People with Sole Mental Illness Should Have Access to MAiD

Note: This article addresses mental illness and medical assistance in dying. Reader discretion is advised. For support, call or text Canada’s Suicide Crisis Helpline at 9-8-8.

Read a brief primer about Canada’s MAiD legislation.

An individual’s request for MAiD under any circumstances is an extremely personal existential matter, deserving of nuanced consideration. Unfortunately, public discussions about MAiD for individuals with mental illness as the sole underlying condition are often polarized and acrimonious. This is deeply problematic. An issue this complex requires a balanced and thoughtful approach in which those with opposing views – including those with lived experience of mental illness – can collaborate.

Those who are strongly opposed to MAiD where mental illness is concerned tend to have the loudest voices, and yet they are not in the majority – both among the Canadian public ¹ and among psychiatrists. ² Many opponents imply that MAiD assessors would approve any patient who asks, without question – which, if true, would be a criminal act – or that we are ignorant of the complexities of assessing these patients. This is far from the truth.

Prior to Bill C-7 in 2021, MAiD for sole mental illness was not excluded in the Charter or by law. The exclusion in Bill C-7 provided a delay in implementation of MAiD for this group to allow more time to develop additional safeguards. Since 2021, there have been more delays, despite additional guidance and protocols developed in 2022 by the Government Expert Panel on MAiD and Mental Illness and by Health Canada in 2023. The decision to delay access to MAiD assessments for those who have sole mental illness is illogical and discriminatory.

The delay is illogical because under current law, people with mental illness who also have a qualifying physical condition, such as chronic kidney disease or multiple sclerosis, can be assessed for MAiD. Those with the same mental illness but without a qualifying physical condition cannot.

Therefore, if the argument for the delay is that individuals with mental illness are more vulnerable (perhaps due to socioeconomic hardship or lack of adequate supports), then excluding this group alone fails to provide meaningful protection. People with the same vulnerabilities (those with mental illness who also happen to have a qualifying physical condition) are already potentially eligible for MAiD.

The delay is discriminatory because it perpetuates the assumption that suffering from mental illness is less severe than suffering from physical illness. Yet the government’s Fifth Annual Report on MAiD indicates that psychological experiences are the most prominent sources of suffering in MAiD requests. For example, 95.5 per cent and 96.3 per cent of patients, on track one and two respectively, who had been approved for MAiD in 2023 reported a loss of ability to engage in meaningful activities. ³ Mental illness can cause this same kind of loss.

The delay is also discriminatory because it sustains several false presumptions. First, it wrongly presumes that the medical and psychosocial complexity of people requesting MAiD for sole mental illness is greater than for those requesting MAiD for physical illness.

Second, it presumes that people with mental illness requesting MAiD are by default suicidal whereas those with physical illness are not. However, people with physical illness can also be suicidal.

Third, it incorrectly presumes that mental illness is always treatable whereas physical illness is not. The unfortunate truth is that a small number of people with mental illness, including those who are not socially disadvantaged and who have had access to excellent quality of care, do not find improvement. Some of these individuals do reach a point where they want to request MAiD.

A key misconception underlying the delay is that people with mental illness are less able to make rational life-or-death decisions than those with physical illness. However, the government has already asserted that some people can make a rational choice to end their lives. A crucial part of the MAiD assessment is evaluating “capacity” – an individual’s ability to understand the relevant medical facts about their condition (including their diagnosis, prognosis, treatment options and risks and benefits of treatment versus no treatment, including MAiD), to make logical choices and to appreciate how their decision will affect them and their loved ones.

Capacity can be compromised by many factors, such as physical or mental illness, acute stress or medication side effects. A person who is suicidal does not demonstrate clear reasoning, but because those without mental illness can also be suicidal, excluding people with sole mental illness does not solve the problem of ensuring that MAiD requestors are capable and not suicidal. Because most people living with mental illness have the ability to appraise their options in a rational manner, it is stigmatizing to exclude people with sole mental illness from the right to be assessed for MAiD.

It is vital to remember that assessment for MAiD does not automatically mean approval.

The process for track 2 requests – where death is not reasonably foreseeable – is extremely rigorous, and includes additional safeguards beyond those required for track 1 requests (where death is reasonably foreseeable). Patients must be informed of, and offered, alternative treatments and demonstrate “serious consideration” of these options: that is, they must show the ability to truly imagine the impact of both MAiD and alternative treatments. My track 2 assessments often occur over months to years and include multiple lengthy visits, and in-depth collaboration with a patient’s medical team and loved ones.

I understand concerns about socioeconomic hardship limiting access to good-quality mental health care. For example, many individuals struggle to find publicly funded psychotherapy. Our provinces and territories need to invest more in mental health treatment and services, community resources and social supports. These resources should be expanded regardless of MAiD. Note that a MAiD request primarily driven by lack of resources would not be eligible because the request needs to be based on a “grievous and irremediable medical condition.” ⁴

By pre-emptively ensuring that people with sole mental illness cannot even ask to be assessed for MAiD, the government is depriving these individuals of the right to autonomy over medical decisions that is currently afforded to other Canadians. People with mental illness often already feel stigmatized, and this decision perpetuates the stigma.

Read an argument for why MAiD should not be accessible to people solely with mental illness.

Dr. Justine Dembo is an assistant professor of psychiatry at U of T, a staff psychiatrist at Toronto General Hospital, and a consultant at Sunnybrook Health Sciences Centre in Toronto. She has been a MAID assessor since 2015, and she has researched, taught and published on the intersection of MAID and mental illness since 2009. She was a member of Health Canada’s Government Expert Panel on MAID and Mental Illness, as well as an Expert Witness in the Truchon v. Canada and Lamb v. Canada cases. She has also been a member of the Canadian Psychiatric Association’s Working Group on MAID and mental illness since 2020.

1. As found in an Ipsos Population Survey, July 2023
2. As found by the results of a member consultation on Medical Assistance in Dying by the Canadian Psychiatric Association, 2020
3. From the Fifth Annual Report on Medical Assistance in Dying in Canada. Government of Canada. 2023.
4. From An Act to Amend the Criminal Code (Medical Aid in Dying).