Assisted Death Framework to Expand to Canada

Toronto-

Canada is preparing to expand its framework for medical assistance in dying to become one of the largest in the world, a change that some want to delay due to concerns that vulnerable people have easier access to death than to a life without pain.

Starting in March, people whose only underlying condition is mental illness will be able to access assisted dying. Mental illness was ruled out when the most recent law on medical assistance in dying (MAID) was passed in 2021.

This will make Canada one of six countries in the world where a person with a mental illness who is alone and not near natural death can find a physician to assist them in dying.

Individuals will still need to apply and be deemed eligible by two clinicians who will need to determine whether they have an irremediable condition causing them intolerable suffering and whether they have capacity – whether they understand and appreciate their condition, the decision and its consequences.

“Cases of life fatigue in Canada are happening,” said Madeline Li, a cancer psychiatrist specializing in palliative care who has implemented an assisted death framework for her Toronto hospital network.

“I’ve become very comfortable with MAID for people who are dying. I’m less comfortable expanding the indications. … We’ve made MAID so open that you can ask for it for practically no any reason.”

More than 30,000 Canadians have died with medical assistance since it became legal in 2016 – more than 10,000 of them in 2021, representing 3.3% of deaths in Canada that year, according to official data. The vast majority were deemed close to their “natural” death. Last year, 4.5% of deaths in the Netherlands and 2.4% of deaths in Belgium were medically assisted.

Clinicians and experts are working on a Model Mental Illness MAID Standard of Care for groups regulating clinicians.

But some are calling for the expansion to be delayed; others say the existing system is flawed because people suffering from a lack of treatment or support can access assisted dying.

Some people have said in local news reports that they seek assisted dying because they don’t have proper housing or other supports.

The federal agency serving Veterans Affairs says at least one employee suggested spontaneous assisted death to at least four veterans between 2019 and 2022. It is investigating another such allegation, a spokesperson said in an email, adding that assisted dying advice was not a service of the ministry. Some have cited this as an example of misuse of the system.

Some psychiatrists opposed to the expansion say that it is impossible to determine whether a mental illness is “irremediable.”

A spokesperson for Health Minister Jean-Yves Duclos said the government was working with its counterparts to ensure “a solid framework is in place” when assisted death becomes available for mental illness.

A delay would mean that “people who are currently suffering intolerably … would have to continue to suffer,” said Toronto doctor Justine Dembo, who assesses patients for assisted dying and was part of an expert panel on the topic.

Dembo expects shortages of assessors and providers due to job-related stigma and demand.

Jocelyn Downie, part of the group setting standards of practice, said while some people in intolerable pain might suffer less if they had timely access to treatment or supports, denying them assisted death does not solve the problem: it just means that they continue to suffer.

LP, who suffers from anorexia and asked to be identified by his initials, hopes to have access to assisted dying when it becomes available. Without it, she says, she will continue to suffer until illness or suicide kills her.

“It would just be more dignified.”