Parliament first legalized euthanasia and assisted suicide in 2016. In March 2021, Parliament removed important safeguards and expanded medical assistance in dying (MAiD) to those whose death is not reasonably foreseeable, including Canadians with disabilities. At that time, they also included a clause that will expand euthanasia to those with mental illness as of March 17, 2023.

Following the legalization of assisted suicide in 2016, the Council of Canadian Academies was tasked with, among other topics, writing a report on euthanasia as it relates to mental illness as the sole underlying medical condition.

An Expert Panel reviewed historical considerations, mental disorders in Canada and how they relate to MAiD, what MAiD for mental illness looks like in other jurisdictions, and the implications of prohibiting or permitting more MAiD for those with mental illness.

This report was published in 2018, before euthanasia access was expanded by Parliament. As such, the focus is on patients who are near the end of their life. However, concerns raised throughout the report remain relevant now and are worth revisiting as we work to stop the expansion of MAiD to those suffering from mental illness.

Is Mental Illness Incurable?

The report states that it is unclear whether a mental disorder can ever be determined to be incurable or untreatable. Some conditions are considered ‘treatment-resistant,’ but it is rare that there is no improvement in a mental disorder when treatment is provided, even if the mental disorder does not disappear entirely. Psychiatrists often disagree on the incurability of specific illnesses.

Canadian law permits MAiD for those who are enduring intolerable suffering, but what qualifies as ‘intolerable suffering’ is determined solely by the patient. Countries like Belgium and the Netherlands require that patients and physicians together determine whether suffering is unbearable or if there are other options that can be tried to relieve suffering. The report clarifies that, if MAiD is expanded to those with mental disorders and the criterion for determining suffering is not changed, Canada will be the most permissive country in the world for MAiD.

Does Mental Illness Impact Capacity and Autonomy?

At various points, the report mentions the difficulty in assessing capacity to consent in those with mental disorders. Mental illness often affects the ability to make decisions and it can be difficult for doctors to determine how far that extends. Additionally, it could be difficult to determine whether the patient is rationally choosing MAiD, or if they have a distorted perception of their suffering because of depression or hopelessness. This also raises questions about how external pressures from family, society, or doctors affect a patient’s decision about MAiD.

MAiD remains closely related to suicide, something that Parliament acknowledged when euthanasia was first legalized. Although there are multiple factors associated with suicide, mental illness is considered one of the strongest risk factors, and the Expert Panel disagreed on whether MAiD and suicide could be properly distinguished.

Stigmatizing Mental Illness

Canada has some history of stigmatizing those with mental illness. The Panel reports that “supporters of sterilization justified such practices on the basis of a widely held belief that the lives of people with mental disorders were less valuable than the lives of those without,” (p. 47) and some are concerned that the legalization of MAiD for mental illness will have the same effect.

Critics suggest that permitting MAiD for those with mental illness could fundamentally alter the practice of psychiatry. Doctors might more readily give up on patients, encouraging them to choose MAiD. Likewise, various patients might be reluctant to go to a mental health care provider because they are concerned about MAiD. The Ottawa Catholic Physicians’ Guild told the Panel that, “Tampering with the trust needed in the doctor-patient relationship by inserting the possibility of [MAiD] as an outcome, may undermine psychiatric treatment; ambivalent patients, knowing that [MAiD] could be placed on the table as a treatment option, but not really wanting death, may avoid disclosing their suicidal ideations to their physician for fear of having MAiD foisted upon them” (p. 165).

Overall, the practice of mental health care has become more focused on seeking to improve quality of life and provide meaning, purpose, and hope to patients. Allowing MAiD for mental illness may cause patients to lose a sense of hope and meaning, and to think that death is the only viable option instead of focusing on improvement or recovery.

Need for Further Research

At multiple points throughout the report, the Panel admits that the data and evidence around MAiD for mental disorders is unclear. However, they recognize that providing MAiD for mental illness may further certain inequalities. For example, in one study in the Netherlands, 70% of MAiD recipients for cases of mental illness were women. There are also concerns about what this expansion would do to suicide prevention efforts, particularly in Indigenous communities and for others who do not have adequate access to mental health care and supports. More information is needed on what kind of impact MAiD has on family, friends, and society, whether it has implications for the overall suicide rate, whether it is incompatible with suicide prevention, how to assess capacity, how to determine if a request is autonomous, and how to avoid external pressure for MAiD.

Some members of the panel believe MAiD should be expanded to those with mental illness, and others believe that it should not. Thus, the implications and safeguards are addressed by looking at various possible angles and concerns that could be addressed.

Safeguards/Recommendations

The primary issue the committee discusses is what effect changes will have on inclusion. They are concerned, on the one hand, that people will access MAiD who should not be accessing it and, as a result, the vulnerable will not be protected. On the other hand, they are worried that others will be restricted by creating additional barriers to access MAiD.

For guidance, the Panel looked particularly at Belgium and the Netherlands, countries which have been offering MAiD for mental disorders for a couple of decades. Statistically, 1-2% of all euthanasia cases in Belgium and the Netherlands are patients with mental disorders, and the highest percentage of those cases are patients with depression. As mentioned above, women are disproportionately represented in these numbers.

Although some committee members do not endorse MAiD for mental illness, the committee did discuss different options for safeguards that Parliament could consider. Some of these safeguards are based on recommendations that have been provided to the governments of Belgium and the Netherlands to improve MAiD law in those countries.

Specific safeguards discussed include:

1. Require two independent experts to agree that a patient is eligible for MAiD. Could also require doctors to consider previous requests for MAiD which were declined to avoid ineligible patients simply finding a doctor who is willing to provide MAiD.
2. Require a multi-disciplinary evaluation in order to evaluate suffering beyond medical factors. This evaluation would consider factors such as grief, loneliness, stigma, shame, or lack of support.
3. Require a roundtable, committee, tribunal, or judicial approval to ensure that authorization is given by a separate body and that there can be further discussion about eligibility.
4. Require the involvement of family and/or other third parties to ensure that families’ thoughts are considered in the evaluation.
5. Ensure that a psychiatrist determines if there are any treatment options that have not been tried which could help before MAiD is approved.
6. Train healthcare workers to assess capacity and autonomy of decision-making.
7. Ensure that there is an adequate waiting period between a patient’s request for MAiD and their death. Some have suggested up to a year before MAiD can be provided to an eligible patient.
8. Require that the patient and physician agree that there is no prospect for improvement based on the best available evidence. A patient can only be deemed untreatable after every available intervention has been tried.
9. There should be better reporting and review of MAiD cases to ensure compliance with existing regulations and to get more data about the impacts of MAiD.

Conclusion

The committee concludes the report by sharing the disagreement among members and stating, “Ultimately, however, the issue of whether to alter the existing law to further permit or restrict MAiD [for mental illness] is a challenging question upon which people disagree.” This is certainly not an endorsement of MAiD for mental illness and the committee raised many valid concerns throughout the report. Yet, three years after the report was released, Parliament passed Bill C-7, which included a clause to allow MAiD for mental illness by 2023. The Preamble to Bill C-7 admitted that we need more research on MAiD for mental illness, yet Parliament moved forward with it anyways.

This spring, an Expert Panel appointed by the government will release a report to provide recommendations on how MAiD for mental illness can best be implemented. If MAiD expands to those with mental illness, the recommendations discussed in this report may be important to protect vulnerable Canadians, but will not adequately protect those who struggle with mental illness. We must still advocate for the complete removal of the clause that will expand MAiD to those with mental illness.