Amid growing concern among the public, psychiatrists, and other mental health professionals, the Canadian government is seeking to delay the legalization of its proposed medical assistance in dying (MAID) for mental illness law that is slated to pass on March 17.
Canada already has the largest number of deaths by MAID of any nation, with 10,064 in 2021, a 32% increase from 2020. With the addition of serious mental illness (SMI) as an eligible category, the country is on track to have the most liberal assisted-death policy in the world.
Concerns about the additional number of patients who could become eligible for MAID, and a lack of evidence-backed standards from disability rights groups, mental health advocates, First Nations leaders, psychiatrists, and other mental health providers, seems to have led the Canadian government to give the proposed law some sober second thought.
"Listening to experts and Canadians, we believe this date needs to be temporarily delayed," said David Lametti, Canada’s minister of Justice and attorney general of Canada; Jean-Yves Duclos, minister of Health; and Carolyn Bennett, minister of Mental Health and Addictions, in a December 15 joint statement.
Canada’s Parliament — which approved the expansion — will now have to vote on whether to okay a pause on the legislation.
However, the Canadian Psychiatric Association (CPA) has not been calling for a delay in the proposed legislation. In a November 2021 statement, the CPA said it "does not take a position on the legality or morality of MAID," but added that to deny MAID to people with mental illness was discriminatory, and that as it was the law, it must be followed.
"CPA has not taken a position about MAID," the association's President Gary Chaimowitz, MBChB, told Medscape Medical News. "We know this is coming and our organization is trying to get its members ready for what will be most likely the ability of people with mental conditions to be able to request MAID," said Chaimowitz, who is also head of forensic psychiatry at St. Joseph’s Healthcare and a professor of psychiatry at McMaster University, both in Hamilton, Ontario, Canada.
Chaimowitz acknowledges that "a majority of psychiatrists do not want to be involved in anything to do with MAID."
"The idea, certainly in psychiatry, is to get people well and we’ve been taught that people dying from a major mental disorder is something that we’re trained to prevent," he added.
A 'Clinical Option'
Assisted medical death is especially fraught in psychiatry, said Rebecca Brendel, MD, president of the American Psychiatric Association (APA). She noted a 25-year life expectancy gap between people with SMI and those who do not have such conditions.
"As a profession we have very serious obligations to advance treatment so that a person with serious mental illness can live [a] full, productive, and healthy [life]," Brendel, associate director of the Center for Bioethics at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.
Under the Canadian proposal, psychiatrists would be allowed to suggest MAID as a "clinical option."
Harold Braswell, PhD, associate professor at the Albert Gnaegi Center for Health Care Ethics at St. Louis University, St. Louis, Missouri, calls that problematic.
"It's not neutral to suggest to someone that it would be theoretically reasonable to end their lives," Braswell told Medscape Medical News.
It also creates a double standard in the treatment of suicidal ideation, in which suicide prevention is absolute for some, but encouraging it as a possibility for others, he added.
"To have that come from an authority figure is something that’s very harsh and, in my opinion, very potentially destructive," especially for vulnerable groups, like First Nations people, who already have elevated rates of suicide, said Braswell.
Since 2016, Canada has allowed MAID for medical conditions and diseases that will not improve and in cases where the evidence shows that medical providers can accurately predict the condition will not improve.
However, in 2019, a Quebec court ruled that the law unconstitutionally barred euthanasia in people who were not terminally ill. In March 2021, Canada's criminal code was amended to allow MAID for people whose natural death was not "reasonably foreseeable," but it excluded SMI for a period of 2 years, ending in March 2023.
The 2-year stay was intended to allow for study and to give mental health providers and MAID assessors time to develop standards.
The federal government charged a 12-member expert panel with determining how to safely allow MAID for SMI. In its final report released in May 2022 it recommended that standards be developed.
The panel acknowledged that for many conditions it may be impossible to make predictions about whether an individual might improve. However, it did not mention SMI.
In those cases, when MAID is requested, "establishing incurability and irreversibility on the basis of the evolution and response to past interventions is necessary," the panel noted, adding that these are the criteria used by psychiatrists assessing euthanasia requests in the Netherlands and Belgium.
But the notion that mental illness can be irremediable has been fiercely debated.
Soon after the expert report was released, the Center for Addiction and Mental Health (CAMH) in Toronto noted on its website that there are currently "no agreed upon standards for psychiatrists or other healthcare practitioners to use to determine if a person’s mental illness is 'grievous and irremediable' for the purposes of MAID."
Chaimowitz acknowledged that "there’s no agreed-upon definition of incurability" in mental illness. Some psychiatrists "will argue that there’s always another treatment that can be attempted," he said, adding that there has been a lack of consensus on irremediability among CPA members.
Protecting Vulnerable Populations
Matt Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus in Aurora, said the question of irremediability is crucial. "Most people with mental illness do get better, especially if they’re in treatment," Wynia told Medscape Medical News.
For MAID assessors it may be difficult to know when someone has tried all possible treatments, especially given the wide array of options, including psychedelics, said Wynia.
Braswell said there is not enough evidence that mental illness is incurable. With SMI, "there’s a lot more potential for the causes of the individual’s suffering to be ameliorated. By offering MAID, you’re going to kill people who might have been able to get out of this through other non-lethal means."
Currently, MAID is provided for an irremediable medical condition, "in other words, a condition that will not improve and that we can predict will not improve," said Karandeep S. Gaind, MD, chief of psychiatry at Toronto’s Humber River Hospital and physician chair of the hospital’s MAID team.
"If that’s the premise, then I think we cannot provide MAID for sole mental illness," Gaind told Medscape Medical News. "Because we can’t honestly make those predictions" with mental illness, he added.
Gaind does not support MAID for mental illness and believes that it will put the vulnerable — including those living in poverty — at particular risk.
With the proposed expansion, MAID is "now becoming something which is being sought as a way to escape a painful life rather than to avoid a painful death," said Gaind, who is also a past president of the CPA.
One member of the federal government’s expert panel — Ellen Cohen, who had a psychiatric condition — wrote in The Globe and Mail that she quit early on when it became apparent that the panel was not seriously considering her own experiences or the possibility that poverty and lack of access to care or social supports could strongly influence a request for MAID.
Social Determinants of Suffering
People with mental illness often are without homes, have substance use disorders, have been stigmatized and discriminated against, and have poor social supports, said Wynia. "You worry that it’s all of those things that are making them want to end their lives," he said.
The Daily Mail ran a story in December 2022 about a 65-year-old Canadian who said he’d applied for MAID solely because of fears that his disability benefits for various chronic health conditions were being cut off and that he didn’t want to live in poverty.
A 51-year-old Ontario woman with multiple chemical sensitivities was granted MAID after she said she could not find housing that could keep her safe, according to an August report by CTV News.
Tarek Rajji, MD, chief of the Adult Neurodevelopment and Geriatric Psychiatry Division at CAMH, said social determinants of health need to be considered in standards created to guide MAID for mental illness.
"We’re very mindful of the fact that the suffering, that is, the grievousness that the person is living with, in the context of mental illness, many times is due to the social determinants of their illness and the social determinants of their suffering," Rajji told Medscape Medical News.
Many are also concerned that it will be difficult to separate out suicidality from sheer hopelessness.
The CPA has advised a group that’s working on developing guidelines for MAID in SMI and is also developing a curriculum for mental health providers, Chaimowitz said. As part of that, there will be a process to ensure that someone who is actively suicidal is not granted MAID.
"I do not believe that it’s contemplated that MAID is going to accelerate or facilitate suicidal ideation," he said. Someone who is suicidal will be referred to treatment, said Chaimowitz.
"People with depression often feel hopeless," and may refuse treatments that have worked in the past, countered Gaind. Some of his patients "are absolutely convinced that nothing will help," he said.
The expert panel said in its final report that "it is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time," are necessary to establish "irreversibility" of mental illness.
Chaimowitz said MAID will not be offered to anyone "refusing treatment for their condition without any good reason." They will be "unlikely to meet criteria for incurable," as they will have needed to avail themselves of the array of treatments available, he said.
That would be similar to rules in Belgium and the Netherlands, which allow euthanasia for psychiatric conditions.
An estimated 100-300 psychiatric patients receive euthanasia each year in those countries, according to a 2021 commentary in Psychiatric Times by Mark S. Komrad, MD, a Towson, Maryland-based psychiatrist.
There are still troublesome cases.
As previously reported by Medscape Medical News, many in Belgium were distressed recently at the news that a 23-year-old woman who had survived a terrorist attack, Shanti De Corte, requested and was granted euthanasia.
As the deadline for implementation of MAID grew closer, calls for delay grew louder, especially given the lack of concrete standards for providers.
During the waning months of 2022, Gaind — who said he was suspended from CPA for "unprofessional interactions" and allegedly misrepresenting CPA’s processes and governance matters — announced the launch of a new organization, the Society of Canadian Psychiatry, in November calling for a delay in MAID of at least 1 year so that evidence-based safeguards could be implemented. The petition has been signed by more than 200 psychiatrists, along with several dozen physicians, MAID assessors, individuals with mental illness and family members.
The Association of Chairs of Psychiatry in Canada (ACPC), the Canadian Association for Suicide Prevention, the Council of Canadians with Disabilities, a group of indigenous leaders, and the Ontario Association for ACT and FACT, psychiatrists who provide care to individuals with severe mental illness, among other groups, joined the call for a delay.
In its December announcement, the Canadian federal ministers said a factor in seeking a delay was that standards guiding clinicians would not be delivered until at least February — too close to when applications would be opened.
Upon hearing about the federal government’s intentions, the chair of the expert panel, Mona Gupta, MD, told The Canadian Press that she did not think it was necessary to put off implementation because necessary safeguards were already in place.
Chaimowitz awaits the standards but is optimistic that for mental illness, "the process will be tightly controlled, closely monitored, and open to scrutiny," he said.
Braswell is not convinced. The concern is that adding people with mental illness is "going to overload the capacity of the government to monitor this practice," he said.
Is the US Next?
Although Canada and the United States share a border, it’s unlikely that US states will allow aid in dying for nonterminal illness, much less for psychiatric conditions any time soon, said Braswell and others.
Ten states — California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington — have laws allowing assistance in dying, but for terminal illness only.
In 2016, the APA adopted the American Medical Association policy on medical euthanasia, stating, "that a psychiatrist should not prescribe or administer any intervention to a nonterminally ill person for the purpose of causing death."
Brendel said the field is acutely aware that people with mental illness do suffer, but that more work needs to be done — and is being done — on "distinguishing wishes to hasten death or end one’s life from these historical or traditional notions that any premature death is a suicide."
There is also increasing discussion within the medical community, not just psychiatry, about a physician’s duty to relieve suffering, said Wynia. "There’s debate basically about whether we stand for preserving life essentially at all costs and never being involved in the taking of life, or whether we stand for reduction of suffering and being the advocate for the patients that we serve," he said.
"Those are both legitimate," said Wynia, adding, "there are good reasons to want both of those to be true."
"I suspect that 20 years from now we will still be having conversations about how physicians, how psychiatrists ought to participate in preserving life and in shepherding death," said Brendel.
But to Gaind, the debate is not just esoteric, it’s a soon-to-be reality in Canada. "When we’re providing death to people who aren’t dying, to me that’s like providing what amounts to a wrongful death," he said.
Alicia Ault is a Saint Petersburg, Florida-based freelance journalist whose work has appeared in publications including JAMA and Smithsonian.com. You can find her on Twitter @aliciaault.
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Cite this: Concern Grows Over 'Medical Aid in Dying for Mental Illness' Law - Medscape - Jan 23, 2023.