The debate over whether Canadians with mental illness should have access to a medically assisted death ramped up this past week raising questions around why it’s so heavily scrutinized and who is most impacted.
On Wednesday, the Special Joint Committee of Medical Assistance in Dying (AMAD) tabled its final report recommending that the government amend the Criminal Code to “indefinitely exclude” people whose sole underlying condition is a mental illness from applying for medical assistance in dying (MAID).
While MAID has been available in Canada for the last decade, it was only five years ago that people without a reasonably foreseeable natural death became eligible to apply.
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That same year, the government also said people with mental illness were temporarily excluded from MAID until 2023. But the government has since extended that exclusion twice. Now, unless Parliament intervenes, people whose sole underlying condition is a mental disorder will be able to apply for MAID as of March 17, 2027.
The issue has been heavily debated in Canada among experts, politicians and people with lived experience — each weighing in with different perspectives. Here’s a look at some of the questions being raised.
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In an interview Thursday, Dr. Sanjeev Sockalingam, chief medical officer of health at the Centre for Addiction and Mental Health, told CBC’s The Current that this isn’t a debate about suffering, because doctors see the toll mental illness takes on people every day in their emergency departments and clinics.
Rather, Sockalingam and other experts have repeatedly said that when it comes to mental illness they can’t say whether someone won’t get better over time or with new treatments.
“Our ability to predict people’s long-term prognosis is actually variable,” he said. “We are not in a state of having a more precise ability to predict outcomes for patients with mental illness, long-term.”
The other issue many point to is that it’s difficult to determine if someone is suicidal as a result of their mental illness, or if they have a genuine wish to die using MAID.
Dr. David Gratzer, a Toronto-based psychiatrist, says that’s because mental disorders “can impair judgment.”
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With that in mind, he says it’s “very difficult to tell the difference between somebody who has thought this through, who has decided that they just aren’t getting better from treatment, that the downside of living is greater than the upside of living. And to distinguish this from somebody who’s in a crisis.”
But for some with mental illness, who have spent years struggling and want access to MAID, the legislated exclusion feels discriminatory and they say it takes away their right to choose.
There are still a lot of unknowns and debate among mental-health specialists when it comes to defining treatment-resistant cases.
For example, there is still no consensus on what difficult-to-treat depression means, as it depends on a number of factors, including how many medications or therapies a patient has tried, at what dose and for how long.
“If you can’t agree on the exact disorder, it becomes much more difficult to agree on the treatment, and even more complicated to say when treatment is useful and when treatment isn’t useful,” said Gratzer.
Generally, a person might be considered “tougher to treat,” if they don’t respond to at least two or three different medications, says Gratzer.
But that doesn’t mean they’re not going to get better with time, or that they won’t eventually respond to a future treatment, he says.
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For example, newer treatments for depression, such as psychedelic drugs like ketamine, transcranial magnetic stimulation (TMS) or magnetic seizure therapy (MST), have brought newfound hope to some, said Gratzer.
Both TMS and MST involve some type of magnetic stimulation of the brain. For TMS, the magnetic pulses target nerve cells and change the way the brain functions. Meanwhile, MST creates a seizure in a specific part of the brain, increasing blood flow to areas responsible for symptoms.
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Dr. Jennifer Swainson, an Edmonton-based psychiatrist who specializes in difficult-to-treat mood disorders, says new treatments have shifted her perspective on patients who had seemingly run out of options about a decade ago.
“Now that they’ve had ketamine available to them, they’ve really recovered and they’ve got a good quality of life,” she said.
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But she admits that it’s difficult to balance future possibilities with people suffering right now.
“Do we expect those people to wait,” she asked. “And how long do we expect them to wait?”
According to the Canadian government, mental illness includes conditions that are “primarily treated within the domain of psychiatry, such as depression and personality disorders.”
Mental illness doesn’t include neurocognitive and neurodevelopmental disorders, or other conditions that impact cognitive abilities, according to the government.
These are conditions like dementia or Parkinson’s disease, which are already eligible for MAID under current legislation.
Should Canadians with mental illness have access to MAID?
Following AMAD’s report this week, federal Justice Minister Sean Fraser says the government will take the next few weeks to review it before responding with a decision.
Fraser, who is leading the handling of the file, wouldn’t give a date when asked by CBC News as to when they will reach a decision, but said he will review the committee’s testimony and do his own engagement.
If the government wants to pause the expansion of MAID eligibility — either temporarily or indefinitely — it will have to introduce proposed legislation.
