9 things to know about medical assistance in dying for mental illness

In Canada, Medical Assistance in Dying (MAiD) is changing. In 2023, people who have a mental disorder as their sole underlying medical condition will become eligible for an assisted death. Originally, that was scheduled to happen on March 17, but the government has asked for a delay. Here are 9 things you need to know:

1. It is part of the changes to the MAiD law that began in 2021.

When assisted dying first became legal in Canada in 2016, only people with terminal illnesses like cancer were eligible.

In March 2021, the law changed to include people with physical conditions like chronic pain who weren’t actually dying, in other words, their death wasn’t “reasonably foreseeable.”

Psychiatric illnesses -- which some say can be serious and incurable -- were excluded for 2 years, while federal officials studied how to safely include them along with physical illnesses.

A special federal joint committee was set up to study assisted dying, including how MAiD could be provided to people with mental disorders.

This is the interim report.

A final report from the joint committee was due in October 2022.

An expert panel studying MAiD for mental illness also issued this report with recommendations.

2. No specific type of mental disorder is excluded from qualifying for a medically assisted death.

Like physical illnesses, a person asking for MAiD must be found by assessors to have a "grievous and irremediable" medical condition -- meaning a serious and incurable illness, disease or disability in an advanced state of irreversible decline with intolerable suffering.

In countries like Belgium and the Netherlands, which have allowed assisted dying for mental disorders for two decades, requests are made by people suffering from a variety of psychiatric conditions including: depression and other mood disorders, PTSD, schizophrenia, psychotic disorders, neurodevelopmental disorders like autism and personality disorders like borderline personality disorder.

3. Defining an "incurable" mental illness isn't always easy.

People who ask for MAiD for a mental disorder will be assessed on a case-by-case basis to determine if the person's disorder is "grievous and irremediable".

In countries with psychiatric euthanasia laws, that usually requires proof that the patient has had an extensive history of trying therapies that didn’t work.

A second assessor must agree. The expert panel recommends that one of the assessors be a psychiatrist independent of the person's medical team and an expert in the mental disorder the patient has been diagnosed with.

4. As with all forms of medically assisted death, the patient's doctor, psychiatrist, or family don't have to be part of the decision, and may not know about the MAiD until after the person has died.

Physicians and families are never allowed to speak with each other if a capable person asks them not to, whether it’s about MAiD or any other healthcare practice.

According to the expert panel recommendations, assessors should try to obtain input from other sources, including the patient’s physician and family.

However, if the patient asks assessors not to contact family or their mental health practitioners, they are required to respect the patient's wishes.

If the assessor determines that they cannot do a proper assessment without family or another doctor's involvement, then the patient can be turned down for MAiD.

5. Additional mental health treatments can be recommended before a MAiD approval, but the patient can also say no to any additional therapy.

The expert panel on MAiD for mental illness recommends that MAiD assessors "should ensure that people have had an extensive treatment history and access to appropriate care."

The legislative safeguards also say that a patient must have "seriously considered" additional treatment. However, under Canadian law, no one can be forced to undergo a treatment they don't want.

Refusing treatment does not mean that a person has automatic access to MAiD.

6. People can have a medically assisted death even while they’re waiting for treatment.

This point has caused a lot of controversy in Canada. Some doctors argue that a patient must have access to the fullest possible range of treatment, including social supports like housing, before becoming eligible for MAiD. They say that if someone is waiting for treatment, it means the person doesn't have an incurable illness because they haven’t tried everything to get better.

However, others argue that just because a person is waiting for treatment doesn’t mean their illness is incurable. They say people can wait for treatments that are unlikely to improve their condition.

7. Some doctors are calling it state-sanctioned suicide.

Doctors disagree on whether it is possible to reliably distinguish between a person who is requesting MAiD because they’re suicidal and one who is requesting MAiD after serious consideration. Some psychiatrists argue that patients request MAiD when they’re suicidal and therefore doctors should never help a mentally ill person end their life.

8. Some experts believe the number of MAiD deaths among those with mental disorders is likely to be low while others believe it will be high.

Data from some European countries show that only 1-3% of deaths from euthanasia are among those with mental disorders. Reports from the Netherlands show that only 5% of requests made by persons with mental illnesses are granted. The vast majority are rejected.

Critics say that in Canada the number of mentally ill people that will die by MAiD will be high because our legislative safeguards will be less restrictive. They argue that Europe requires patients to try certain treatments and they have better access to mental health services.

9. In the past mental illness hasn't prevented a person from accessing assisted dying.

Since assisted dying first became legal in Canada in 2016, a person with a mental disorder could still qualify for MAiD, provided they had a physical illness that made them eligible, for example, a person with terminal cancer may suffer from depression or a person with chronic pain may have anxiety. As long as a patient had a physical illness that met the eligibility criteria, they could qualify for assisted dying. In 2023, people will no longer have to have a physical illness to qualify; they can be eligible solely because of their mental illness.