SoySupreme
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Canada will soon offer doctor-assisted death to the mentally ill. Who should be eligible?
Canada is still determining who should be eligible for MAID for mental illness, but some experts say it could become the most permissive jurisdiction in the…
This is great news. Drepressedcels that have tried every treatment available and can no longer cope won't have to suffer further. Now they can rope with dignity. Serge and Master aren't here anymore but this is a great victory for a cause they championed for years
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One year from now, in March 2023, Canada will become one of the few nations in the world allowing medical aid in dying, or MAID, for people whose sole underlying condition is depression, bipolar disorder, personality disorders, schizophrenia, PTSD or any other mental affliction. In the Netherlands, MAID for irremediable psychiatric suffering has been regulated by law since 2002, and a new study by van Veen and colleagues underscores just how complicated it can be. How do you define “grievous and irremediable” in psychiatry? Is it possible to conclude, with any certainty or confidence, that a mental illness has no prospect of ever improving? What has been done, what has been tried, and is it enough?
Canada’s high court ruled in 2015 that an absolute prohibition on doctor assisted dying violated the Charter, that competent adults suffering a “grievous and irremediable” medical condition causing intolerable physical or psychological suffering had a constitutional right to medically hastened death.
That decision formed the impetus for Canada’s MAID law, Bill C-14, which allowed for assisted dying in cases where natural death was “reasonably foreseeable.”
In 2019, a Quebec Superior Court justice ruled the reasonably foreseeable death restriction unconstitutional, and that people who were intolerably suffering but not imminently dying still had a constitutional right to be eligible for euthanasia.
In March 2021, Bill C-7 was passed that made changes to the eligibility criteria. Gone is the “reasonably foreseeable” criterion and, as of March 17, 2023, when a two-year sunset clause expires, MAID will be expanded to competent adults whose sole underlying condition is a mental illness.
Already, the removal of imminent death has made MAID requests far more complex, providers say. These are known as “Track Two” requests. At least 90 days must pass between the first assessment and the administration of MAID. Most involve chronic, unrelenting physical pain — nerve impingement, significant muscle spasms, neuropathic pain, chronic headaches. Ottawa MAID providers have received roughly 80 Track Two requests over the past year. “I think we’ve had only two proceed,” said Dr. Viren Naik, medical director of the MAID program for the greater Ottawa area. Of the 30 providers within The Ottawa Hospital program, only four are willing to see Track Two patients, and Naik says he’s probably going to lose two more of them. Many are conflicted when people aren’t close to dying. “Making sure that they’re not requesting MAID because they’re vulnerable in any way has also been a challenge. If I take that to mental health, I think those issues are only going to compound.”
Euthanasia for mental illness has, in fact, already occurred in Canada. Testifying before a Senate committee studying Bill C-7 last year, Vancouver psychiatrist Derryck Smith told the story of “E.F.”, a 58-year-old woman who suffered from severe conversion disorder, where a person’s paralysis, or blindness or other bizarre nervous system symptoms can’t be explained by any physical findings. She suffered from involuntary muscle spasms. Her eyelid muscles had spasmed shut, leaving her effectively blind. Her digestive system was a mess, she was in constant pain and needed to be carried or use a wheelchair. In May 2016, Alberta’s Court of Queen’s Bench allowed her an assisted death.
Smith took part in another case involving a 45-year-old Vancouver woman who had suffered from anorexia nervosa since she was 17. She’d endured a “gauntlet” of treatments, he said, had been certified several times under the Mental Health Act, involuntarily hospitalized and force fed by a tube in a manner that left her feeling “violated.” “At the time I assessed her, she had virtually no social life … no joy in her life.” Smyth determined the woman had capacity to agree to assisted death.
Others argue that mental illness can sometimes be irremediable, the suffering intolerable and that competent, capable people have the right to make their own judgements and decide how much uncertainty they’re willing to accept. They reject the arguments around vulnerability and that MAID is an “easier” path to suicide. In one study, 21 Dutch people who had a wish for assisted death because of suffering from mental illness said they wanted a “dignified” end of life. “Suicide was perceived as insecure and inhumane, for both the patient and others,” the authors write. The people saw “impulsive suicidality” as different from a request for doctor-hastened death. “Suicidality, although sometimes also planned, was perceived as an act out of desperation and crisis; a state of mind in which there is no more room for other thoughts or control over actions. A wish for (assisted dying) was more well considered.”
Under Canada’s MAID law, people requesting assisted dying for a medical condition can refuse treatments they don’t find acceptable. It’s not clear whether the same will hold where mental illness is the sole underlying condition. The law also states that intolerable suffering is wholly subjective and personal. It’s what the person says it is, and, unlike the Netherlands, a doctor doesn’t have to agree.
Under those criteria, Canada could become the most permissive jurisdiction in the world with respect to MAID and mental illness, according to an expert panel of the Council of Canadian Academies.
“We don’t force people to undergo treatment in order to realize their autonomy,” says Dalhousie University’s Jocelyn Downie, a professor of law and medicine. “We don’t compel people with cancer to try chemotherapy — they don’t have to have tried any if they want to have MAID, because we are basically respecting their autonomy. We’re saying, ‘You don’t have to make that choice, even though many people would think that is a reasonable thing to do, to try these things before you proceed.’ But we don’t force that.”
What will psychiatrists in Canada be looking for? A robust, eligibility assessment process, Neilson says. That any request for doctor-assisted death is one of “durability and voluntariness,” that it’s a settled one, free of undue, outside influences. That it’s not an impulsive wish. “It’s not a request they are making in the height of a despaired moment, or at a time when they are vulnerable.” That standard treatments have been offered, attempted and failed, with no other reasonable alternatives. That at least one independent psychiatrist expert in the specific disease be involved in the assessment, which is problematic. In many parts of the country, it can be a challenge to find a psychiatrist to treat mental illness, let alone provide an assessment for assisted death.
