In Canada, assisted dying is a rights-based issue that resulted from constitutional court cases, rather than voter-initiated ballots or government initiatives. These cases were brought and won by both terminal and non-terminal patients, including Jean Truchon who had cerebral palsy. His primary motivation for considering assisted death was not medical, but due to the loneliness brought on by the pandemic. This raises concerns about people making decisions to die due to social reasons such as poverty, isolation, and loneliness.
Assisted dying is legal in 15 countries, including 10 US states and Washington, DC. In these countries, cases involving primarily psychiatric conditions are rare, making up about 1% of all cases. Canada’s assisted dying laws lack certain safeguards that other countries have, such as a requirement to try all reasonable treatments and a review process. Additionally, doctors are able to initiate the conversation and eligibility for MAID will soon be extended to people suffering solely from mental conditions. There is no one monitoring whether those in Canada who are legally allowed to do so are following the law and regulations. Canada has long since rejected paternalism in medicine, as stated by the Supreme Court decision that a person is not obligated to undergo treatments that are not acceptable to them, even if the result of not doing so is death. There is a very thorough process in place for assisted dying, with a range of eligibility criteria and extra safeguards. Canadians are free to make their own choices, but when it comes to assisted death, people are vulnerable. John Maher, a psychiatrist in Ontario, Canada, works to ensure his patients live life the way they want and that mental illness does not prevent them from doing so. It was initially thought that people would opt for assisted dying due to lack of access to palliative care, however the data has shown that over 80% of those who receive MAID in Canada are receiving palliative or hospice care at the time of their death, and 88% have access to such care. This is higher than the wider Canadian population, where only a minority of people are receiving palliative care before they die. The data from MAID providers also shows that 21% of people who received MAID had palliative care for less than two weeks, however there is no objective marker for the quality of palliative care received. Since MAID was legalized in Canada, there has been an increase in funding for research for palliative care and an increase in the number of people receiving and dying with palliative care at home. MAID is most commonly requested by those with a cancer diagnosis or end-stage organ failure, and the wait times for MAID in Canada are shorter than the wait times for many specialized services. John Maher’s job as a MAID provider requires him to ensure his patients have been offered resources and services that could potentially reduce their suffering. National polls have consistently shown that the Canadian public supports assisted dying, including religious people and those with disabilities. where a person has a mental health disorder…where the suffering is so profound…that they can’t access the care they need.That’s why we need to make sure everyone has access to the care they need.
Two polls that asked Canadians about their views on MAID for mental illness came back with very different results. One poll showed over 60% of Canadians in favor, while another poll, in particular looking at MAID for mental illness, showed that only 31% of Canadians support it. I don’t think Canadians have a full understanding of what is happening, but those organizations that are focused on what’s happening and drawing attention to it - namely the 137 disability organizations in Canada, the national indigenous organizations, the mental health organizations, the United Nations - everyone who is looking at this and understanding what is going on is gravely concerned about the discriminatory impact of this legislation.
Canadians have been talking about and debating assisted dying since the 90s. There are multiple reports, multiple committees, multiple news stories, multiple court cases to suggest that Canadians are aware of what the issue is. There is no consensus among Canadian psychiatrists on when any particular psychiatric illness is incurable, and under the law that comes into effect in 2024 in Canada, a psychiatric illness must be incurable and a person must be in a state of irreversible decline. But we can’t say who that is. Consensus in health care is rarely required.
There is no consensus amongst doctors about whether they can accurately predict a prognosis of six months. Yet it’s an eligibility requirement for assisted dying in several countries, including the United States. However, in Canada, for MAID to proceed, two independent clinicians must be of the opinion that the patient’s condition is incurable. When someone has a terminal illness, say cancer, we have a pretty good idea of how long they might live, although it may not be precise. In mental illness, we have no idea. People get better after five years, after ten years. These are very, very different conditions and very different circumstances.
Only one in three Canadians have access to mental health care who need it, and only one in five children. We know from disability organizations across the country that disability supports are completely inadequate to live a meaningful life. People are suffering in ways that we can do something about. Would you support providing MAID to someone while they’re waiting for treatment or care that could help them? But it’s down the road a bit. I would happily stand with you and call for our government to do better than what it’s doing. It’s a separate issue. There can come a time, on a case-by-case basis, where a person has a mental health disorder where the suffering is so profound that they can’t access the care they need. That’s why we need to make sure everyone has access to the care they need. or other factors…are actually driving people to request MAID.
Every situation is individual and needs to be assessed in a unique way. There may be cases when a certain treatment is too far away, too expensive, or inaccessible to the patient. In these cases, we must consider not holding them hostage to society’s failings and consider offering MAID if it’s truly what they need. John can tell us something from his personal experience that has strengthened his conviction on this issue. As a psychiatrist, he works with a community mental health team supporting people with serious mental illnesses. He has seen how MAID has introduced into their clinical worlds and how patients are already saying they will no longer try treatment or seek help. He shared an experience of a patient, Ray, who was 62 years old with metastatic lung cancer. Ray had been asking for MAID for some time and, after meeting the eligibility criteria, John was able to tell him he was eligible. He saw a physical transformation in Ray, and Ray decided to proceed with MAID. At the rooftop garden of the facility in which he was living, Ray gave his final consent before John administered the medication. Ray grabbed John’s hand and said, “I know this is going to sound odd, Dr. Green, but I think you saved my life.”
Stefanie clarified a piece of misinformation about MAID, that Canadians cannot access it based on factors such as homelessness or poverty alone. John clarified that some have argued that MAID for non-terminal conditions is not suicide, but in fact, in one US survey of over 1.4 million Americans, 80% of people reported that they thoughtfully planned their suicide.
John noted that Canada currently collects data on the physical illnesses that lead to requests for MAID, but not on the socioeconomic reasons people might request it. We don’t know whether poverty, homelessness, being on a waitlist for treatment, or other factors are actually driving people to request MAID. Being refused disability benefits and not knowing why, John and I are almost in agreement that people are choosing Medical Assistance in Dying (MAID) and we should. Canada has recently expanded the type of data it is gathering on patients who request and receive MAID, and it will be interesting to see if the data mirrors what is known from international jurisdictions - that it is the socially advantaged who are accessing assisted dying, not the socially disadvantaged.
We have a good idea of why people are requesting MAID, primarily because they can no longer do the things that bring meaning to their lives, they can no longer do activities of daily living, and they have lost a sense of dignity or independence. Research could potentially help us better understand what leads to this type of suffering, and if we could find it, it could help us to treat it.
I am concerned that this law may have the unintended but profoundly disturbing consequence of having people feel like they are a burden and that they should choose death over life, rather than demanding that care and support be provided. However, Canadians are grateful for this option, and not a single person has been charged with misappropriate action.
I think Canada’s approach to assisted dying is more than adequate, and it may be a model for other regions to consider in their own care.