the side of making MAiD accessible, not on the side of compliance with the Criminal Code,” she said. 

The government’s approach is especially troubling, Grant said, considering “we are talking about exemptions from Canada’s murder and aiding-suicide laws.”

Lyon and Lemmens joined with Dr. Scott Y.H. Kim, a bioethicist-physician, in writing a paper for the January 2025 edition of the American Journal of Bioethics calling for major reform in MAiD oversight.

Canada’s high rate of MAiD deaths “likely reflects not a broad Canadian consensus but the capture of a policy-making and implementation process by a small group of activists and clinicians colonizing medicine to become an ideologically driven vehicle for expanding MAiD access and delivery,” they wrote.

To counter government prioritization of MAiD, they wrote that patient safety, including protection against premature deaths, should be emphasized through a more transparent, relevant and robust compliance regime.

The B.C. Catholic examined seven years’ worth of public disciplinary records of the College of Pharmacists of B.C., the College of Physicians and Surgeons of B.C. and the B.C. College of Nurses and Midwives and was unable to find any record of disciplinary action related to MAiD. Likewise, there are no public records of any criminal charges related to a professional’s handling of MAiD.

Curiously, there is no public record of the lone disciplinary case for which the FOI papers provided any detail. The case is described in a three-page “Ministry of Health Decision Briefing Note” drafted in January 2021. It outlines the case of a B.C. doctor, whose name is not disclosed, who filed a report to the oversight unit that “failed to include a second assessment concluding eligibility, as required under federal law.”

As well, the briefing note reported that the oversight unit “also identified additional issues with the physician’s documentation of this case, which contravene the College of Physicians and Surgeons MAiD Practice Standards.”

“… The absence of a second independent opinion is exacerbated by an apparent disregard of an assessment of ineligibility,” the note states. It concludes by recommending that the oversight unit refer the case to both police and the doctors’ college “for appropriate investigation.” It is not known whether Deputy Minister Brown acted on the recommendation.

A spokesperson for the doctors’ college said that privacy concerns prevent it from releasing information about any referrals from the MAiD Oversight Unit. 

A spokesperson for the nurses’ college said a B.C. Catholic request for follow-up information on disciplinary matters would be treated as an FOI application and be answered by the end of August.

The package of information received by The B.C. Catholic did not provide any details of the years in which the unit recommended disciplinary action or criminal investigations, or to which college or agency.

However, the B.C. government did make that very information available in 2023 in response to an FOI request by Dr. Deborah Cook, a Member of the Order of Canada recently inducted into the Canadian Medical Hall of Fame.

The government response lists two B.C. referrals to law enforcement — one in 2019 and the other in 2021 — related to breaches of Section 241.2 of the Criminal Code of Canada, which sets out the eligibility criteria and safeguards for medical assistance for MAiD. The document does not say which professions were involved in the criminal referrals.

In addition, the single-page document to Cook listed three referrals to the pharmacists’ college, two to the nurses’ college in 2019 and 15 to the doctors’ college from 2019 to November of 2023. The unit found that in four of the doctors’ cases and in the two nurses’ cases, the medical assessor had concluded that a patient was eligible for MAiD even though the assessment “did not find they met all individual eligibility criteria.”

Schadenberg said the apparent lack of disciplinary action or criminal charges is further evidence that B.C.’s MAiD oversight is ineffectual, despite the Supreme Court of Canada’s Carter decision, which led to the 2016 legalization of MAiD, carrying a requirement for stringent oversight. 

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Schadenberg remarked that prosecuting such crimes will always be frustratingly difficult because “any witness on the other side is dead.”

Indeed, “it’s like the perfect crime,” he said. “You don’t get into trouble, and anybody who could effectively complain about it is dead.”