Medical Assistance in Dying for Mental Illness

Mental illness and medical assistance in dying

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.

Straight talk on suicide - graphics of phoenix and semicolon

The Straight Talk on Suicide page has crisis and safety planning resources, along with info on suicide-related topics from the perspective of someone who’s been there.

49 thoughts on “Medical Assistance in Dying for Mental Illness”

  1. Yes, I think that should be an option, also for people with mental illness, although possibly assessment in that case should take longer.

    1. Thank you for writing this interesting, well researched and important piece. I agree with what you said that people should have the right to decide when they’re going to die. In my own situation there have been times when I’ve been suicidal and I don’t think I would’ve been in the condition to go through all these steps to ask for MAiD. It is true what you said about suicide is usually the only option to these folks. A terrible, brutal, lonely end to unbearable suffering.

      I guess for me the dilemma lies between is this going to go on forever or will I feel differently next week or month or year if I somehow endure it a little bit longer? And then be glad later that I did? When in the depths of depression, everything feels like it is covered in darkness. It is almost impossible to think of a way out. I read somewhere once that suicide is a permanent solution to a temporary problem. The difficulty becomes in deciding if it is temporary or permanent. And how much longer you can take it.

      You always say that you are having such a difficult time moving around, talking, and thinking. Yet you write so brilliantly! Thank you so much for hanging in.

      1. Thank you! That saying that suicide is a permanent solution to a temporary problem bugs me because it assumes that all problems are temporary, which just isn’t the case.

        The way the law currently stands in Canada for people with a physical condition where natural death is not reasonably foreseeable is that the assessment process must last at least 90 days. I would be okay with it being long for mental health conditions; I think that can help to differentiate between being acutely suicidal and wanting to end chronic suffering.

  2. I definitely feel like it should be an option, especially when you consider the alternative. Personally, I think it’s cruel to expect those with mental illnesses to continue living when there is no hope for their recovery.

  3. I’m onboard with MAID in the case of “a terminal illness with death being reasonably foreseeable.” It’s my understanding that the original impetus is for people who can’t commit suicide, for example, ALS. They’re quality of life declines, but they still want to stay past the point when suicide would be functionally possible.

    That is not the case with mental illness. The suffering with MI can be so intractable. Like you, I’m not currently suicidal or experiencing ideation, but it’ll come back. It always does. I’m constrained at the moment by love, and the desire not to harm those I love, but I know, eventually, mental illness will trump even that. I wonder if the next time will be when I get it done. But, I don’t believe in MAID for me. I’m capable.

    The possibility for abuse is also rife. The mentally ill are barely tolerated by large swathes of society: I worry this will let them “correct” that. And, asking people to kill you is a hard thing.

    A tough topic indeed. I’m admiring of your strength and fortitude in addressing it. I treat it in my circle like masturbation: it’s something we don’t talk about 💖

    1. I wonder about the likelihood of abuse. I haven’t heard any stories since MAiD was introduced of people being pressured to end it all. In terms of mental illness, I see a greater likelihood of people dying because of the system neglecting them than providers pushing people to choose MAiD. If anything, I see providers being likely to deny people access to MAiD even if the law allows it.

      1. It’s tricky. I’d feel better about it if I didn’t consider most politicians to be corrupted by their climb to the stop.

        1. I have no faith in politicians themselves, but I do think they’ve found a good balance with the safeguards built into the law thus far. It’ll be interesting to see what they come up with regarding mental illness. I’m not familiar with any of the people on the expert panel they’ve put together, but from their bios it looks like a good group of people.

          1. I just worry that MAID seems easier and cheaper than helping those with chronic and severe mental illness. I have hope, but it’s kind of a dark and fatalist hope.

            1. I honestly don’t see it making a difference in funding. If they’re hoping to kill off people with mental illness, they’re already killing them by neglect. Why pay more to kill them with MAiD when the status quo is already doing the job?

            2. I read an op-ed about a year ago: the writer was concerned that fatigued supports might push MAID on those they help.

  4. I have mixed feelings on this. On the one hand, does someone who is suffering that much pain, where recovery or pain management is no longer an effective option need to continue suffering? But on the other hand, I see a lot of potential for abuse. We already know that it’s difficult for the needs and wishes of the mentally ill to be taken seriously, and I can see the potential for family members and/or physicians claiming to be speaking for the mentally ill patient. And yes, that already happens outside the context of medically assisted death (and could also happen in cases where the patient wants to die and the family members/doctors speaking on their behalf claim they do not or cannot make that decision), but death is a pretty irreversible consequence.

    1. Safeguards definitely need to be but in place, and they are. The potential for abuse is there, but I think the likelihood of it actually happening with safeguards in place are fairly low. If anything, I see health care providers not taking requests for MAiD seriously and just brushing off the person making the request as not being suffering “enough” for it to count. To me, that’s more consistent with how mentally ill people are currently dismissed.

      1. Good point. I think this will be the kind of law where the devil will really be in the details. The need for safeguards to protect against potential abuses, particular when it comes to instances where it’s not clear if the patient has the faculties to speak for him/herself, is a stronger argument for writing the law (and other laws affecting this population) properly, more so than an argument for not having the law at all.

        1. Canada first brought in MAiD laws in 2016, and I think they did a pretty good job coming up with the safeguards. The request has to be made voluntarily and in writing, and an independent witness has to confirm that it’s voluntary. Two person has to be assessed by two medical practitioners who are independent from one another need to assess the patient and determine the condition is grievous and irremediable and the patient is able to give informed consent. The patient must be given the opportunity to withdraw consent at any time. Final informed consent can only be given in advance if the person is expected to lose the capacity to consent soon. With the new tweaks to the law, if death isn’t reasonably foreseeable, the person must be offered alternatives to deal with their suffering, and the assessment period must last at least 90 days.

  5. To be honest, this is a particularly difficult subject to discuss, not only in practice but also in general. Individuals have divergent beliefs for logical or irrational reasons. Certain individuals gravitate toward religious and traditional ideas, among other things. Euthanasia is a grey area between right and wrong. Is it universally right or wrong, or does it vary by culture, making discussion more difficult? Additionally, we must define “existential suffering,” as life is inherently suffering. Switzerland, one of the first countries to legalize assisted suicide, conducted a study and discovered that, aside from severe medical conditions, loneliness was the second most frequently mentioned component of existential suffering, with nearly two-thirds of participants discussing it—loneliness appears to be a significant factor in requesting AS. Loneliness appears to be widespread, especially with the growth of technology, but could it be a grounds for someone to request Assisted Suicide?

    Personally, I believe that while it should be someone’s choice to some level, there should be legislation governing that option. That is, suicide is one of the main causes of death among young people. If it becomes just an option, we may lose a greater number of young people than anticipated—life can be rather brutal. Too many people already believe that suicide is a rational response to their most agonizing issues. This is extremely difficult especially that existential suffering is unique to each individual.
    I do have a contemplating question, however. Since we are born into this world with no choice, must we legally have the choice to take our final breath of life?

    1. In Canada, access to MAiD is limited to people with a grievous and irremediable medical condition, so under our laws, existential suffering or loneliness wouldn’t qualify someone for access to MAiD.

      I don’t think most people who are acutely suicidal would qualify as having a grievous and irremediable medical condition, so I don’t think many of them would be able to access MAiD anyway.

      As to your question, people already do have the ability to choose when to take their final breath. MAiD just offers a more humane way of doing so.

  6. 🤔 I’ve gone back and forth with this from a personal perspective. My resolve came to being satisfied, whether happy or suffering, by a certain age. If by 70 I am not dead, I consider that enough life for me. I don’t want to live or suffer to be any older than that despite the opinion of loved ones. I’ve asked my sister if she would go with me to Switzerland to have it done (I don’t know the legalities but have had this very discussion with my sister). Having co-occurring illnesses isn’t something I asked for so suffering with it should be limited by choice and individual decision. I am pro-assisted suicide.

  7. This topic is very dear to my heart and a nuanced matter to me. Like you. Due to treatment resistant conditions.

    I’ve similar thoughts. This YouTube documentary supports your and my personal view to some extent.

    I’ve watched it several times to be honest… I do think BPD is treatable with the RIGHT integrative long term complex trauma therapy, and that the Scandinavian system has let her down severely. That if the public system didn’t suck — contrary to how Scandinavia is depicted as a utopia by the USA — and if she and her family was given all the money needed for private therapy and stuff for her needs (residential complex trauma centre? Supported Independent Living? etc) maybe she could recover “enough” for a life she doesn’t want to exit. I’m fully blaming the system, NOT her or her family. I understand the heartbreaking choice. Because me and B have discussed it A LOT. And my nation has no “intensive outpatient programs” or “partial hospitalisation program” and in-patient is so freaking terrible. A long list. Including no privacy and physical and chemical restraints as “first resort”. I’ll type up a rant soon.

    1. Interesting video. I guess my take is that just because a condition is treatable in general doesn’t mean that there is a right treatment for a given individual. For example, with BPD, complex trauma treatment might work for some, but not everyone with BPD has complex trauma. And if she says she’s tired, fair enough. Death is a natural part of life, and if that’s what she wanted, I don’t think she should have to wait around because some other treatment might exist that might work. And just because certain treatments are available doesn’t mean they would necessarily be acceptable to the individual.

      I completely agree that there are serious systems issues. But I don’t think people should have to continue unbearable suffering while waiting for the system to be fixed, which may or may not change anything for that individual.

  8. Difficult question. My knee jerk reaction is “no, assisted death is not an option for anyone”. But then, while I am borderline depressed, I still haven’t lost that elusive thing – hope, and I can’t speak for those that have. Is life worth living without hope?

  9. In the Netherlands there is also assisted suicide (which we call euthanasia mostly). Last year, it made the news when two people with Tinnitus were given the go when they had asked for help, saying the Tinnitus made their lives unbearable.

    I’ve lived with Tinnitus since I was 12 and it really can be hard. I became a hip patient at age 16 with my first surgery at 17. I finally got diagnosed with ADHD and Asperger’s when I was 30/31. I got Fibromyalgia at age 33. I’ve lived with a lot of pain and discomfort and some days I still struggle so hard. So knowing that, if it becomes unbearable for me, I may receive help, yeah it’s kind of a comfort for me. It also helps me to make the most of it as long as I can…

    Several family members have passed away by euthanasia. Most had advanced stages of Cancer. So seeing them suffer also made me happy in a way that there was a way to find eternal relief for them. While they weren’t the oldest of people, they did suffer on a daily basis and I had peace with their choices.

    So yeah, I am very glad that this option exists for those in desperate need.

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