Medical Assistance in Dying for Mental Illness

Should people with mental illness have access to medical assistance in dying? In Canada, that’s going to happen in the near future, but exactly what it will look like hasn’t been decided yet. This is something I support, but a lot of people don’t, so I thought I’d write about it.

A bit of background

Canada first introduced Medical Assistance in Dying (MAiD) legislation in 2016, following a 2015 Supreme Court ruling (source). For people to access MAiD through a physician or nurse practitioner required a “grievous and irremediable condition” and a terminal illness with death being reasonably foreseeable. Various safeguards were put in place.

For a condition to count as grievous and irremediable, a person must meet all three of the following criteria:

• “have a serious illness, disease or disability”
• “be in an advanced state of decline that cannot be reversed”
• “experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable”

The law excluded people whose sole illness was mental illness from being able to access MAiD.

Changes to MAiD law in 2021

In 2019, the Supreme Court in the province of Quebec struck down the requirement for death to be reasonably foreseeable, ruling that it was unconstitutional. The Court gave the government until 2021 to revise the legislation.

Canada has an elected House of Commons and an appointed Senate. The House of Commons came up with a new version of the MAiD legislation, but the Senate said nope, and passed the bill back with recommended changes. These changes included removing the mental illness exclusion. The House of Commons agreed, but they added a 2-year wait for implementation to allow time for the development of protocols. That bill became law in March 2021.

Concerns about MAiD for mental illness

During the government’s consultation process for the 2021 law, they received input about expanding medical assistance in dying to include people with mental illness. The consultation report says:

“A majority of those who provided comments were not in favour of extending MAID to people who suffer from mental illness. They expressed concerns that people with mental health issues, such as depression, may feel that MAID is their only option, when effective therapies could lead to full recovery. Rather than extending the option to terminate lives, many respondents felt that the focus should be on increasing preventative measures, supports, resources, and intensive treatment for people with mental health issues, as well as increasing resources for people with physical disabilities.”

A position paper by the Canadian Mental Health Association said they were “deeply disappointed”. The paper said: “We know that cases of severe and persistent mental illness that are initially resistant to treatment can, in fact, show significant recovery over time. Mental illness is very often episodic.”

From a medical perspective, one of the arguments that’s been put forward (e.g. from CAMH, the Centre for Addiction and Mental Health) is that mental illness doesn’t qualify as a grievous and irremediable condition because it can’t be predicted whether someone will recover or not. CAMH also puts forward the recovery model as part of their argument against MAiD. That annoys me, because the whole idea of the recovery model is autonomy and self-determination. I support the recovery model, but it should not be trotted out as a reason to deny a patient their choice.

Support for MAiD

The Canadian Psychiatric Association released a position statement saying that people with psychiatric disabilities should not be discriminated against in having access to MAiD. The position statement also noted: “Psychiatrists who assess eligibility for MAiD are expected to be rigorous in conducting capacity assessments and identifying symptoms of mental disorder that are likely to affect decision-making.”

In 2020, former journalist John Scully posted an article on the Dying with Dignity Canada website in which he criticized mental health professionals who claim that they know best that there’s always hope for recovery. He concluded by saying: “No compassion, no relief, no death – unless the sufferer is then forced to die by suicide. This is one of the most undignified ways of dying, with botched attempts, finality by often brutal methods, followed by shock and intolerable pain for unprepared loved ones. That’s the reality of denying MAID for the mentally ill.”

My thoughts

I see a difference between suicide and MAiD. Suicidality can be a symptom of mental illness, and where that is the case, that single symptom doesn’t suddenly make an illness grievous and irremediable.

I see medical assistance in dying as a humane option for people who are not experiencing suicidal ideation, but whose illnesses are treatment-resistant over the longer term and there’s no reason to think that that will magically change somehow. This isn’t just about the present-moment suffering; the cumulative effect of ongoing suffering that is painful and exhausting.

I’m in my early 40s. I’ve had multiple family members live until their 90s or even past 100. I do not want another 50 years of this bullshit. Life is something I do by default. It’s not something I want. I’m not suicidal; I’ve experienced that as part of my depression before and that’s not what this is. This is wanting the option to end my life when I see fit in a more humane way than suicide.

I’m glad that the Senate brought in this option for people with mental illness. It bugs me to read things like CAMH’s position paper, because why should they, in their position of ease, get to decide what hope there is for my recovery? They can talk recovery all they want, but I’ve been continually sick for the last 5 1/2 years, so I say they can take their full recovery bullshit and shove it up their asses. Until psychiatry has treatments that are effective for everyone, they need to quit making assumptions about people’s suffering.

I also think it’s ridiculous to think that government will choose to continue to underfund mental health care because they’re hoping people will just off themselves and get it over with. They already don’t give a shit about people with mental illness; whether there’s MAiD or not isn’t going to change that.

Over to you

What are your thoughts on mental illness and medical assistance in dying? Do you think it should be an option?

The Government of Canada has created a flow sheet showing the MAiD process, and the Centre for Suicide Prevention has created an infographic showing the difference between suicide and MAiD based on the initial MAiD law that applied only to reasonably foreseeable death.