Critics caution against plan to expand medical assistance in dying to those with mental illness

The Centre for Addiction and Mental Health (CAMH) Queen Street campus is seen in Toronto, Sunday, March 14, 2021. (THE CANADIAN PRESS/Cole Burston)

Hope is what kept Laurel Walker alive as thoughts of suicide overwhelmed her, and that is exactly what she says would be stripped from people battling the same darkness if Canada forges ahead with plans to expand medical assistance in dying to those with a mental disorder.

Proponents of the expansion, set for March 17, maintain that providing MAID to people with an incurable physical illness without giving the same right to those with an irremediable mental illness amounts to discrimination on the basis of a disability. Critics counter that there is insufficient evidence to predict whether or not someone will recover from a mental illness.

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Recent comments out of Ottawa suggest expansion is not a certainty. Justice Minister Arif Virani said Wednesday that cabinet will consider the input of a joint parliamentary committee, medical experts and other stakeholders in deciding "whether we move ahead on March 17, or whether we pause."

Walker, 44, said her biggest concern is that vulnerable people languish on long wait lists and can't afford to pay for psychological care that is not publicly funded.

"That is a disconnect, and for that reason I think it's irresponsible to go ahead with MAID for mental health," said Walker, who developed anxiety and post-traumatic stress disorder in her 20s, when she was hospitalized.

Her struggle with depression began in high school but she said the care she needed was not available in her home province of Nova Scotia. It took about 20 years for her to secure treatment at a private in-patient facility in Ontario.

"I attempted suicide in 2005. I ended up locked down at the hospital. I wouldn't have been able to rationally make a decision, but I could apply for MAID (soon)," said Walker, adding she has not needed any mental health services in the public system since completing treatment a decade ago.

"I remember my dark times, and it felt hopeless. The fact that I considered ending my life, and tried, it's so sad to me. People living with a mental health issue, who would even consider MAID, are in a great, great deal of pain."

Allowing MAID without adequately funding treatment for people who may repeatedly end up in emergency rooms is akin to saying there is no hope, she said.

Canadians have had access to MAID for incurable physical illnesses or disabilities since 2016. Five years later, following a Quebec court decision, the law no longer required a person's natural death to be reasonably foreseeable. But people with a mental illness would not be eligible until March 2023, providing time for an expert panel on mental illness to make recommendations on safeguards and guidance.

However, the expansion was paused in February for a year after some psychiatrists and national groups, including Toronto's Centre for Addiction and Mental Health (CAMH), the country's largest psychiatric teaching hospital, raised concerns including the need for better access to care. Since then, a curriculum has been introduced to guide MAID assessors and providers.

A parliamentary committee on MAID that is expected to submit its recommendations to the Senate and the House of Commons by Jan. 31 reconvened in November, when it heard testimony from experts including psychiatrists wanting an indefinite halt to euthanasia for people with a mental illness. A repeated fear was that doctors and nurse practitioners would use their personal values to assess eligibility though it may not be possible to distinguish a MAID request from someone wanting an assisted suicide.

The Canadian Centre for Suicide Prevention agrees, saying there is a need for consensus on the definition of irremediability for any mental disorder affecting people who are not dying.

In an emailed statement Friday, the Centre for Addiction and Mental Health said it was "pleased that the government is considering a delay in extending MAID eligibility to people whose sole underlying medical condition is mental illness."

"At this time, the health-care system is not ready and health-care providers do not have the resources they need to provide high quality, standardized and equitable MAID services," Dr. Tarek Rajji, chair of CAMH's medical advisory committee, said in the statement.

However, Dr. Konia Trouton, president of the Canadian Association of MAID Assessors and Providers, said the country's first nationally accredited MAID curriculum, launched in September, includes a section on mental illness to help clinicians determine if someone is seeking suicide.

"We believe the health-care system is ready for March when we anticipate the current restriction will be lifted," Trouton said by email on Friday.

"CAMAP as an organization representing the professionals who do this work, think the clinicians are ready," said the family doctor, who has been an assessor and provider of MAID in British Columbia, Alberta and Ontario.

Doctors and nurse practitioners who are new to MAID would have 27 hours of online training, along with 12 hours of workshops. Those with experience get six hours of education, Trouton said in a previous interview before Virani's comments.

The curriculum trains clinicians to differentiate between "an acute preoccupation for suicide and a request for assisted dying" by considering factors including the type of treatment the person has had, how they fared and whether they tried it, along with any medication, for an "appropriate duration," said Trouton, adding that depends on the particular illness.

People whose death is not reasonably foreseeable must already be assessed by two independent doctors or nurse practitioners. If neither is an expert on the applicant's medical condition, they are required to consult a specialist. The same safeguard will apply to people with a mental illness, Trouton said.

Dr. Jitender Sareen, head of psychiatry at the University of Manitoba, said he and many of his colleagues believe a psychiatrist should be involved in the assessment. But he said the expert panel's draft of a regulatory standard did not call for that requirement.

Trouton said provinces and territories could decide they want a psychiatrist to make a MAID referral, or be involved in a patient's care, but that remained to be seen.

Various jurisdictions say they will not put all their plans in place until Ottawa introduces legislation. Quebec, however, has barred the expansion of MAID, saying a mental illness does not qualify someone for a medically assisted death.

As for concerns about lack of treatment, applicants would be informed about available options, Trouton said, and those without a family doctor would be connected to a primary care provider.

Dr. Gary Chaimowitz, past president of the Canadian Psychiatric Association, said that while lack of access to treatment is a "massive and very important issue," he did not believe that would be "an avenue to get MAID" for those seeking suicide.

A survey by the association in 2020 showed 41 per cent of members who replied agreed or strongly agreed that people with a mental illness should be considered eligible for MAID, Chaimowitz said. The survey was sent to 2,056 members, and 474 of them responded.

It also found that only one quarter of respondents disagreed or strongly disagreed that it is possible for a mental disorder to be considered irremediable.

Dr. Sonu Gaind, chief of the psychiatry department at Sunnybrook Health Sciences Centre in Toronto, is among those against expanding MAID. He said Belgium has legislative requirements for due care and that there should be "no reasonable alternative" before someone is approved for euthanasia, but Canada has no such safeguard.

"We just say the person needs to be informed of available treatment options," Gaind said.

"I don't think it's responsible for us to be saying we would look at providing death to someone who isn't dying before we ensure that they've had access and opportunity for standard and best care to try to help alleviate their suffering."

He said evidence from Europe suggests women with a mental illness, especially those marginalized by "social suffering" due to poverty, lack of housing and community supports, would be most at risk if MAID is expanded without strong legislative safeguards.

"For psychiatric euthanasia, you see twice as many women -- about 70 per cent, compared to 30 per cent for men. It parallels the two-to-one ratio that we see of women to men who attempt suicide when mentally ill, and most of them don't complete suicide. And most of them don't try again either. That's a pretty concerning thing."

Rather than treatment, ongoing care and community services, MAID would be a cheaper alternative "so people can die with dignity" when they don't have the supports to live that way, he said.

The federal government said in 2021 that it would better track who is accessing MAID and how it is being delivered. But no such information was included in the latest annual report on MAID, released in October, showing 13,241 people died by euthanasia last year.

Health Canada said it is working with provinces and territories to collect data on what was discussed and the services -- such as counselling and housing -- that were offered to people when they were assessed for MAID.

"These new data will be included in future annual reports," the regulator said in an email.

If you or someone you know is thinking about suicide, support is available 24/7 by calling 988.

This report by The Canadian Press was first published Dec. 17, 2023.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
-- With files from Nicole Ireland in Toronto