Feds still not ready to approve mental illness as sole reason for MAID

Medically assisted dying is a singularly personal choice and a heartbreakingly complex issue. Since the adoption of Bill C-7 in 2016, the Canadian legislative framework for MAID (medical assistance in dying) has based eligibility on a person having a “grievous and irremediable medical condition.”

According to Vancouver Island University, “Island Health has consistently had the highest yearly provisions of MAID in Canada since its legalization in 2016. The claim makes sense within the context of data released by the federal government that showed that in 2022, 5.5% of total deaths in BC were by assisted suicide.

There are currently two clinical pathways to access MAID: Track-1 where a natural death is reasonably foreseeable and Track-2, where it isn’t.

Mental Illness does not qualify a person to an assisted death

Mental illness falls under the Track-2 pathway to MAID but because it is not “reasonably a foreseeable natural death” decisions in determining the validity of requests for the provision have become contentious.

In a final report of an expert panel on MAID and Mental Illness (AMAD), the authors said: “The assessment process for persons whose natural death is not reasonably foreseeable is also often more challenging due to the nature and complexity associated with medical conditions of this population and the unique circumstances of the person making the request.”

“The number of Island Health physicians and nurse practitioners willing to assess and provide Track-2 MAID (under which mental illness would also fall) is low,” said Dr. Caroline Variath, a Vancouver Island University (VIU) nursing professor. She and her project co-lead Jill Gerka recently won a Michael Smith BC Health Research Award for their ongoing work on improving access to people wishing to access MAID for Track-2.

Work at VIU continues toward an inclusionary network

Collaborating closely with Island Health’s Palliative and End-of-Life Care team, Variath and Gerka and their team at VIU want “to improve experiences with and access to Track-2 MAID for patients and their families and to support clinicians assessing and providing it. They want to “create a network that consists of patient-partners, multi-disciplinary clinicians, researchers, and trainees.”

It is unclear, though it falls under Track-2, whether her project will also advocate for people with mental illness as the sole reason for their request for MAID.

Determining and declaring a person has a disease from which they will not recover—in other words, its irremediability—is comparatively more straightforward in the case of physical illnesses such as cancer or degenerative diseases such as ALS than it is for mental illness.

Unsurprisingly, cancer is the condition for which 63% of all medically assisted deaths are requested in Canada. Four in 10 Canadians who received MAID in 2021 identified inadequate control of pain as the reason for their request.

Meantime, on Parliament Hill

Last February, the federal government introduced legislation (Bill C-39) to extend the temporary exclusion of eligibility in circumstances where a person's sole underlying medical condition is a mental illness until March 17. However, new legislation (Bill C-62) introduced last week by the Liberal government led by Health Minister Mark Holland, Ya'ara Saks, the minister responsible for mental health and addictions, and Justice Minister Arif Virani is designed to extend that March date by three years.

The governing Liberals sided with a parliamentary committee’s recommendation that it continue to explore some of the complex concerns from medical and psychiatric practitioners about the Track-2 provision on mental illness as the sole reason for seeking MAID.

Witnesses to the Special Joint Committee on Medical Assistance in Dying reported that “it is difficult, if not impossible, to accurately predict the long-term prognosis of a person with a mental disorder.”

Some witnesses told the committee “There is no way to distinguish requests for MAID MD-SUMC from suicidality” and while there is a host of safeguards built into the application and approval process, that concern presents a serious question and justification for the delay.

While some advocates, such as Dr. Donna Stewart, the head of research and academic development at the University Health Network (UHN) Centre for Mental Health Research think the delay “discriminates against the mentally ill,” the Canadian Association for Mental Health (CAMH) in its recommendation to the government, said “the clinical guidelines, resources and processes are not yet in place to assess, determine eligibility, support or deliver MAID when eligibility is confirmed to people whose sole underlying medical condition is mental illness.”

Not everything is equal here

There appears to be a bias in the field when it comes to recognizing one form of insufferable pain but not another.

“We accept the fact that modern medicine cannot alleviate all suffering in the physical realm,” said Justine Dembo, a  psychiatrist at Torontos’s Sunnybrook Health Sciences Centre in Toronto. “I worry when psychiatrists cannot accept this fact in the psychiatric realm.”

Upon hearing of the new legislation, some Canadians suffering from mental illness and unwilling to wait for another three years now plan to go to Switzerland, where assisted dying is a practice that’s been anchored in the penal code since 1942.

“If MAID SUMC (where a mental disorder is the sole underlying medical condition) had been allowed next month and they’d qualified, they could have died in their own country with their friends and family close by to comfort them,” said the UHN’s Stewart.”