Canada should “indefinitely exclude” people whose only medical condition is a mental illness from being eligible for medical assistance in dying (MAID), a committee of MPs and Senators says.
The committee released its long-awaited report on June 17, the 10-year anniversary of Canada legalizing MAID.
Right now, Canadians whose only medical condition is a mental illness are not eligible for MAID. That ban is set to lift in March.
But the committee says the restriction should stay in place — indefinitely. The government should change the Criminal Code to specifically exclude MAID for the sole purpose of mental illness, it said.
There continue to be “grave concerns” with allowing MAID for mental illness, the committee wrote. Medical professionals also do not agree on whether the practice should be allowed.
In a statement to Canadian Affairs, the press secretary for Justice Minister Sean Fraser said the government will review the committee’s report and the evidence it heard before making a decision about how to proceed.
The 98-page report makes only one recommendation to the government, but stresses the debates surrounding MAID for mental illness.
It detailed the concerns some have raised about whether mental illnesses meet the legal MAID eligibility criteria of being an “irremediable” medical condition and whether a request for MAID can be distinguished from suicidal ideation.
The committee included five senators and 12 MPs. Seven of the MPs are Liberals, four are Conservatives and one is Bloc Quebecois.
The report shows the debate about this issue is far from finished. Some committee members recommended the Supreme Court of Canada weigh in on allowing MAID for mental illness, while others called for stricter oversight of MAID.
Ongoing debate
Parliament has been debating whether to allow MAID for mental illness for years.
In 2021, Parliament passed a law that would allow MAID for the sole purpose of mental illness in 2023. Parliament then extended that date twice — first to 2024, then to 2027.
For those concerned about MAID for mental illness, this latest report is welcome news.
“It was the most responsible recommendation that the committee could make,” said Dr. Sonu Gaind, a psychiatry professor at the University of Toronto and past head of psychiatry at two Toronto hospitals.
Gaind has long argued against MAID for mental illness, saying doctors cannot definitively determine whether a mental illness will improve.
“The evidence tells us we cannot make those predictions with any accuracy or honesty,” he said.
The Centre for Addiction and Mental Health also praised the report’s recommendation.
In a statement, the centre said it “supports” an indefinite delay.
The centre noted a lack of “evidence-informed, consensus based criteria” for determining the irremediability of mental illness and distinguishing requests for MAID and “suicide intent.” There also needs to be more resources for mental health, the centre said.
Disability advocates also praised the report. In a statement, Inclusion Canada said the government should “implement the recommendation without delay.”
Advocates for MAID were disappointed by the committee’s recommendation.
“This indefinite exclusion will have real and severe negative implications for people across Canada,” Helen Long, CEO of MAID advocacy group Dying With Dignity Canada, said in a statement.
“This is stigmatizing, discriminatory and unconstitutional, and we remain dismayed in any decision that continues to prevent all Canadians from accessing their Charter rights equally.”
Four options
In its report, the committee says the government has four possible options.
The first is to allow MAID for mental illness in 2027 under the current MAID laws. The second is to introduce legislation to ban MAID for mental illness for a definite or indefinite length of time. Third, the government could introduce legislation to permanently ban MAID for the sole purpose of mental illness. And finally, Ottawa could ask the Supreme Court of Canada for an advisory opinion on whether excluding MAID for mental illness would be unconstitutional.
Senators Dr. Rosemary Moodie, Pamela Wallin and Kristopher Wells wrote in a dissenting opinion that the question of MAID for mental illness should be referred to the Supreme Court.
The committee’s work was “highly irregular and flawed,” the three senators wrote. Most witnesses who spoke to the committee opposed MAID for mental illness, they said. The committee would have benefitted from hearing from more MAID assessors as well as the Canadian Psychiatric Association, which recently published guidance about assessing MAID requests when the sole condition is a mental illness.
Luc Thériault, the only Bloc Quebecois MP on the committee, shared the senators’ views.
Thériault also criticized the committee’s work, calling it “undoubtedly the worst exercise” he has been part of since the first joint committee on MAID was established.
Reviews before death
However, the committee’s report also showed that some long-time committee members have changed their minds.
Senator Pierre Dalphond had previously advocated for allowing MAID for mental illness. Now, he is among those calling for an indefinite pause.
MAID for mental illness is complex, he wrote. If it were to be allowed, a group of psychiatrists, psychologists and legal experts should review every case of MAID for mental illness before it is administered, he wrote. This panel should not be involved in the patient’s MAID assessment.
In a separate supplementary opinion, Conservative MPs and Senators wrote that the government should also increase the information collected about who requests and receives MAID in Canada. This should include information about individuals’ social and economic situation, psychiatric history and prior MAID assessments.
The government should also review the “effectiveness and enforceability of the current MAID safeguards,” and establish minimum national standards for MAID oversight that would include pre-death reviews of MAID cases.
Dr. Ramona Coelho, a family doctor in London, Ont. who previously served on the Ontario chief coroner’s MAID Death Review Committee, agrees that there needs to be a review of current MAID safeguards — even in cases where a person’s death is reasonably foreseeable.
“[For] persons near the end of their lives, suicide prevention principles still apply,” she said. People who are dying still need access to adequate palliative care and therapies to manage their symptoms, she said.
The Ontario chief coroner’s MAID Death Review Committee has previously noted several cases of concern where a person’s death was reasonably foreseeable. These include a woman who was approved for MAID after being denied a space in a long-term care facility.
“Autonomy is not an adequate safeguard, and other things must be reviewed to make sure that safeties are in place,” Coelho said.
‘The worst crime’
Committee co-chair Marcus Powlowski, a Liberal MP, wrote his own supplementary opinion. In it, Powlowski, who was an emergency room doctor and has several law degrees, wrote about why he believes a ban on MAID for mental illness should be upheld.
“To take a life is a decision that is far more profound than any other decision,” he wrote. “It is irreversible. Furthermore, to take someone’s life has for a very, very, long time been considered the worst sin, the worst crime.”
Powlowski expressed support for allowing MAID for patients who are dying and suffering intolerably. But he said there was little evidence that professional regulators have “seriously pursued allegations of misconduct of MAID providers.” This “ought to give rise to concern.”
The ban on MAID for mental illness exists to keep people from hurting themselves, and to protect families from the pain of losing a loved one.
Social circumstances, including having fulfilling relationships, stable housing and meaningful work, can contribute to someone’s happiness or unhappiness, he wrote. He has concerns about allowing MAID for mental illness when people lack those supports.
“A government offering death as an alternative to addressing these issues is not a humane and compassionate government — it is the opposite,” he wrote.
