Stories About Healthcare—from the Alberta Views magazine archives

Stealing Freedom

Paula Simons — Mon, 01 Jun 2026 15:56:08 +0000

Kay Carter was a retired teacher, an avid traveller, a mother of seven. She lived in a BC retirement home when she was diagnosed with a painful, progressive neurological condition, spinal stenosis. In 2010, unable to access medical assistance in dying in Canada, the 89-year-old travelled to Switzerland to obtain the care denied to her here.

Gloria Taylor was a devout Christian and a lover of Harley-Davidson motorcycles. A mother and grandmother, she was working at a residential care facility for people with developmental disabilities in the Okanagan when she was diagnosed with amyotrophic lateral sclerosis, ALS.

Taylor too wanted to die on her own terms. So, along with the Carter family, she lent her name to a case brought by the BC Civil Liberties Association, a constitutional challenge of the law against MAID. They won at BC’s Supreme Court and at its Court of Appeal. Taylor died before the case went to the Supreme Court of Canada. But in 2015, in Carter v. Canada (Attorney General), that court found criminalizing MAID unjustifiably infringed section 7 of the Charter of Rights and Freedoms. The law, said the Court, was of no force and effect if it prohibited a physician-assisted death for a competent adult who clearly consented to the procedure and had a grievous and irremediable medical condition, including an illness, disease or disability that causes enduring and intolerable suffering.

In response Justin Trudeau’s government passed a law allowing MAID in cases where a person’s death was reasonably foreseeable. But that law was immediately challenged in the courts, because it didn’t deal with people dying by inches, with intolerable, irremediable suffering. Finally, in 2021, Ottawa passed Bill C-7, which extended access to MAID to all people encompassed by the Carter ruling.

The Senate debate on C-7 was deep, profound and moving, as we worked through the thorny legal and ethical issues. Medical assistance in dying was one of the most thoroughly and thoughtfully debated public policy decisions in history—and one widely supported by Canadians and Albertans.

So what to make of Danielle Smith’s decision to ban MAID for people precisely like Kay Carter and Gloria Taylor?

Alberta’s Bill 18, the Safeguards for Last Resort Termination of Life Act, purports to protect vulnerable Albertans. In fact, it flies in the face of the Supreme Court ruling and of federal law. It denies Albertans with intolerable, irremediable medical suffering their Charter right to MAID. People who want to die with dignity, people who want one final chance to exercise agency after so much agency has been taken from them.

The new law also infringes mightily on the rights of those whose deaths are imminent.

Bill 18 forbids doctors to refer suffering patients to another province for a MAID assessment. It forbids health facilities from displaying information on MAID in a poster or pamphlet. It forbids Alberta doctors and nurses from even discussing MAID with a patient, unless the patient initiates the conversation.

All of this may be wide open to legal challenge. But of course, all Smith’s government need do is invoke the notwithstanding clause to get around that pesky Charter.

Most Albertans support MAID for people with irremediable medical suffering.

Criminal law remains a federal domain. Alberta can’t jail physicians if they violate these new laws. Healthcare, though, is provincial jurisdiction. So Bill 18 threatens people who practise MAID, or even provide information about it, with discipline by their professional colleges—and could ultimately cost them their licences. Indeed, it undermines the autonomy of the College of Physicians and Surgeons by making such sanctions mandatory.

It’s a legal loophole. A moral outrage. And a perplexing political strategy.

An Environics poll from this January found 79 per cent of Albertans agree with the Carter decision and support MAID for people with irremediable medical suffering. We are also much more likely to opt for MAID in cases of irremediable suffering than are most other Canadians. In 2024 Quebec had the highest rate of residents who opted for MAID for conditions that weren’t immediately terminal. Alberta was a close second. That’s perfectly consistent with a culture that puts a high premium on personal liberty, independence and self-determination.

Smith has tried to distract us, by claiming to be protecting children and people without mental capacity from euthanasia, and stopping people from making advance directives for MAID. But those things aren’t currently allowed by federal law. Indeed, much of Bill 18 bans things that aren’t actually happening.

Forget the UCP fearmongering. Alberta is doing an end run around the Constitution, depriving the most vulnerable of their Charter rights and denying health professionals the ability to do their jobs responsibly. Like it or not, Alberta is still a part of Canada. This legislation, though, makes Albertans second-class Canadians. It robs us all of the freedom to make fundamental choices about how we live—and how we die.

Paula Simons is an independent Alberta senator and member of the Standing Senate Committee on Legal and Constitutional Affairs.

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Lydia

Patti Lott — Mon, 01 Dec 2025 17:57:26 +0000

Lydia is on a mission, searching the dresser for her lost wedding ring. The contents of the first three drawers lie in a giant heap about her on the floor. Pantyhose and slips and nighties, T-shirts and sweatpants, a flashlight, an assortment of earrings and earring backs, cheap necklaces, half of them broken, a lint remover covered in lint, a set of keys to who knows what, several pencils with broken points. Her bras, Norman’s shorts. Various other bits and pieces of a life. Why on earth does Norman have to keep so many socks and underwear, and why in such a jumble Lydia’s hip complains and her back aches, hunkered down like this, but she’s in a frenzy now, tearing at the underclothes, burrowing through the contents of the last drawer as though excavating a tunnel into the earth.

She’s about to give up when her fingers catch an edge. Something is caught in the drawer’s far corner, a tiny foil envelope which she retrieves with difficulty. Its slippery texture, its size, are familiar but she can’t say why, or what. Those raspberry candies she loved as a girl, maybe, hundreds of them individually wrapped in the bulk bin. One of those would be good right now. She can feel her mouth watering. She pulls at the partly open corner, squints as its contents drop to the floor. In the low light, she feels about on the flower-patterned rug until her fingers brush against something; it feels like a dried-up insect skin or beetle carcass or maybe an old scab. She recoils with a shiver, pulls her hand away, searches unsuccessfully for her glasses in the pocket of her bathrobe, in the items strewn about her, then reaches again, gingerly, bravely.

What is it, she wonders, holding the crispy wrinkled thing at arm’s length, squinting against the window’s glare. When she places it in her palm, its disintegrated insides all but fall away. She blows at the dust in her hand. Now she can see it. It’s—a ring. It’s her lost wedding ring. She is exultant. Norman, I’ve found it! Honey, don’t worry, I found my ring!

She turns to rest her elbows against the edge of the low chair beside her, uses them as leverage to push herself to standing, grunts with the exertion. She does what might pass for a little jig around the bedroom until her floppy pink slippers and her wheezing lungs trip her up, sending her back to the chair. Catching her breath, she slips the frayed brown-gold circumference onto the ring finger of her left hand, pushing it easily over swollen, arthritic knuckles. Gently she twirls the ring round and round, its rough edges catching on the loose skin of her finger. It doesn’t fit at all as she expected it to. It’s too large; it feels all wrong.

Suddenly she sees it for what it really is. Oh, for god’s sake, it’s a shrivelled old condom! What a stupid biddy you are, she says to herself. Where’s Norman Probably still in his workshop. Thank goodness he hasn’t seen her mistake. Angry with herself, she throws the thing. It lands on the bed, falls into a crease in a pillow.

Things have been moved around and missing ever since Richard came by last week to check on her. Everything is topsy-turvy.

Norman is so smart, so capable, always busy with some project or another. When he isn’t working, he’s tinkering away, repairing a household item or inventing some new gadget for them to try out, like an electric potato peeler or a miniature spout that lets you drain the water from a tin of tuna before opening it. He’s tall and strong; he can lift her off her feet if he wants to, just for the fun of twirling her around him, but his fingers are slender and sensitive for such a large man, and able to do precise and delicate work.

Rising slowly from the chair and tightening her robe around her, Lydia catches a brief glimpse of her face in the dresser’s dull, mottled mirror. It’s a good face, a face that launched a thousand ships. Is that right No, that isn’t her. Don’t be ridiculous. Who is it, then Someone beautiful. Ah, yes, Helen of Troy, that’s who. Or Cleopatra. Lydia knows she herself has always been a looker. Didn’t what’s his name, their neighbour, tell her so often enough Those very words—you’re a looker, he’d say. In front of everyone, his wife. Lydia thrives on the attention generated by her fine features and voluptuous figure. You’re a beautiful woman, Norman tells her. She smiles at him through the mirror and backs closer to where he stands watching her. Love me forever she asks him. Of course, he replies. His voice arouses desire in her; she wants to slip her arms around him. She leans backwards into him and loses her balance, falls against the wall. Shoulder throbbing, she turns to face him, to where she thought she saw him standing. Her throat catches with sorrow; emptiness fills her body.

The phone rings, six times before she finds it, right there in the pocket of her robe. Hello Hello Who is it Who Oh, yes, Richard. Of course I recognize your voice. I’m fine. Yes, I’ve been taking care of myself. Yes, I’ve been turning out the lights. Whose business is it, anyway I’m not about to let myself starve to death. I’m fine.

As she hangs up she hears him say, “Talk to you later, Mom.” Mom He called her Mom. Oh, it was that Richard. Her son Richard. She can see him now, as though he’s right there in front of her. A little blond-haired boy of three or four, a toddler still, cute as can be. Their only child. Always getting into trouble, the little monkey, but a sweetheart. Little button of a nose. Honey, she says to Norman’s face in the flowered wallpaper. Honey, Richard called. Then she panics. What is Richard doing, calling her Where is he Didn’t she just tuck him into bed Still holding the phone, she clutches at her robe, turning blindly around from where she is standing. Norman! Norman! She spots the clothes strewn about the bedroom, certain her little boy is in the midst of them. Her mood shifts; now she’s angry. What does Richard think he’s doing, throwing clothes and underwear around like that Young man, she scolds him. This is very naughty of you, getting into Mommy’s and Daddy’s things and making a mess. You clean this up right now, do you understand When I come back into this room I want it shipshape. With that, she heads to the kitchen, annoyance fuelling her step.

She’s had enough of this growing old, dammit. If she has to look at herself in the mirror one more time, she’ll poke her eyes out.

She places the phone in its charger, remembers her lost ring and bends to check for it beneath the oversized desk that serves as her home office. This is where she pays bills and answers email and does their yearly taxes. But now her laptop sits on it, unused. She can’t remember her password, can’t get the annoying thing to work. The way it’s tucked into the corner, the desk forms an inviting space—safe underneath, like a hideout. With effort she bends and crawls halfway in, the desktop a low roof above her. It’s nice in here. She likes it. Crawling out again, she slips her bathrobe off and drapes it over the open side to make a tent. Grunting, she manoeuvres back underneath.

It’s just like Girl Guide camp, like the summer she and her best friend, Samantha, spent an unwashed week swimming and hiking and learning to make fires. Samantha is here now, waiting for her, red pigtails sticking straight out from her head, a grin on her freckled face. The two girls lie on their backs in their secret hideaway, whispering and giggling. Lydia watches the stars until her eyelids become the night and she drifts off to sleep, her back pressing into the hard ground. When she wakes, she feels sore all over. The varicose veins in her legs ache as though someone is landing slow punches on them. Sam, quit it, she tells her friend. That hurts, smarten up. Quit it! I’m not playing anymore.

The pain continues and Lydia pushes her way up to sitting, knocking her head against the bottom of the desk. She swears loudly, moves onto her hands and knees and makes her way awkwardly past the draped robe out into the light of the kitchen. With the help of the desk she hoists herself to standing. The low-slanting sun is bright even through the dirty window; she blinks several times, reorienting herself. Naked, she shivers with cold. Where is her bathrobe Finger to her mouth, she turns round and round on the worn linoleum, her forehead creasing with frustration. She put it on when she woke up this morning, didn’t she What is happening to her memory Ah, there it is, right there on the desk. What’s it doing there Things have been moved around and missing ever since Richard came by last week to check on her. She hasn’t been able to find her pearls, or her small diamond earrings, or her wedding ring. Everything is topsy-turvy.

She goes back to the bedroom. Norman is there now, she’s sure of it. Lydia puts her hand through the gap between the buttons of his shirt. Her fingers stroke his belly and chest, dark hairs twisting softly around her fingertips. She nestles into him, can almost feel the warmth of his hands on the small of her back. She flushes, heat rising in her body. I like that, she says, softly. Don’t stop. She thinks of the striptease she performed for him, slowly taking off her sweater and then her blouse, her skirt and her pantyhose, until she was down to only her bra and panties. You like it, don’t you honey, she’d said, a bit shyly. He’d grinned and reached for her, finishing the rest himself.

Why won’t you hold me she asks Norman now. She catches herself and shakes her head. For heaven’s sake, here she is, thinking about sex. Funny, when you were getting it, it could be all-consuming, but when you weren’t—well, she could hardly remember what it was like.

She indulged in a pedicure, a rare treat, several months after Norman died. When her feet turned soft and pliable from soaking in the hot footbath, the middle-aged esthetician scraped the calluses from her heels and pushed back the cuticles on her toenails. Then she massaged Lydia’s feet and calves. The woman’s hands were warm and strong, and she seemed so comfortable using them on a stranger. Lydia found herself weeping with the unexpected pleasure of it, the loss and yearning the contact awakened in her.

Now the mirror’s reflection reveals her standing alone. Norman Fine, then. Lydia heads again for the kitchen, the ache in her loins pleasurable and frustrating. Her arousal has made her hungry. The fridge is empty but for a half-full carton of milk and a shrivelled head of cabbage. Slamming the door shut, she reaches for the cupboard instead, pulls out a jar of peanut butter and another of honey. At the counter she dips a finger into the peanut butter and licks it off. Mmmm, that’s nice, she says in a low voice. She dips her finger again and licks the tip of it slowly, gently. It tickles a little bit, feels good. She nibbles at it, scratching the tip ever so lightly with her teeth. Another dip into the jar, another languorous lick, this time sucking her finger to the first joint, pulling at it gently, her lips closing around it. Again. Now into the wide-mouthed honey jar—two fingers, three, all of them in her mouth at once, her fingers alive and throbbing, her tongue eager and strong. Hungry, lascivious, so many fingers, the taste delicious and sweet, the warm fullness of her mouth causing her to pant, a moan escaping her parted lips. She can no longer stand up and so she sinks into the chair beside the table. Enough; she is satisfied. She belches, she giggles. Pardon me, she says to the face in the wallpaper. She hasn’t felt this good since she can’t remember when.

The doorbell rings, startling her. No one ever comes to the door; no one visits her tiny apartment. Not that she can think of. She pulls her bathrobe into place and makes her way across the kitchen to the entry, a distance that feels, what with her gassy stomach, bad back and resentful hip, like plenty far enough, like too far. When she finally makes it to the door, stumbling twice and swearing, no one is there. I don’t want any, she hollers down the empty hallway.

She hopes Norman will come home soon. Summer evenings they walk together before bed, holding hands in comfortable silence, or talking about the day behind and plans for the next. She can see his profile from the corner of her eye. His nose is straight, his chin hidden by a short beard. She loves the way his eyes crinkle when he smiles or even when he frowns, which happens only rarely, when he is intent on a project and she irritates him with her interruptions.

Oh, she’s tired. She could fall asleep right here, one hand resting on the handle of the half-open door, her body leaning against the frame. She closes the door and considers making the couch her bed. No, that won’t do. She needs to brush her teeth. They are her pride and joy, straight, still all her own. In the harsh light of the bathroom she forces herself to pull out toothpaste and toothbrush. As she bends to spit, her bathrobe falls from her shoulders, cream-coloured fabric catching on her elbows and ample behind. Raising her head to the mirror, she sees her naked body reflected back at her. She can’t tell where the fabric ends and her skin begins. Dear god in heaven, who is that looking back at her What is that Thank god Norman isn’t here to see her. What does he, still so fit and handsome, see in her anyway?

She’s had enough of this growing old, dammit. If she has to look at herself in the mirror one more time, she’ll poke her eyes out with her knitting needles. That is, if she can remember where she put them. What would it be like, she wonders, to live in a world without mirrors, a cavewoman world, she supposes, where what you look like never even occurs to you?

Her hands are sticky from her feast; she runs them under the water, uses her special bar of lavender soap to take the honey from between her fingers. She barely recognizes her hands, all spotted and wrinkled. They look so bare. Where is her wedding ring Oh, god, where is it She panics, searches the countertop, knocking toothpaste and lotions to the floor. Where has she left it She steps into the darkened bedroom, her heart beating furiously, close to tears. How can she have lost her ring Norman, I can’t find it, she tells him. I’m sorry, honey, I’m sorry.

She lies down on the bed and pulls the rumpled comforter over herself. Sorrow pulls at her, wraps her in its arms. She floats on a vast wave of emptiness, uncertain what it is, exactly, that she has lost. Face buried in the pillow, she feels a touch against her cheek. A ring.
She holds its rough edges to her lips. She remembers. She forgets.

Rancher/therapist-turned-writer Patti Lott lives in the Alberta foothills. Her poetry is forthcoming in Prairie Fire and CV2.

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Should we expand eligibility for MAID?

Donna Wilson and Trudo Lemmens — Tue, 01 Jul 2025 10:10:21 +0000

Donna Wilson says YES

Registered nurse and professor of nursing at the University of Alberta

I finished my first nursing program in 1976 and began working in hospitals. At that time, we were witnessing an explosion in life-saving medications and other healthcare technologies. It was so very exciting to think that people would no longer die of injuries and common illnesses.

What we now call “avoidable” deaths were normal occurences before today’s healthcare technologies became readily available. It wasn’t that long ago that life support became possible. Antibiotics only came into wide use after the Second World War. Canada’s first intensive care unit opened in 1958, but it wasn’t until the 1970s that all larger hospitals routinely had ventilators and heart monitors.

These and other lifesaving technologies were welcome, but a major issue quickly surfaced: the belief that physicians had a moral obligation to use these interventions, even if they were considered futile and even if the patient didn’t want them. Much broad-based concern subsequently arose over patient rights and persistent vegetative states.

The 1975 Karen Ann Quinlan case in the US brought these matters into stark view, as her physicians refused to stop her ventilator despite her irreversible brain damage. In 1976 her parents fought successfully in court to discontinue her ventilator. Quinlan lived another nine years in a coma in a nursing home because of daily tube feeding.

In 1984 the Canadian Nurses Association, Canadian Medical Association, Catholic Health Association and other legal/health groups issued the Joint Statement on Terminal Illness, saying “in conditions of ill health and inevitable death… no resuscitation is appropriate and ethically acceptable. It is also recognized that it is the patient’s right to accept or refuse treatment.”

Life extension remained the norm, however. My first research study in 1991/1992 was on long-term tube feeding, a common practice then in nursing homes and hospitals.

The turning point in Canada was our first widely covered “right to die” case, when Sue Rodriguez requested assisted suicide. Her request was denied in 1994, although four of the nine Supreme Court judges sided with her over changing Canada’s Criminal Code so that adults who wanted to die could have their death assisted by other people.

Additional citizen petitions to the courts led to the June 2016 legalization of MAID for people whose death was reasonably foreseeable. In March 2021 MAID eligibility was expanded, because more citizens petitioned for MAID access. Ill people who were uncertain about when they would naturally die gained the right to have MAID approved for later possible use.

Healthcare technology will improve and society will ever evolve. So it doesn’t surprise me that more people would like the right to apply for and receive assistance to end their life earlier than if nature took its course. We are each best able to determine if our own death is preferable to living longer.

Trudo Lemmens says No

Professor and Scholl Chair in Health Law and Policy at the University of Toronto

We need to refocus MAID on its original purpose: allowing patients who are approaching death to ask healthcare providers to end their life in exceptional circumstances. This means withdrawing Track 2 MAID, the consensual killing of disabled persons whose natural death is not reasonably foreseeable, and strengthening other safeguards, as urged by the UN Committee on the Rights of Persons with Disabilities.

When the Supreme Court ruled in Carter that an absolute prohibition on euthanasia and assisted suicide violated the Charter, it instructed Parliament to balance protecting people against premature death with some form of access to physician-assisted dying. Parliament therefore initially focused its MAID law on end-of-life, with reasonably foreseeable death as a crucial safeguard. It required unambiguous consent, irremediable illness, intolerable suffering and irreversible decline of capability. MAID was deemed exceptionally justifiable based on compassion for people suffering intolerably from irremediable illness, and to provide them more control over their dying.

MAID promoters immediately pushed to stretch access criteria and challenged the end-of-life safeguard. When a Quebec court ruled that providing MAID only at the end of life was unconstitutional, the federal government failed to appeal and instead rushed through its expanded 2021 MAID law, removing safeguards and allowing MAID for disabled persons whose death wasn’t reasonably foreseeable.

Canada now has arguably the most open-ended euthanasia law, with a record of 60,000 deaths. Some 4.7 per cent of all deaths in Canada are by MAID, second only to the Netherlands. Most fall within Track 1 (foreseeable natural death), but many of these people may have had years of life left. Since the expansion, more than 1,000 disabled persons have died under Track 2.

For MAID expansionists, high numbers are a success story. But reports from Health Canada, the Ontario Chief Coroner’s office and various media reveal that many people ask for MAID not due to irremediable suffering in dying but for suffering in life that must be addressed by adequate healthcare and social supports. Suicidal patients, often with intersecting physical and mental disabilities, with years or decades of life left if supported to live, are increasingly hastened to death by MAID.

Killing people or encouraging suicide remain prohibited under the Criminal Code, including for physicians. But the exemption for MAID has given health professionals discretionary powers to end life as a form of therapy, opening the door to abuse and overzealousness. MAID law, weak guidance and oversight, and aggressive MAID promotion have undermined the prohibition. It tells disabled people facing serious challenges that ending their life is a reasonable option. In the name of false compassion, it pushes people over the edge when they need support. It’s hard to imagine a greater social injustice. Further expansion of MAID is unconscionable.

donna wilson responds to Trudo Lemmens

MAID eligibility should be expanded to Canadians with diagnosed mental illnesses. Currently, we are in a three-year pause ending March 17, 2027, to prepare for this extension. After that, people with impactful mental illnesses will be able to request MAID. As in all MAID cases, by law, the requester must complete an application and be assessed as meeting all criteria by at least two nurse practitioners or physicians. MAID will continue to hinge on an autonomous and non-coerced decision being made for professional assistance to end one’s own life earlier than if nature took its course.

Before rebutting Trudo Lemmens, I’ll highlight two key reasons for this expanded eligibility.

The first is that people are the best judge of whether or not their life should continue. As a nurse I’ve seen many terminally ill and dying people awaiting death. They and their family really suffer. I remember one man telling me (before MAID legalization) he’d put down his dog when it suffered, but his sister, who was dying a terrible death, couldn’t have her suffering ended. We have better pain options now, but ill people still suffer in so many ways. The 2023 MAID report highlights two (almost universal) concerns of people who request MAID: loss of ability to perform activities of daily living, and loss of ability to engage in meaningful activities. This is understandable, as 95.9 per cent of MAID recipients had an end-stage illness—cancer in two-thirds of cases—with death immediately foreseeable. As a long-time palliative care advocate, I started to advise Health Canada in the 1990s on the need for hospices, as Canada lagged behind other developed countries in compassionate care options. We still do. The 2023 report shows that 75 per cent of MAID recipients received palliative care, but we lack support for high-quality home and nursing home deaths.

The second reason is that diagnosed mental illnesses have significant long-term effects. Unemployment is common, as is poverty. Over time fewer friends and family can be counted on, and adults living with a mental illness often end up homeless. Most live with multiple physical ailments as they age prematurely. These are people who are diagnosed with a mood disorder (major depression or bipolar), anxiety disorder, substance abuse disorder or another mental illness such as schizophrenia, eating disorder, obsessive-compulsive disorder, PTSD, attention-deficit/hyperactivity disorder or dementia. Most have the capacity to decide if death is preferable over continued life.

MAID is planned, controlled and openly reported; it is a safe and effective procedure for people who choose it.

Lemmens would “refocus MAID on its original purpose: allowing patients who are approaching death to ask healthcare providers to end their life in exceptional circumstances. This means withdrawing Track 2 MAID, the consensual killing of disabled persons whose natural death is not reasonably foreseeable.” His argument reminds me of ones used to try to prevent MAID legalization. Chief among them was the slippery slope fear: that we would become so accepting of killing people that we wouldn’t care or notice when disabled people are encouraged (or forced) to have MAID. Lemmens’s use of the term “disabled” illustrates this fear. The slippery slope has not materialized anywhere MAID is legal. MAID legalization means death-hastening is planned, controlled and openly reported; it is an effective medical procedure for people who choose it and who meet the legal requirements for it.

Lemmens’s wish isn’t reasonable, as many individuals and organizations support the 2020 amendment extending MAID to people who don’t have an evident death date. In 2023 there were 19,660 MAID requests, with 15,343 people receiving MAID, 2,906 dying before they could receive it, 915 deemed ineligible, and 496 withdrawing their request. Most people fear dying and death; having MAID as an end-of-life option is compassionate.

Going back to the 2016 policy would mean assisted death could only occur a few hours or days earlier than if nature took its course. Canadians would again know they need to suffer through almost an entire terminal illness. They’d need to be awake and alert at the time MAID was scheduled, so they could say or indicate they still want it. To achieve this last-minute consciousness, painkillers and sedation are often withheld.

It’s important to try to understand why anyone would have MAID limited to only those in such an advanced state of illness that their death is imminent. Lemmens is a bioethical theorist, not someone with evident healthcare degrees or healthcare employment to show him first-hand how much ill people and their families suffer. His use of the term “patient” is telling. That outdated term reflects subservience to healthcare professional dominance.

Lemmens appears to think MAID is too easy to obtain, something the annual MAID reports show to be untrue. I believe MAID should be available to all Canadians, including those with diagnosed mental illnesses.

trudo lemmens responds to Donna Wilson

Donna Wilson suggests MAID should be expanded because more people want to “receive assistance to end their life earlier than if nature took its course.” She further sees MAID as a response to a medical system otherwise excessively focused on stretching lives. This reflects common misconceptions about MAID and trivializes concerns about state-funded healthcare-provider ending of life.

The argument that legalizing euthanasia is needed to counter aggressive life-extension was once common but no longer holds. Respect for refusal of life-prolonging measures has been essential to medical law and practice for decades. More-holistic medical practices, particularly palliative care, emphasize quality of life and patient and family empowerment, not technology-driven life-extension. Unfortunately, the expansion and prioritizing of MAID risks undermining palliative care.

In fact, MAID via lethal injection (which is not just “receiving assistance”) medicalizes dying itself. This may be why some physicians embrace MAID so enthusiastically. Physicians can have trouble accepting that they have no “fix” for suffering patients. MAID gives them the illusion of medical control over dying, an event that otherwise escapes control. Rather than a reaction against technology gone wild, MAID is a technical way to deal with an essential human experience.

Wilson’s ethical justification that “people want it” also ignores the official justification for MAID as well as the complexity of healthcare and end-of-life decision-making, and the broader context in which choices are made.

No jurisdiction accepts choice as a sufficient basis for legalizing euthanasia. All have criteria that reflect how physicians can only offer it for compassionate reasons in exceptional circumstances. Even standard medical procedures aren’t justified solely based on choice. Healthcare providers must offer evidence-informed care that respects professional standards. Less risky procedures must be tried first. Brain surgery to control seizures is unacceptable, even if patients want it, if less intrusive options may work. Remarkably, Canada’s MAID law introduced death as therapy even when other options to ease suffering exist. Ending of life has become a consumer good “on demand.” This also lets society and our health system off the hook for failing to ensure timely care.

Broadly legalized MAID sends a message: death is prioritized over care for disability and disease-related suffering.

Over-reliance on “choice” ignores the complexity of healthcare decisions. For the UN Committee on the Rights of Persons with Disabilities, Canada’s MAID system’s reliance on choice “creates a false dichotomy.” Choices are determined by psychological (e.g., despair after a disabling accident), economic, cultural and social factors. Poverty, loneliness, power-differentials between physicians and patients, ableist attitudes—rampant in healthcare—family pressures and lack of timely care undermine choice. The Committee also warns that our MAID law sends a message that death can be prioritized in response to disability and disease-related suffering; that a life with disability doesn’t require the same protection against suicide.

Imagine what the 2027 introduction of MAID for sole reasons of mental illness—and its eventual expansion to minors—could entail. Unlike other diseases, many mental illnesses have suicidal ideation as a diagnostic criterion. The trajectory of mental illnesses is uncertain, and psychiatrists can’t reasonably predict who won’t get better. MAID is said to be needed for irremediable medical conditions in people with irreversible decline. But physicians would offer it to people who will likely get better with good mental health care, in which conveying hope is crucial. Imagine a 17-year-old with autism who struggles with depression and refuses care, believing no further option exists. MAID assessors could offer that person death as a form of therapy. Some would prudently explore other options. But MAID here is already dominated by providers who often seem to prioritize access over protection. Recent cases discussed in reports by the Ontario Chief Coroner’s office and in the media reveal that assessors without strong expertise in mental health care or complex conditions already approve or provide MAID to patients with such intersecting illnesses, including some with suicidal ideation.

An ongoing Alberta controversy shows how people can get approved for MAID even when doubts exist about their eligibility. The case involves a woman in her 20s who according to her father has autism but no clearly diagnosed irremediable illness. Neither health authorities nor regulators have been willing to intervene, even though half of the physicians in three subsequent requests for MAID deemed her ineligible, and questions abound about her lack of care and “doctor-shopping” for approval. Rather than expand MAID “because patients want it,” let’s investigate why people ask for it, how we can improve care, and how our existing MAID regime needs to be changed to protect people against premature death.

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The War on Trans Youth Comes to Alberta

Marcello Di Cintio — Sun, 01 Jun 2025 09:30:00 +0000

Kimberly Large knew her conversation with the premier wouldn’t go well.

Premier Danielle Smith had released a video entitled “Alberta Transgender Policy” in January 2024. Scored with soothing acoustic guitar music, and with a watercolour painting of prairie farmland as a backdrop, Smith announced a host of proposed policies focused on transgender youth and 2SLGBTQ rights. Alberta’s queer and transgender community recoiled, and critics quickly denounced the measures as “the most draconian in Canada.”

Kim and Ashley Large, parents of an 11-year-old transgender daughter in Smith’s Brooks-Medicine Hat riding, sought an in-person meeting with the premier as soon as the video aired. “As parents and constituents, we needed to sit across the table from her and tell her what we know to be true as people having first-hand experience,” Kim said. When Kim and Ashley arrived for the interview in October 2024, after months of correspondence with Smith’s office, a staff photographer offered to take a photo of them with the premier. The Larges politely declined.

The meeting made Kim nervous. Since they’d come to discuss such an emotional topic, Kim decided to read a statement the couple had prepared in advance. First, she told the premier how their daughter, assigned male at birth, has always loved to wear girl’s clothes. “At the age of 3, there was a Snow White dress,” Kim recounted. By grade 3, their daughter was already firmly gender nonconforming. “I collected dresses from my friends and thrift stores and presented them to her,” Kim said. “And the look on her face. The joy. No one can tell me this isn’t her.”

As the premier listened, Kim described her daughter’s first appointment at the Pediatric Gender Services Clinic at the Alberta Children’s Hospital in the spring of 2022, how she told her parents she “didn’t want to have boy puberty or become a boy,” and how she returned to school for grade 5 as a transgender girl. Kim also told Smith how, after much consultation with doctors, counsellors and an endocrinologist, they decided their daughter was ready for puberty suppression therapy. “Our biggest fear was intolerance and wanting to shield my baby’s heart from the ugliness of the world. I can’t do that. But we can walk with her, supporting her always, and that’s what we’re going to do.”

Kim then explained to the premier why she was worried for other trans kids in the wake of the government’s new policies. Kim cited a US study reporting a 72 per cent increase in suicide attempts among trans and non-binary youth in states that had passed anti-trans legislation. Medical decisions around youth transition, she told Smith, should be left to medical professionals, parents and the youth themselves—not to government officials.

After Kim finished reading her statement, she asked Smith if she had any questions. Smith had none. “Then she proceeded to tell us why we were wrong,” Kim said. Smith alluded that the medical establishment couldn’t be trusted on gender issues, for example, and snapped back when Kim referred to the new policies as “anti-trans,” insisting that youth can socially transition all they want. “She did not come to listen,” Kim said. “She did not care. She had a few talking points that she regurgitated at us.”

The moment that most astonished the Larges was when Smith told them that since their daughter had such supportive parents, she was going to be okay. “I didn’t know what to say,” Ashley said. “It was like she was saying ‘your kid’s fine. Why do you care about anybody else What does it matter?’” Ashley recalls the confused look on Smith’s face in that moment, as if she couldn’t comprehend why the Larges would oppose policies that wouldn’t personally affect their own child. “I’ll regret forever not asking, point blank, ‘What about the rest?’”

Alberta’s transgender community didn’t feel loved. They felt attacked. But they didn’t feel surprised.

“I want every Albertan that identifies as transgender to know I care deeply about you and I accept you as you are,” said premier Smith in her January 2024 video. “In the case of children aged 17 and under who identify as transgender, I also want you to know that you are loved and supported…. You never have to feel alone or isolated.”

Then she abandoned them. The following October, as promised, Smith tabled three bills aimed at controlling the lives of transgender youth. The Education Amendment Act, 2024, which the government says would require children under 16 to obtain parental consent before changing their names or pronouns at school and obligate teachers to notify parents if students 16 and over request the same. The Fairness in Safety and Sport Act, which would allow schools and sporting organizations to bar transgender girls and women from participating in sports alongside cisgender athletes. And the Health Statutes Amendment Act, 2024 (No. 2), which would prohibit transition-related surgeries and hormonal treatments for minors. Alberta’s transgender community didn’t feel loved. They felt attacked.

They didn’t, however, feel surprised. “We saw a real hyper focus on trans and queer people following the quieting down of the so-called Freedom Convoy,” said Corinne Mason, co-founder of the Queer Parenting in the Time of Parental Rights research project. Mason and their colleague Leah Hamilton—both parents of queer and trans kids—have been following the threats to Alberta’s queer and transgender community, and especially to trans and gender-diverse youth, since before Danielle Smith became premier. They noticed active bigotry towards Alberta’s queer and transgender citizens rising just as the anger against COVID restrictions was abating.

During the pandemic, the Canadians most angered by the government’s COVID measures had gathered to denounce vaccine mandates and other perceived injustices—a movement that culminated in the convoy to Ottawa and the blockade at Coutts. Their shared rage forged a kinship among the protesters. And when the pandemic restrictions ended, they didn’t want to dismantle the communities they’d built. The real Freedom Convoy, as it turned out, was the friends they made along the way.

The movement needed a new target. Railing against critical race theory never really caught on in Canada like it did in the US, and the “15-minute cities” conspiracy lasted about as long. For a while, the agitators focused on “Drag Queen Storytimes.” Alberta libraries had been hosting such events since 2017, at which drag performers read children’s books aloud, but organized actions against them only started post-COVID. Protesters showed up at story times in Calgary and Edmonton to intimidate and harass attendees. They accused organizers of sexualizing children, and held signs decrying “weirdos in drag” and “gender benders.”

The attacks against drag story time had mostly petered out by mid-2023, but the preoccupation with queer and trans issues stuck, especially in regard to youth. The agitators turned their focus from libraries to the legislature. Attendees at the 2023 UCP AGM in Calgary demanded the government take on issues of gender and sexuality in schools. Party members put forward and approved resolutions to require teachers to inform parents of their child’s intent to change their name or pronouns, to prevent schools from providing materials of a sexual nature to students, and to enshrine what they termed “parental rights” in legislation. The new policies premier Smith announced in her January video seemed borne out of these resolutions.

Canada’s Charter of Rights doesn’t protect parental rights. While Smith’s supporters are quick to quote a court ruling asserting that, as outlined by a Government of Canada site on Section 2(a)–Freedom of Religion, “parents have the right to rear their children according to their religious beliefs, including choosing religious education and choosing medical and other treatments,” they tend to skip the caveat that immediately follows: “However, such activities can and must be restricted when they are against the child’s best interests.”

Regardless of the legal reality of parental rights, or lack thereof, the idea acts as an effective rallying cry and recruitment tool. “‘Parental rights’ as a term is used to bring people into right-wing extremist movements under the guise of loving, protecting and wanting the best for your children,” Mason said. “Because who doesn’t want that?”

The tactic attracts a diversity of actors and broadens the political tent. “Under the guise of parental rights, you’ve got everyday moms, who might be concerned about what sex ed their kids are learning, in the same boat as the Proud Boys,” Mason said. White nationalists march alongside religious zealots. The only qualifications one needs to join this particular club is transphobia.

Ironically, these issues attract a wide swath of people, yet inspire wide-ranging policies about a community that is vanishingly small. While an accurate count of transgender youth in Alberta doesn’t exist, the 2021 Canadian census showed there are about 7,300 transgender and 5,200 non-binary people in Alberta, together comprising less than 0.4 per cent of the population 15 years of age and older. Chances are, the people agitating against transgender youth have never even met a trans person.

A rally outside Calgary City Hall on Feb 3, 2024, to oppose the government’s transgender policies.

The video came out, and all our lives shifted dramatically,” Mason said.

Life has never been easy for Alberta’s trans youth and their families. Now it’s even harder. “I can tell you personally we are all experiencing more insidious and sometimes more emboldened forms of harassment, discrimination, hate and threats,” Mason said. Soon after Smith’s announcement, Mason’s family was accosted during a birthday dinner at a restaurant. Diners at the next table noticed Mason’s partner’s T-shirt from Skipping Stone, a trans and gender-diverse advocacy organization. “They just started absolutely ripping on us as abusers and pedophiles and groomers,” Mason said. “They called gender-affirming care ‘mutilation.’ ” All this occurred in front of Mason’s child. Eventually restaurant staff kicked the agitators out.

Other parents of trans kids have similar stories. They’ve told Mason that Smith poured gasoline on an anti-queer and anti-trans fire that was already burning. “We are all living with that fire burning in so many parts of our lives. It’s at work. It’s at restaurants. It’s at our kids’ soccer practice. It’s at school. It’s at playdates.”

And it’s at the doctor’s office. Peer-reviewed medical research has found that for some trans youth an estrogen- or testosterone-driven puberty will exacerbate gender dysphoria and cause elevated stress. A prescription for puberty blockers provides youth and their parents time to explore future medical options for transition without risking irreversible changes to their bodies. Access to blockers is directly linked to better mental health and well-being outcomes, and in some cases will lessen the need for surgical interventions in the future.

Despite this data, trans patients have faced discrimination from healthcare providers. In the past year Mason has heard a growing number of stories of family physicians who, instead of simply prescribing hormones or puberty blockers, as they would with any other medication, now insist a trans patient seek specialized care. Trans people have also experienced heightened gatekeeping around referrals. General practitioners have refused to send young trans patients to gender specialists, advising them to ask again at a later date if they still want the appointment, thus discounting their medical needs as a phase they’ll grow out of. “The discrimination is getting worse,” Mason said.

This all seems darkly familiar to Victoria Bucholtz, a historian at Mount Royal University with a particular interest in the rise of fascism in Europe in the early 20th century. In Alberta in 2025, she said, “we’re seeing the differential treatment of people based on perceived value—the idea that we’re not all equal and that some people’s rights are negotiable.” That, she said, “is definitely classic fascist behaviour.”

Bucholtz and other advocates feel the UCP’s new legislation is aimed at nothing less than the eradication of trans life. “Once they start denying our humanity around sports and bathrooms,” she says, “it gets easier to legislate us out of existence in other ways.” She predicts an exodus of transgender Albertans unless Smith’s policies are reversed.

This will come too late for some. “There’s already been trans youth who have taken their lives in this province because they no longer see a future for themselves,” Bucholtz said. “Last summer we lost a young member of our community, and their surviving family said they believe that it’s 100 per cent related to this.”

Premier Smith poured gasoline on an anti-trans fire that was already burning.

In September 2024 about 50 people assembled at Medicine Hat’s Athletic Park to participate in the nationwide “1 Million March for Children” protest. They walked to City Hall, where they rallied in favour of “parental rights” and against “gender ideology” in education. Julia Ingram, mother of a 13-year-old transgender daughter named Skyler, joined a group of counter-protesters up the street at the public library. “We were just there with our signs showing love,” Julia said.

They received no love in return. The parental rights demonstrators snarled insults at Julia and her colleagues and called them pedophiles. The worst part of the day for Julia, however, was seeing people she recognized in the crowd of haters. “I’ve been in the city for a long time,” she said. “I know there are people who don’t like me, and don’t like my family, and don’t agree with how we live. To be able to put a face to those people was really gutting.”

Skyler first switched to she/her pronouns in Grade 3. Her classmates didn’t understand the change and teased her. “It’s really weird being trans,” Skyler said. “But it was a big day for me.” Julia had met with Skyler’s principal, vice-principal and school counsellor in advance of the change. The school staff supported Skyler’s pronoun transition, but it took two years for the change to stick. Finally, in Grade 5, teachers referred to Skyler as “she” for the entire school year. “I remember thinking, ‘Wow. I’m actually being respected.’”

No transition journey is easy. Skyler’s father didn’t accept her identity at first. He does now. “We’ve come so far,” Julia said. “We went from wiping off nail polish before her dad came home, to her dad bringing her on a father–daughter trip to Lake Louise.” Just like Kim and Ashley Large with their daughter, ensuring Skyler is supported at home remains Julia’s top priority.

Skyler began her puberty-blocking therapy just a few weeks before the legislation came into effect. The thought of being denied the treatment terrified her. “Not to sound crazy, but I would be really messed up if I couldn’t have hormone blockers. Suicidal. Really depressed. Life would be hard.” Skyler has transgender friends, though, who won’t receive the blockers. “It really sucks for them,” she said. Two of them are gifted athletes who won’t be able to pursue sports under the new rules banning transgender girls from competing on cisgender teams.

In response to the UCP’s policies, Skyler created a YouTube channel, “ProtectTransYouth.” One of her first short videos featured distorted images of the premier flashing alongside screengrabs of news headlines related to the trans policies, all set to a nightmarish soundtrack of woozy funhouse organs—the aesthetic opposite of Smith’s video from the previous January. A caption encourages viewers to sign a petition to stop the legislation.

Julia believes her daughter’s outspoken nature and ferocity—her “attitude and life and brightness”—bode well for her future. “She’s gonna be the first trans kid to do a lot of things,” Julia said, beaming.

Skyler is specific. “I want to work at a nuclear reactor,” she said. “Or be an MLA.”

Not all trans kids enjoy such family support. Hawthorne Guthrie started transitioning when he was 14. His puberty was already in progress by then and it was too late to block it. Instead, he sought hormone replacement therapy (HRT). First, though, Hawthorne had to go through two years of appointments, diagnoses and consultations. Once the therapy started, his medical transition advanced quickly. Hawthorne grew his beard within four months of HRT, though he attributes this as much to his Mediterranean genetics as to the testosterone. “I’m Greek,” Hawthorne said, now 19 years old. “I was already halfway there.”

Hormone medications, whether Hawthorne’s testosterone or Skyler’s puberty blockers, do more than ensure trans youth feel comfortable in their own bodies. Fairly or otherwise, these treatments also allow other people to be more at ease around them. “Gender dysphoria affects every aspect of a person’s life,” Hawthorne said. “It’s not just a discomfort within the body. It’s a discomfort with how people perceive you.” The further a trans youth progresses on their transition journey, especially if they “pass,” the more they’re accepted. This acceptance affords them safety.

Had he been a 16-year-old trans kid in Alberta today, and living under Smith’s new laws, Hawthorne wouldn’t be able to access HRT and enjoy the solace the treatment brought him. Transitioning socially wouldn’t have been enough for him. “HRT was absolutely something I needed to feel fully comfortable,” he said. “That’s not the case for everyone.” He believes that without the therapy, he would never have been safe at school. “I’d be checking my head on a swivel every time I tried to walk into a men’s bathroom.”

Hawthorne grew up in a “nightmare household.” His mother didn’t support his decision to transition. She believed Hawthorne had been brainwashed by the “woke mind virus” and figured his gender dysphoria was a phase he’d inevitably get over. She came around eventually. Hawthorne’s father, though, never did and is no longer part of Hawthorne’s life.

Like many trans kids, Hawthorne found safety at school, particularly with two of his teachers. In his Ontario junior high, Hawthorne would spend many lunch hours with his school’s music teacher and leader of the GSA club. The two would sit in the music room, play guitar and talk. After Hawthorne and his mother moved to Calgary, Hawthorne’s high school English teacher became his new lunchtime confidant. “Sometimes I just sat beside him and read quietly,” Hawthorne said.

Both teachers provided Hawthorne with something vital and fundamental. “It’s so important to know that you have somebody around you who supports you, who respects you, who’s going to have your back, and who really sees you,” Hawthorne said. Such teachers are especially important for youth who don’t have such supports at home. “I grew up in an environment where I never felt seen. So just having those little safe spaces, especially with teachers, was amazing. It was everything.” Without safe people in safe spaces, Hawthorne might not have come out as trans at all.

Had these teachers disclosed their conversations with Hawthorne to his parents, the results would’ve been catastrophic. “If my being trans was thrown into the loop, that would’ve been really, really horrible,” Hawthorne said. “That’s an understatement. It would’ve been disastrous.” When questioned about the dangers of mandating teachers to out trans kids to potentially violent parents, premier Smith has said Alberta already has “child protection laws that will be strictly enforced.” Smith loves trans kids enough to rescue them after they’ve been abused, and maybe punish their abusers, but not enough to prevent them from being abused in the first place. In other words, why worry about preventing fires as long as we have a fire department to fight them once they’re blazing?

Two days after the UCP’s Health Statutes Amendment Act, 2024 (No. 2) received royal assent, Egale Canada, Skipping Stone and several families in Alberta launched a lawsuit against the Alberta government. Lawyers claim the statute violates the Charter rights of young Albertans—particularly their right to security of the person, their right to be free from cruel and unusual treatment, and their right to equality.

Mason, and many of the families of trans youth they speak to, have invested their hopes in such legal battles and court injunctions. The outcome of this suit remains uncertain. The premier has already threatened to use the notwithstanding clause to override the Charter if necessary. “But at least we can tie these up in court for as long as we can in order for their families to have the most protection and the most access to life-saving care,” Mason said. The longer they can hold up the legislation, “the longer trans kids can continue playing on their soccer teams with their friends and enjoy their regular lives.”

In the meantime, transgender Albertans and their advocates are gathering resources in order to minimize the harm inflicted on their community. “There are already major pushes to build support networks to help trans youth who are struggling and facing negative mental health outcomes because of this,” Bucholtz said. And they want to make all Albertans understand what’s at stake. “It’s shocking how many people still don’t know what’s happening to us.”

Hawthorne agrees. “People don’t listen until we’re dead,” he said. “The time for polite allyship is over.”

Marcello Di Cintio is the author of several non-fiction books, including Driven, Pay No Heed to the Rockets and Walls.

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Read more from the archive “System in Chaos” November 2014.

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March 10-14, 2025

Alberta Views — Fri, 14 Mar 2025 19:13:30 +0000

Monday, March 10: Legal action began against the UCP government law that prevents doctors from providing gender-affirming treatment, including puberty blockers, for those under 16, arguing it is unconstitutional to deny medical care to a specific group of Albertans and a violation of the Charter right to equality.

March 10: NDP leader Naheed Nenshi said Premier Danielle Smith should cancel her taxpayer-funded Florida speaking engagement at a fundraiser for PragerU, where she will co-host with Ben Shapiro, who supports Canada becoming the 51st state.

March 10: The Sexual Assault Centre of Edmonton has paused intakes due to significant and unexpected cuts from the UCP.

Wednesday, March 12: Forestry and Parks Minister Todd Loewen introduced legislation that, among other measures to “modernize hunting,” allows 12-year-olds to hunt without adults around.

March 12: An agreement was signed by Premier Smith and Ichiro Takahara of the state-owned Japan Organization for Metals and Energy Security at the CERAWeek energy conference in Texas. Japan is the province’s third-largest export market, with trade totalling $3-billion in 2024.

Thursday, March 13: The provincial government suspended the loan program of Alberta’s largest cattle industry lender, Picture Butte Feeder Cooperative, after an inspection, alleging financial mismanagement. PBFC, with 227 members, owes $281-million, which it says is the same amount it has loaned to its members.

March 13: A statement of defence was filed in court on behalf of Alberta Health Services and Health Minister Adriana LaGrange. It disputes the allegations in former AHS CEO Athana Mentzelopoulos’s wrongful dismissal suit by claiming she was terminated because she did not advance the UCP government’s plan to divide AHS into four organizations.

March 13: Amid a measles outbreak in Little Red River Cree Nation, LaGrange is not recommending all residents get a measles vaccination, saying it’s “a parental choice.”

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March 3-7, 2025

Alberta Views — Fri, 07 Mar 2025 23:05:31 +0000

Monday, March 3, UCP backbencher Scott Sinclair (Lesser Slave Lake) said he won’t support Budget 2025 because he’s “furious” at the amount of money for Alberta’s two major cities.

March 3, The government appointed Raymond E. Wyant, former chief judge of the Provincial Court of Manitoba, to lead an independent third-party investigation into irregularities in contracts amid an ongoing healthcare scandal. He has a $500,000 budget to report by June 30 and will be paid $31,900 a month. NDP leader Naheed Nenshi questioned the validity of the process: “He is limited to rely only on the information provided by the government itself.” Alberta’s auditor general, Doug Wylie, is also looking into contracting and procurement at the Health ministry and Alberta Health Services (AHS).

Tuesday, March 4, US President Donald Trump implemented a 25 per cent tariff on all Canadian goods and a 10 per cent tariff on Canadian energy. In 2024 Alberta’s exports to the US totalled $162.6-billion, of which $132.8-billion were energy products.

Wednesday, March 5, Alberta announced it would stop buying American alcohol and cease contracting with US companies, including a halt on purchasing VLT machines from the US—a $100-million annual expense. About 10 per cent of liquor products in Alberta are imported from the US. In 2023–2024, $292-million in US liquor was sold in Alberta. The Canadian Association of Energy Contractors said it opposes retaliatory tariffs. The 25 per cent retaliatory tariff on US sand, for example, means $250-million a year in extra costs to Alberta’s oil and gas industry.

Thursday, March 6, The Alberta RCMP launched an investigation into AHS and allegations of political interference and potential conflicts of interest within its procurement practices.

Friday, March 7, Premier Danielle Smith said her government is planning to send its supply of unused children’s pain medication to Ukraine. The government paid $70-million to MHCare Medical for the medication in 2022 during a countrywide shortage. Alberta received only about 30 per cent of the shipment and the company that provided it is now embroiled in a contracting scandal. Alberta has been sitting on 1.4 million bottles of the medication after officials determined in 2023 that it posed serious health risks to infants.

March 7, The UCP removed MLA Sinclair from caucus after he said he would vote against Budget 2025.

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Feb 24–28, 2025

Alberta Views — Fri, 28 Feb 2025 20:35:48 +0000

Monday, February 24, 2,000 education support workers from Calgary and area hit the picket lines. They joined 4,000 more workers in Edmonton, Fort McMurray, and the Sturgeon School Division who are already on strike.

Tuesday, February 25, Health Minister Adriana LaGrange fired CIO (Chief Information Officer) of AHS Penny Rae. Rae is recognized as one of Canada’s top women leaders in digital health. Previously, on January 8, LaGrange had fired the CEO of AHS, Athana Mentzelopoulos, who filed a $1.7-million wrongful dismissal lawsuit. Then, on January 31, LaGrange fired the entire AHS board.

Tuesday, February 25, Pete Guthrie, the Minister of Infrastructure, resigned from cabinet, saying he lacked confidence in the government’s procurement processes. Earlier he had called for LaGrange to step down during investigations into serious allegations made by Mentzelopoulos.

Tuesday, February 25, The legislative assembly resumed sitting for its spring session.

Thursday, February 27, the government presented Budget 2025. Highlights:

• $5.2-billion deficit on total spending of $79-billion, with more money for contingencies, tariffs and disasters

• $26-billion for capital projects such as hospitals and highways, including $2.6-billion for new schools

• personal income tax cuts costing the government $1-billion in foregone revenue and saving individual Albertans roughly $750 a year

• contributions are projected to grow the Alberta Heritage Savings Trust Fund to $250-billion by 2050

Budget 2025 also allocates $180-million over three years to build two 150-bed addiction treatment centres, one in Calgary and one in Edmonton, under the proposed Compassionate Intervention Act, which allows forced treatment.

As the Budget was being presented, 50 busloads of striking education support workers protested outside the legislature. The average school support worker in the province makes $34,500 per year, said CUPE Alberta president Rory Gill.

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Masking Fear

Paula Simons — Wed, 01 Jan 2025 10:00:55 +0000

Excuse me, are you senator Simons?” It’s early afternoon at the Old Strathcona Farmers’ Market and I’m buying myself a big bag of carrots, for the borscht I intend to make for dinner. Senators—and political columnists—enjoy a strange degree of semi-celebrity. We’re not quite famous enough to be regularly recognized, so any time a stranger comes up to me to say hello, I’m a little bit surprised, and a little bit leery.

Still, the Venn diagram of people who shop at the hipster Old Strathcona Market, and people who might be expected to follow my work in the Senate contains a lot of overlap. So if I’m going to be recognized anywhere in Edmonton, it’s likely here.

“I just want to thank you,” the woman says. “I want to thank you for wearing a mask.”

It’s true. I’m at the market this afternoon wearing a sturdy N95. A couple of years ago, lots of people in this crowded market would have been wearing masks too. But on this sunny Saturday, the woman and I are pretty much the only two people still masking up—despite news reports that indicate COVID-19 rates are rising again and the flu season has arrived early.

She thanks me one more time, not just for wearing a mask in the market but for sharing videos and photos of myself, with my mask, on social media. She tells me how much it helps her to find the courage to mask herself when she sees me, a public figure, doing so.

If the sight of my mask makes you angry or uncomfortable, you should ask yourself why.

I thank her and continue my shopping. But her voice echoes in my ears.

Yes, I’m still wearing a mask. And yes, it takes some courage. Any time I post images of myself in a mask on my Facebook page, the insults and jeers come thick and fast, mocking me for wearing “a face diaper” or for being too stupid to know that COVID is “over.”

I’ve had strangers shout angry abuse at me as I walk through airports. But I think the most exasperating are the jokes and eyerolls from colleagues and family members, who seem to take my mask as a personal affront or insult. These friends and relations bug me—jokingly, but incessantly—to take it off, or tease me for what they perceive as my neurosis. I had one Senate colleague make fun of me for masking—only to tell me, in his next breath, that he was just getting over his fourth case of COVID.

People ask me: Why are you still wearing a mask Isn’t it uncomfortable or inconvenient Aren’t you tired of it?

Well, yes. It is. All of those things. And yet I mask. Even if that makes me an outlier.

I have what you might call “a high-risk lifestyle.” I fly on jam-packed airplanes twice a week. I attend many meetings and busy receptions with hundreds of guests. So the odds of my being exposed to the coronavirus are higher than average—and so are my odds of spreading it to others.

I have a personal health history that makes me wary. I shan’t bore you with details. Let’s just say that if I were to get COVID, it might be nastier than the average case. I’ve been careful to get every shot, to wash my hands, to mask in crowded indoor spaces. And, touch wood, I haven’t had COVID. Yet.

I confess, though, I do feel a glimmer of glee every time I trigger a troll with my mask.

Maybe that’s naughty. Look, I know people are tired of COVID, I know how badly we all want to forget how awful things were at their worst, how many millions died, how many more were left with long-term health consequences. Like a modern-day memento mori, my masked face reminds people of horrors they’d rather deny. But no matter how hard we wish it away, we’re still dealing with an infectious disease that can make some people quite sick, even though the latest mutations and variants are less dangerous than the original virus.

Perhaps my mask isn’t protecting me as much as I think it is. At this point, I accept that it’s also something of a talisman, to help me deal with my anxiety about catching this disease, or about spreading it to someone more vulnerable than I am. But I don’t apologize for that. If I am wearing a mask for my own psychological comfort, well, that’s not really anyone else’s business either. Frankly, I’m sick and tired of people harassing me about it, online or in person.

But my encounter this day at the farmers’ market reminds me that I’m not just wearing my mask for myself. I’m wearing it for all the people who are masking because they are seriously immunocompromised. Or because they’re caring for someone who is immunocompromised. I’m wearing it as a public figure, to give permission to everyone else who needs or wants to mask. I will go on masking, to tell them they are not alone. And to remind everyone else that this thing isn’t done with us yet.

So, if the sight of me, in my mask, makes you angry or uncomfortable Perhaps, instead of making fun of me, you should ask yourself why.

Paula Simons is an independent senator and the host of the podcast Alberta Unbound. She lives in Edmonton.

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The Hidden Connections in the Skybox Photo

Nate Pike — Wed, 01 Jan 2025 10:00:21 +0000

At the start of the pandemic in the early days of 2020, Alberta Health Services (Tyler Shandro was then minister of health) made the decision to source personal protective equipment, or PPE, from a holding company that was run by someone who, up until that point, predominantly worked in the field of oilfield training—Mraiche Holding Corporation.

The contact for Mraiche Holding Corporation was a Sam Hassan Mraiche using an email address from another one of his companies, Carver PA, a corporation that, by their own description, “specializes in providing training to the petrochemical industry.”

That initial purchase of PPE was reportedly for $228-million and included masks, gowns and thermometers. Most of the supplies were made in China. The quality control was so bad it made widespread news.

The masks, delivered under the brand name Vanch, were reportedly of such low quality that many didn’t even fit the faces of healthcare workers properly. They had nose pieces that unsafely didn’t hold their shape and because of that, couldn’t create a seal providing the proper protection for healthcare workers braving the pandemic. Perhaps worst of all, many masks came with an odour that healthcare workers claimed was making them sick.

Many have since pointed out the masks were not made by a single manufacturer, but by multiple manufacturers with varying quality. Contrary to the Government of Alberta documentation, Vanch is not the name of the manufacturer. It’s the brand name of a Chinese stationery group which sourced the masks from anyone who could meet their order, and then packaged the masks in their Vanch-branded boxes. Nonetheless, AHS continues to use Vanch masks.

So, to be clear, at the start of the pandemic, when protection for healthcare workers should have been a foremost concern, a company that had no obvious experience or track record in providing healthcare personal protective equipment received a sole-source contract for products that turned out to be substandard and allegedly harmful to the very healthcare workers it was supposed to protect.

And that company was run by Sam Mraiche.

AHS was paying 85¢ a mask from Mraiche Holding Corp. compared to 50¢ a mask from Acklands-Grainger. So Mraiche Holding Corp. was charging 70 per cent more for a lesser quality product, and Albertan taxpayers covered that cost.

This sole-source contract for problematic PPE was, in effect, the birth of a new company called MHCare Medical, operating under the Mraiche Holding Corporation (or Mraiche Investment Corporation) umbrella. And it wasn’t the last time they would deliver problematic product to Alberta at great cost to the taxpayer.

Later in the summer of 2022, Canada experienced a tridemic caused by ongoing waves of the Omicron COVID variant, a spike in RSV among children, and an early start to the flu season with a strain of influenza B that particularly affected kids. This caused an unprecedented demand for children’s pain and fever medication in the forms of acetaminophen, most commonly known as the brand name Tylenol, and ibuprofen, most commonly known as children’s Advil and Motrin.

It’s also worth noting that over the first half of 2022, most public health measures across Canada, except voluntary vaccination, were abandoned. In August of 2022, Sick Kids Hospital in Toronto recommended parents get prescriptions for those medications [acetaminophen and ibuprofen] to ensure supply in advance of the flu season, even though they are non-prescription, over-the-counter medications and a prescription would not ensure supply if the pharmacist were out of stock. By the time the Canadian Pharmacists Association was able to get out a rebuttal, mass hoarding in advance had already begun emptying shelves in eastern Canada and causing a 53 per cent increase in sales in US pharmacies along the border.

This caused a nationwide shortage of these two medications heading into the fall respiratory virus season. To make matters worse, the 2022–2023 influenza season started in October, roughly six weeks earlier than expected. As soon as pharmacies got stock, people would clean out shelves to stockpile it at home, even if their kids weren’t sick. In September 2022, Health Canada began working with global manufacturers to adapt their products for the Canadian market. By November 2022, the federal government had approved the import of nine brand name products from the United States and Australia, resulting in the import of over 4.4 million units over the winter. In parallel, Canadian manufacturers massively ramped up production of children’s acetaminophen and ibuprofen under brand names trusted by Canadians to release 13.9 million units by May 2023.

Normal demand across Canada for these medications is 300,000 to 400,000 bottles per year. The combination of sudden surge in illness in 2022 plus the hoarding emptied retailer shelves. But as sharply as that pediatric influenza B spike began in October, it fell in November, and largely ended over Christmas. It became obvious over the month of November that Health Canada’s pumping the market with imports would catch up to the market by year-end, especially with the drop in pediatric influenza and the related calming and hoarding.

Nonetheless, on December 6, 2022, premier Danielle Smith and then health minister Jason Copping announced they were signing a deal with Turkish company Atabay Pharmaceutical for five million bottles of children’s acetaminophen and ibuprofen to supply to Alberta pharmacies at a cost of at least $80-million.

Danielle Smith said: “Your government is taking action to help provide the medication Alberta families need. I’m happy to announce that we have secured a supply of five million bottles of children’s acetaminophen and ibuprofen for Alberta families right now.

“Your government is working with Alberta Health Services and Health Canada on the details and logistics to import this medicine, and you can feel confident that we are all moving as quickly as we can so that Alberta families can get what they need, and it will be available at your local pharmacy in short order once it arrives.”

They claimed this medication would be available for import in a few weeks if Health Canada practised the spirit of co-operative federalism. They also claimed parents would be able to keep their kids out of the hospital if they could buy the medication in pharmacies.

Danielle Smith said: “I think one of the reasons for this announcement is to make sure that we are providing parents with the medication they need so that they can treat at home and ensure that they can break the fever at home. That’s the most important step we can do to keep the pressure off the hospital.”

During this shortage many physicians issued public statements that while these medications provide comfort care, they aren’t lifesaving, and they don’t halt the progression of a virus. They manage the symptoms.

Copping falsely claimed that there was no manufacturer in Canada, even though Johnson & Johnson manufactures their version of these products in Guelph. Copping also falsely claimed that Health Canada had approved the raw ingredients from the Turkish manufacturers but not the final product.

Even after the debacle with PPE, the government used Mraiche’s company in a sole-sourced contract to obtain children’s medication.

Alberta has about 700,000 children under the age of 12. The Alberta Pharmacists Association claimed they could use about 500,000 bottles, if received in December as promised by Smith and Copping, but did not commit to buy any. Alberta was ordering more bottles than the entire population of the province. Five MILLION bottles.

Premier Smith and health minister Copping were confident that Albertans wouldn’t be on the hook for the surplus, and that Alberta would be able to sell the bottles to other provinces. For additional context, five million bottles is about 10 to 14 times the entire national demand for children’s pain and fever medications. Between imports and increased domestic production, Health Canada stockpiled over 18 million bottles that winter. Surplus inventory after the winter was more likely to be a problem than a shortage. Out of the $80-million total budget, the Government of Alberta committed to purchase $70-million worth of meds at $14 a bottle, which is about twice the retail price. The other $10-million was for unspecified internal costs.

The Atabay dosage was not the same as the North American dosage, which is a safety issue triggering advance warnings from pharmaceutical colleges as well as Alberta Blue Cross. Because of this, the Atabay products could only be brought in by “exceptional import” in a process requiring attestation of the shortage by Alberta’s Chief Medical Officer of Health.

But there was also the problem that Atabay hadn’t supplied medicine to the Canadian market, and their products—that Alberta taxpayers had just paid millions for—did not meet Health Canada specifications: dosage, child safety caps, warnings, dosing devices, packaging, labelling and more.

Copping admitted that Alberta taxpayers would have to subsidize the price to other provinces to match their wholesale prices; that wholesale cost of $14 a bottle was, and is, significantly more than the normal retail cost of the trusted supply that had already seen a huge manufacturing increase a month before this deal was even made.

The problems continued.

The medication itself didn’t even start to arrive until January, but because of issues with the labelling and the dosing, that first shipment of 250,000 bottles could only be distributed to Alberta hospitals, where nurses could be trusted to perform the extra work of converting the dosage before administering the medication to patients. Medication for the public to purchase in pharmacies didn’t arrive until late March, two months after Health Canada allowed another exceptional import and well after the shortage of the trusted brand name supply had been resolved.

The medication had to be stored behind the counter, as the pharmacists were required to teach parents how to adjust the dosage. But the problems didn’t stop there. Because of the delay in nine shipments, and the wrong dosage, no other provinces had any interest in buying them. Also, since Health Canada has not provided regulatory approval for any Atabay product at a national level, any other province could only get them on a case-by-case application to Health Canada—again for exceptional import—which again would require a shortage.

Alberta was ultimately only able to import 1.5 million of the five million bottles purchased, because the shortage justifying the exceptional import had ended and Health Canada never provided approval for anywhere other than Alberta. New health minister Adriana LaGrange directed this massive overshoot to Alberta hospitals. This inventory was dumped into AHS books even though AHS never had a shortage and had its own suppliers through 2022 and 2023, and the original stated intent for these medications was that they had been purchased for retail sales in pharmacies.

Perhaps most concerning, though, the medication that was distributed to hospitals for use was only approved for ages 2 and up. AHS determined that because of its consistency, if used with newborn babies in the neonatal intensive care units, it could place them at a risk of a condition called necrotizing enterocolitis, which kills the intestines of infants, when the medication is administered through feeding tubes.

Alberta Health Services discontinued the use of the medication entirely. Fortunately, nobody was hurt. All told, Alberta hospitals used the medications for only two months before returning to their already established supply. But that only further underscores the question: if the medication was originally purchased to be distributed in pharmacies for the public to buy, why was it ever redirected to the hospital supply?

Alberta only received 1.5 million bottles of the five million bottles the province paid for. And of that 1.5 million, only a total of 4,700 bottles made it to community pharmacies for the public and only 9,000 bottles made it into hospitals across the province. Alberta ended up paying to store the rest of the medication, and has no way to recoup any of the money spent. Given that only 13,700 bottles ever made it into any kind of circulation, Danielle Smith paid $5,839.42 per bottle using taxpayers’ money.

Although the government tried to hide the existence of a middleman who allegedly orchestrated the entire deal, it has since been confirmed to be the importer, MHCare Medical, the company owned by Sam Mraiche. They received the $70-million from Alberta Health. It is unknown how much of that they paid to Atabay for the 1.5 million bottles actually shipped. It’s also unknown whether the five million bottle minimum purchase was required by Atabay or by MHCare Medical.

Even after the safety debacle with the masks and the PPE, the government still decided to use Mraiche’s company in a sole-sourced contract through AHS to obtain children’s medication. The products never received regulatory approval, they had the wrong dosage despite a custom manufacturing run, and multiple shipments were required to get the safety caps and labelling right—seemingly by trial and error—requiring secure disposal. Again, all paid for by Alberta taxpayers. Some have since speculated that individuals within the UCP government had attempted to purchase the five million bottles of Atabay product in order to bootstrap MHCare Medical into being a national distributor of pharmaceutical products, starting with the children’s acetaminophen in the hopes that there would still be a shortage when the imports finally arrived.

The taxpayers carried all the risk of that minimum buy, of the failure to meet the regulatory requirements and of demand drying up before the late arrival of the product. It was an entirely predictable $80-million catastrophe. The mismanagement of the government and MHCare Medical caused both parties to fail at establishing MHCare as a distributor of pharmaceuticals, if that was their goal. To this day, they only have a Health Canada licence to import, not to distribute or retail. They do not list any pharmaceuticals for sale.

How is it that Sam Mraiche and MHCare medical kept getting contracts after their Vanch masks failed to meet the required ASM standard Most of them wouldn’t fit or hold any shape, and many of them caused breathing issues and skin rashes in healthcare workers. And after 100 per cent of the children’s acetaminophen product failed to have the standard dosage, was never approved by Health Canada outside of exceptional circumstances, was months too late and effectively cost $80-million to only get 13,700 bottles to hospitals or pharmacies?

In 2023 Sam received the Queen’s Platinum Jubilee medal from UCP minister Muhammad Yaseen in a ceremony that was quickly posted to the MHCare promotional website and their YouTube channel. There’s no advertising like free advertising.

Sam Mraiche has won more than a quarter billion dollars in sole-source contracts from Albertans to supply medication that was only used in hospital for two months, was minimally used in pharmacies, that no other province wanted; and masks and other PPE that healthcare workers call problematic.

On May 10 Danielle Smith flew to Vancouver with two staffers and an impressive entourage to watch a game in an elite private skybox with tickets that were gifted to her by a private citizen, one Sam Jaber. Jaber was appointed to the board of Invest Alberta on November 22, 2023, by Danielle Smith. The fact that Smith accepted these tickets is a problem in and of itself or at least it would be almost anywhere else in Canada….

Who else was at the game The photo of the premier at the hockey game appears to be a peek into the sprawling network that Sam Mraiche has built for himself. In the back row, we have Aaron Barner, senior executive officer for the Métis Nation of Alberta, then Sam Mraiche, then Andrea Sandmaier, the president of the Métis Nation of Alberta, and then Sam Mraiche’s wife. Also in the picture are David Eby and his family. But the key to understanding all of the invisible connections in this picture is the person who isn’t even in it, the person who made the whole picture possible: Sam Jaber.

Mr. Jaber is a businessman and accountant whose primary business appears to be the accounting firm Jaberson and Associates. That business is run out of an industrial office strip mall at 5430 136 Ave NW in Edmonton. The other business run out of that address is Phoenician Accounting and Tax Services. Jaberson and Associates and Phoenician share a business address, phone number and a client portal that says “Welcome to the Jaberson and Associates client portal” but is hosted on the Phoenician website.

Four numbered companies were registered by Sam Jaber in September of 2023, just two months before he was appointed to Invest Alberta. The records address for all four companies is Sam Jaber’s offices. All four of these numbered companies use the contact email address ocorcescu@carvercorporation.com.

An online search reveals that Olesea Corcescu used to be a payroll administrator for Phoenician Accounting, an accountant with Carver and a senior accountant with MHCare Medical.

The registered office for all four companies is 3001, 14815 119th Ave NW in Edmonton. That address is also the location of the Carver building, a three-storey office block that also serves as the headquarters for MHCare and the Carver PA Corporation. That’s the same Carver Corporation that Sam Mraiche used as his contact throughout the Vanch debacle before he converted the holding company to MHCare Medical Corporation in 2020.

Sam Mraiche, whose companies provided controversial products on not one but two high-profile occasions, and who has presumably made a boatload of money off of those deals on the taxpayer dime, has a long-standing business relationship with Sam Jaber. The same Sam Jaber that gave Danielle Smith expensive elite skybox tickets.

From the Oct 27, 2024, episode of The Breakdown, a podcast about provincial politics produced by Nate Pike. Founded five years ago, The Breakdown has over 40,000 followers on social media and YouTube and is available on most podcast platforms.

You can find The Breakdown on X @TheBreakdownAB

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Should healthcare have user fees?

Shawn Whatley and Shazma Mithani — Sun, 01 Dec 2024 20:36:00 +0000

Shawn Whatley says YES

Physician and author of the report “The Case for User Fees in Canada” (MLI, 2022)

User fees can’t fix all of medicare’s problems. But a properly designed user-fee program would increase efficiency and equity while decreasing overconsumption and waste.

Consider a common example. A mother brings her feverish crying child to a clinic. “Since we’re here already,” mom asks, “Could you see my other children too?” Most parents don’t waste time on minor symptoms. But having made the effort to get one (sick) child to the clinic, parents often want their other (mildly sick) children seen also. On any given day, a few patients will come to clinic with questions they would never have asked if they faced a small user fee.

Canada curbs consumption by rationing access to care. We limit spending and make everyone wait in line. Physicians are forced to say, “I simply can’t see your other kids. You can go to the emergency department if you’re worried.” Physicians get paid to see more patients, but often have no time to do so.

Twenty-nine OECD countries now have universal health care, and 21 of them include a patient fee at the point of service, with exemptions for the elderly, poor and chronically ill. User fees focus limited resources on those who need them most.

They also improve horizontal equity. For example, one patient with early osteoarthritis of their hip will follow instructions about weight loss and exercise to manage symptoms. They’ll get annual checkups, and eventually they’ll get a joint replacement. Another patient, with similar symptoms, will ignore advice, book appointments every few months, demand referrals to multiple specialists and ask for repeat CT scans until they too eventually need surgery. Given similar incomes and expenses, should patients pay the same for medical insurance if they show markedly different choices about medicare resources?

Despite the evidence supporting well-designed user fees, poorly designed fees cause real harm. Canada has already tried several bad designs. Vulnerable patients avoid necessary care and skip treatment with even the smallest fee. For this reason, modern fee programs have robust exemptions for the elderly, poor or chronically ill. Furthermore, fees don’t change patient behaviour for some services. No one seeks open-heart surgery because it goes on sale.

User fees reduce overconsumption and increase equity but don’t work well at raising revenue. In fact, focusing services on patients with the greatest needs might actually increase the cost of care overall. Morality, not economics, drives the case for fees.

Small, flat, easy-to-understand user fees work best. However, even well-designed fees would not be enough without other changes. We already have major barriers to care. Why charge $20 to see a doctor if a patient waits months to get seen?

User fees are like medication: we need the right agent for a particular patient with a specific problem in a defined setting. One size never fits all. Canada ruled out user fees 40 years ago. The latest evidence suggests they might help us today.

Shazma Mithani says no

Emergency physician at Royal Alexandra Hospital and Stollery Children’s Hospital

User fees to improve access to healthcare have been proposed for decades as a “solution” to growing use of the healthcare system. It’s no surprise they’ve come up again in the context of post-COVID healthcare system strain.

At a superficial level, the concept of user fees would make sense to most people. A nominal fee to access the system should prevent patients from overusing the system and lead to decreased emergency department overcrowding, shorter wait times, lower system costs and better patient outcomes, all while putting more money into the system, right?

Turns out it’s a lot more complicated than that. Data from around the world show us the exact opposite. User fees may deter unnecessary care, but they’re also really good at deterring necessary care.

Last year I treated a patient who presented to the ER with symptoms of a heart attack. They were driven to my community ER, where no cardiologist is on site, after deciding against taking an ambulance because of concerns about cost (an ambulance ride in Alberta, even for emergencies, costs about $350). If they had taken an ambulance, they would’ve been diagnosed with a heart attack by the paramedics and taken directly to a larger hospital with cardiology services. Instead I saw this patient in the community ER, diagnosed their heart attack, then had to transfer them to a larger hospital, all of which wasted precious time. As all doctors will tell you, in the context of a heart attack “time is muscle,” meaning that every minute of delay before opening up a blocked blood vessel leads to more heart muscle dying.

Many people think user fees curb “unnecessary” use of the healthcare system. Part of the problem with this narrative is that patients aren’t trained in medicine. It shouldn’t be up to a patient to decide the seriousness of their symptom before deciding whether it’s financially “worth it” to go in. Even for people who can afford to pay, as soon as a fee is involved, it leads to second-guessing, downplaying and, inevitably, delayed care. For almost all medical conditions, early intervention and treatment improves outcomes and ends up decreasing longer-term costs and use of the healthcare system.

When a patient with diabetes delays care and ends up having a severe complication such as diabetic ketoacidosis, what could have been a simple (and cost-effective) visit turns into an emergency resuscitation and multi-day hospital stay. When a patient with blood in their stool ends up waiting for their symptoms to become more severe, what could have been a simple polyp removal turns into months of chemotherapy, surgery to remove their missed colon cancer, and ongoing presentations to the ER with complications of their cancer.

Simply put, user fees lead to delays in care. These delays in care lead not only to increased financial costs, but costs to patient outcomes, quality of life and years of life.

shawn whatley responds to shazma mithani

Patients forgo necessary care if they face large, one-size-fits-all fees. Even small fees cause harm in poorly designed programs. Quebec and Saskatchewan tried ill-formed fee experiments, which caused low-income and elderly patients to skip treatment. Well-designed user fees include exemptions for specific patients and conditions. Clearly, we don’t need a fee on routine immunizations or screening for breast, colon and cervical cancers. Too many patients avoid preventive care already.

The best argument against user fees in Canada is Canadian medicare itself. We are world-famous for wait times and regulation. Adding user fees to medicare would add another roadblock to a system strangled with barriers to care.

This touches something buried beneath the user fee debate. When it comes to decisions about waiting and payment for care, Canada assumes someone other than the patient knows best. Dr. Mithani captures this sentiment when she writes, “Patients aren’t trained in medicine. It shouldn’t be up to a patient to decide the seriousness of their symptoms before deciding whether it’s financially ‘worth it’ to go in.”

Anti-patient ideas run deep in medicare. Dr. Charles Wright, a former Vancouver hospital administrator and wait list consultant said, “Administrators maintain waiting lists on purpose, the way airlines overbook. As for urgent patients on the list who are in pain, the public system will decide when their pain requires care. These are societal decisions. The individual is not able to decide rationally.” A former deputy minister of health of Ontario put it this way: “We have waiting lists for some procedures as a means of better organizing our system.”

The same sentiment applies to payment. A senior Canadian health researcher said, “I think we have to be very careful about empowering the consumer, because they will make choices that are not in their own health interests.” Canada’s foremost health economist, Bob Evans, agrees and writes that the “rational consumer” is a “highly dubious assumption.”

Canada built its system of “free care” in the 1960s, at the end of a peculiar period in history. The average Canadian was in their mid-20s, with few medical concerns. Older patients had survived the Second World War and the Depression. They knew how to protect a shared asset, such as medicare, and trusted government to manage it.

We built an all-you-can-eat health system for a population that ate very little. It now has an almost endless appetite.

Today the average Canadian is in their early 40s. The percentage of people over 65 has doubled. Trust in government has evaporated. Modern Canadians demand convenience, access and excellence in a way older generations never imagined. As a society, we’ve reverted to a more typical attitude towards shared resources, known as “the tragedy of the commons.” This is the tendency to overconsume shared assets to the point of destroying the asset itself. The Depression-era slogan “Use it up, wear it out, make it do, or do without” would never fly today.

This puts Canada in a bind. We built medicare for a population that no longer exists. Having built an all-you-can-eat healthcare system, for a population that ate very little, we now have a population with an almost endless appetite for care. So we scramble to limit access from behind the counter. Note, all countries must limit (ration) the amount of care patients can access. One extreme strategy is to base care entirely on a patient’s ability to pay for it. Canada stands at the opposite extreme: central planners control how much free care citizens are allowed to access.

Herein lies the crux. Health economist Victor Fuchs put it this way 50 years ago: “[A] basic point, often obscured in public discussions, is that the public must pay for care under any system of finance… even when the payment mechanism makes it appear that the bills are being sent elsewhere.” He added, “Financing systems can make a significant difference to families at the highest and lowest levels of income, but the average family will have to pay the same under any system.”

The heart of this debate isn’t about costs, crowding, wait times or outcomes. It’s about control. User fees place a crack in the assumption that planners know best—they’re a step toward a middle ground. User fees shift some decisional responsibility and power away from planners and toward patients themselves. In thousands of small decisions each day across the country, user fees would encourage patients to limit overconsumption and waste. This would improve efficiency and equity, thus improving overall welfare. These improvements remain beyond the reach of rationing or central control. Planners can’t compete with the mass of individual patient decisions.

Other countries find user fees essential. Canada would need a new mindset for user fees to work. Change is hard. But we need to change and consider things such as user fees, or we risk losing medicare itself.

shazma mithani responds to shawn whatley

The term “health care zombies,” which aptly describes terrible ideas in healthcare that refuse to die, was coined in 1998 by Barer et al. Healthcare user fees have long fallen into this category and will continue to do so.

In my opening argument I gave examples of why user fees simply don’t make sense. Patient stories are so valuable at illustrating a point, but as a physician I always look at the data. Dr. Whatley asserts that evidence suggests user fees may help the healthcare system, so let’s take a deeper look into what the evidence does show.

Most proponents of user fees make two main arguments: that fees will decrease use of the system and that they will help put money back into the system. Presumably the goal is to increase sustainability of the healthcare system.

I was happy to see Dr. Whatley acknowledge that user fees don’t serve to raise revenue. In fact the evidence shows that user fees can actually end up costing the system more, because of the administrative costs of collecting and accounting for these fees. A study in Quebec in 2010 showed that in order to generate enough revenue to make sense, fees would need to be quite high (for example, a fee of $65 per visit would have only contributed 2 per cent of that province’s $27-billion health budget). And these are 2010 numbers. In 2023–2024 Quebec’s healthcare expenditure was over $50-billion, meaning that a $65 user fee would now have an even smaller impact in offsetting healthcare costs.

This “revenue” narrative is also a favourite of governments who argue that user fees will help offset growing healthcare costs. The data clearly shows that user fees end up being expensive, inefficient and wasteful. The money used to administer fees could instead be used much more effectively to improve healthcare access. Further, the evidence is irrefutable that primary and preventive care reduces downstream health and hospital costs. Introducing user fees creates barriers to accessing primary care, which only ends up costing the system more in delayed and more complex healthcare.

User fees cause worse patient outcomes and deter patients from using the system when they need it.

As for the argument that user fees decrease healthcare utilization, the evidence is more nuanced than what Dr. Whatley presents. We can look back to when parts of Canada did have user fees. Back in the 1960s, Saskatchewan briefly introduced user fees. Data show that although the use of healthcare services in that province dropped, the decrease was most significant among people who were least able to afford to pay fees but most likely to need healthcare. In fact, contrary to Dr. Whatley’s suggestion that user fees increase equity, the evidence shows that fees actually diminish it.

The argument that user fees reduce healthcare utilization also ignores the fact that they also cause worse patient outcomes and higher mortality rates—far more important metrics to assess. A review from 2018 looks at these. The authors studied 17 countries and assessed whether lower out-of-pocket expenditures led to improved health. Not only did the data show that health outcomes improve when patients face lower out-of-pocket costs, it also showed reduced mortality in several countries. Lower out-of-pocket expenses for patients can literally be lifesaving.

This data should make one thing very clear: user fees deter patients from using the system for unnecessary and necessary reasons. It should never be up to patients to decide whether a visit to a clinic or the ER is warranted or not. And that mother with the feverish child should be able to have all of her other children seen in a primary care setting. Rather than increasing barriers to care or trying to deter people from seeking care, we should be focussed on removing barriers and optimizing access to care.

In particular, the focus should be on improving access to robust primary care. Good primary care prevents worsening chronic health conditions and subsequently reduces use of the healthcare system. When people have access to primary care, all it takes is a handful of appointments per year to manage diabetes, high blood pressure or high cholesterol (at a cost to the system of far less than $1,000/year). When these chronic health conditions are not regularly managed, it puts this same patient at risk of a heart attack, stroke or complications from their diabetes, with each hospital visit costing thousands of dollars per visit and even more when people require admission to hospital.

More work must be done to improve patients’ health literacy so that they better understand what options are available to address their health concerns and are better equipped to make decisions about their care and reduce unnecessary use of the healthcare system.

Is there overuse of the healthcare system Sure. Are user fees the solution No.

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