The federal government's plans to extend medical assistance in dying (MAID) to people with mental illness remain controversial despite a year-long pause aimed at establishing adequate protections for patients as well as guidelines for health workers.
Hope kept Laurel Walker alive as suicidal thoughts overwhelmed her. If Canada moves forward with its intention to expand medical assistance in dying to people with mental disorders, she believes people struggling with the same darkness would be deprived of hope.
Supporters of an expansion of medical assistance in dying, scheduled for March 17, argue that granting medical assistance in dying to people with a terminal physical illness without granting the same right to those with a terminal mental illness is a form of discrimination represents a disability. Opponents counter that there is not enough evidence to predict whether or not a person will recover from mental illness.
Recent comments from Ottawa suggest expansion is not a certainty. Justice Minister Arif Virani said on Wednesday that the Cabinet would consider the opinions of a committee of medical experts and other stakeholders before deciding on March 17 whether the government would proceed.
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Federal Minister of Justice Arif Virani (file photo)
Photo: The Canadian Press / Sean Kilpatrick
Ms. Walker's biggest concern is that vulnerable people are on long waiting lists and cannot afford to pay for mental health care that is not covered by government programs.
There is a discrepancy and for this reason I believe it is irresponsible to push ahead with medical euthanasia in certain cases of mental illness.
Ms. Walker is a 44-year-old Halifax resident who suffered from depression, anxiety and post-traumatic stress disorder for 20 years before being hospitalized. She doesn't want to see MAID expand next March to people whose only medical problem is mental illness.
Her battle with depression began in high school, but she said the care she needed wasn't available in her home province of Nova Scotia. It took about 20 years before he sought treatment in a private hospital in Ontario.
I attempted suicide in 2005 and ended up in the hospital. “I wouldn't have been able to make a rational decision, but I could have applied for MAID soon,” Ms. Walker said, adding that she hasn't needed mental health care in the public system since she completed treatment 10 years ago .
I remember my dark times and it was hopeless. The fact that I thought about ending my life and tried to do so is terribly sad for me. People with mental health problems who would even consider medical euthanasia suffer enormously.
Allowing medical assistance in dying without adequately funding the treatment of people who are at risk of ending up in the emergency room again and again is tantamount to saying there is no hope, she said.
The incurable aspect of mental illness
Since 2016, Canadians have had access to medical assistance in dying for physical illnesses or terminal disabilities. As of 2021, following a Quebec court decision, the law no longer requires that a person's natural death be reasonably foreseeable.
People with mental illness should be eligible starting in March 2023 to give a group of mental health experts time to make recommendations.
But the expansion was put on hold for a year last February after some national psychiatrists and groups, including the Center for Addiction and Mental Health (CAMH) in Toronto, the country's largest psychiatric teaching hospital, raised concerns, particularly about the need to ensure better access.
A curriculum has since been introduced to guide MAID assessors and providers.
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The Toronto Center for Addiction and Mental Health (CAMH)
Photo: Radio-Canada / Myriam Fimbry
A parliamentary committee on MAID, which is expected to submit its recommendations to the Senate and House of Commons by January 31, met again in November when it heard testimony from experts including psychiatrists who called for an indefinite cessation of MAID for people with mental health problems illnesses cause .
A frequently expressed concern was that doctors and nurses would use their personal values to assess a patient's suitability. It is also difficult to distinguish a request for MAID from a person wanting an assisted suicide, it is argued.
The Center for Suicide Prevention says it is necessary to reach consensus on the definition of “incurable” for any mental disorder that affects people who are not dying.
In an emailed statement on Friday, CAMH said it was pleased that the government was considering delaying the extension of eligibility for medical assistance in dying to people whose only underlying condition is mental illness.
Currently, the healthcare system is not ready and healthcare providers do not have the resources they need to provide high quality, standardized and equitable MAiD services.
Dr. However, Konia Trouton, president of the Canadian Association of MAID Evaluators and Providers (CAEPA), suggests the medical assistance in dying training program, which includes a section on mental illness, will help doctors and nurses determine whether a person is attempting suicide commit.
We believe the healthcare system is ready for March [prochain]”If we expect the current restrictions to be lifted,” said Dr. Trouton in an email Friday.
“ACEPA is an organization that represents the professionals who do this work and believes that clinicians are ready,” said this family doctor, who has worked as a MAID assessor and provider in British Columbia, Alberta and Ontario.
Doctors and nurses new to MAID would benefit from 27 hours of online training as well as 12 hours of workshops. Anyone with experience will benefit from a six-hour training course, explained Dr. Trouton in a previous interview.
The program trains clinicians to distinguish between an acute suicide concern and a request for euthanasia by considering the type of treatment the patient has received and whether the person has attempted to cope for an appropriate period of time, including with medication, explained Dr. Trouton.
Involve a psychiatrist in the assessment
People whose death is not reasonably foreseeable must already be examined by two independent doctors or nurses. If neither party is an expert in the applicant's health condition, the applicant is obliged to consult a specialist. The same guarantee applies to people suffering from mental illness, explained Dr. Trouton.
Dr. Jitender Sareen, head of the department of psychiatry at the University of Manitoba, said he and many of his colleagues believe a psychiatrist should be involved in that assessment. He emphasized that the expert group's draft regulatory standards do not provide for this measure.
Dr. Trouton said provinces and territories could decide whether to include a psychiatrist in the MAID process, but that remains to be seen.
Provincial and territorial governments say they won't implement their plans until Ottawa introduces legislation. However, Quebec banned the expansion of medical assistance in dying on the grounds that mental illness does not give rise to medical assistance in dying.
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Observers want psychiatrists to take part in the assessment process of patients who need medical assistance in dying.
Photo: Shutterstock / DedMityay
Regarding concerns about lack of treatment, applicants would be informed of possible options, Dr. Trouton, and those who do not have a primary care physician would be connected with a primary care provider.
A survey conducted by the Canadian Psychiatric Association in 2020 found that 41% of responding members agreed or strongly agreed that people with mental illnesses should be eligible for MAID. The survey was sent to 2,056 members and 474 of them responded.
Dr. Sonu Gaind, head of the department of psychiatry at Sunnybrook Health Sciences Center in Toronto, is among those who oppose expanding medical assistance in dying.
He explained that in Belgium there are legal requirements for adequate care and that there should be no reasonable alternative before a person is admitted to receive MAID, but that Canada has no such guarantee.
He stressed that data from Europe suggests that women with mental illnesses, particularly those marginalized by social suffering caused by poverty, lack of housing and lack of community support, would be at greater risk if medical assistance in dying were expanded without strong legal guarantees would.
The federal government said in 2021 it would better track who has access to medical assistance in dying and how it is provided. However, the latest annual report on MAID, released in October, contained no such information and showed that 13,241 people died last year thanks to MAID.
Health Canada said it is working with provinces and territories to collect data on the services – including psychological monitoring and accommodation – offered to people when they were screened for MAID.
This new data will be included in future annual reports, the agency said in an email.
Do you need help?
If you are thinking about suicide or worried about a loved one, staff across Quebec are available 24 hours a day, seven days a week.
Phone: 1 866 CALL (277-3553)
Text: 535353
Chat, information and tools: www.suicide.ca