TORONTO (AP) — Canada has arguably the world’s most permissive system of euthanasia — the practice of doctors and nurse practitioners killing patients with an injection of drugs at their request. Canada allows euthanasia for people who aren’t terminally ill but are suffering unmanageable pain.

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

Here’s a look at the main takeaways from an AP investigation into euthanasia in Canada, commonly known there as medical assistance in dying, or MAiD.

Some doctors fear providing euthanasia, even in legal cases

Canada allows euthanasia for people with “irremediable suffering” from serious but nonfatal medical conditions and disabilities.

After euthanasia was legalized in 2016, doctors and nurses set up email discussion groups as confidential forums to discuss potentially troubling cases, with limited patient details. They’re now run by the Canadian Association of MAiD Assessors and Providers, an educational and research organization.

Dozens of messages provided to the AP by a participant in the forums — on condition of anonymity, due to the confidential nature of the messages and cases — show a fraught process where medical professionals test the limits of what conditions warrant euthanasia.

In one case, a middle-aged worker whose ankle and back injuries made him unable to resume his previous job told his doctor the government’s measly support was “leaving (him) with no choice but to pursue MAiD.” His doctor told forum participants the patient met legal criteria, with severe pain, strained social relationships and inability to work.

Others agreed, but the doctor hesitated because the man cited reduced government payments as a key factor — and the doctor noted fear of being portrayed in the media as having euthanized someone “in a case where services were inadequate.”

Case of homeless people spark debate

Cases of homelessness appear regularly on the private forums.

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

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

Data suggest marginalized people are affected

Government officials have largely refuted the idea that socially disadvantaged people are being euthanized.

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

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

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

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

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

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

Privately, officials admit concern

Canadian officials have examined worrisome cases that haven’t been publicly disclosed.

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

In one, a 74-year-old patient who’d suffered blood pressure, a stroke and blindness was increasingly dependent on their spouse. The patient told their doctor they were interested in euthanasia, citing deteriorating vision loss and quality of life.

Among other issues identified, officials wrote the patient’s euthanasia was scheduled “based on the spouse’s preference of timing” and questioned whether “the patient’s death was genuinely voluntary.”

Canada pushes boundaries

Theo Boer, professor of health care ethics at Groningen University in the Netherlands, said that unlike other countries with legal euthanasia, Canada appears to be providing it for social reasons in some cases.

“That may be what Canadians want, but they would still benefit from some honest self-reflection about what is going on,” he said.

Some of that reflection is happening in the confidential providers’ forums. They’ve debated whether it’s valid to euthanize people for obesity in several cases. They’ve also beem divided over ending the lives of people in mourning.

Canada’s government said it legalized euthanasia to reduce suffering and support individual autonomy — and polls have consistently shown public approval.

But its laws are now being challenged on all sides. The advocacy group Dying with Dignity filed an August lawsuit in Ontario, alleging it’s “discriminatory” to exclude mentally ill people from euthanasia. Meanwhile, a coalition of disability-rights organizations in another lawsuit argued that euthanasia legislation has resulted in the premature deaths of people with disabilities.

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