CASP Issues Statement About MAiD for Mental Illness - Canadian Association For Suicide Prevention

December 14, 2022, Canmore, Alberta, Canada

As a national organization that envisions a Canada without suicide, the Canadian Association for Suicide Prevention (CASP) is issuing this statement to outline serious concerns about the further expansion of Medical Assistance in Dying (MAiD) to include mental illness conditions, which is set to be implemented in mid-March 2023.

“Just as life is getting harder in Canada, it is getting easier to die.” ⁽¹⁾

It is important to be perfectly clear, that when considering MAiD in the context of someone who is not dying as a result of their condition, such as a mental disorder alone, we are talking about suicide. By the very definition of suicide, which is the act of killing oneself, if the condition from which they are suffering is not killing them, then the act of providing medical assistance in dying is doctor-assisted suicide.

With respect to MAiD when the sole underlying condition is a mental disorder, CASP asks all Canadians to consider the following:

Recognizing that the legal requirement of “irremediability” of a mental disorder in order to qualify for MAiD, there is insufficient research into this prognosis and, therefore, insufficient data to conclude irremediability of any mental disorder. As such, currently, a mental disorder alone does not satisfy this aspect of the legal test for MAiD.

CAMH provides a useful statement:

“As we have made clear, we do not believe that eligibility for MAiD should be extended to people whose sole medical condition is mental illness at this time. Before eligibility is extended, there must be thoughtful and inclusive discussions to develop consensus definitions of irremediableness and suicidality.” ⁽²⁾

A physician’s decision to offer MAiD as a treatment option for mental illness, should always be objective, based on evidence, and never be subjective. In the absence of evidence of irremediable mental disorder, physicians will be unable to assess and validate a patient’s eligibility for MAiD. Without scientific evidence, any rigorous assessment will ultimately come down to subjective decision-making by the physician and the patient.

Regarding the capacity for a patient to consent to MAiD, the very nature of mental disorders may impair the decision-making capacity of the patient. Those suffering from a mental disorder are routinely encouraged to avoid making major decisions while in the midst of their suffering. The decision of ending one’s life prematurely is enormous and grave and must not be made while in the throes of mental illness.

For patients seeking and/or considering MAiD, who suffer solely from a mental disorder, a full disclosure by the attending physician must include:
- according to the best available science to date, it is impossible to make an accurate prognosis regarding the ‘irremediability’ of a patient’s mental illness;
- the potential exists, that with more aggressive, intensive, and/or individualized care, the patient’s suffering could be alleviated and, therefore, they could live a life that meets or exceeds what the patient may consider to be a worthwhile existence for years or decades to come; and
- based upon the above, it is not possible to grant MAiD to anyone suffering solely from mental disorder because the legal test set out in the legislation cannot be satisfied.

Physicians are being called upon to interpret MAiD legislation, and to have the requisite knowledge, skill, and judgement to assess and/or provide MAiD, in keeping with that legislation. However, with respect to mental disorder being the sole underlying condition, such knowledge should include recognizing the lack of requisite scientific evidence regarding ‘irremediability’, thus negating the ability to assess and/or provide MAiD for patients whose sole underlying condition is mental disorder.

With respect to physicians not willing to provide MAiD for persons whose sole underlying condition is mental disorder, there may be another reason to deny the request, beyond those of conscience or religion. They may not be willing to provide MAiD to a patient due to the lack of evidence that irremediable mental illness exists. Consequently, requiring a physician, who refuses to provide MAiD on the basis that there is no scientific evidence to support that the condition is irremediable, to make a referral to another physician for treatment deemed to be unwarranted forces the referring physician to commit professionally unethical behaviour.

CASP is joined by a host of other national organizations and medical societies calling for a pause to the expansion of MAiD, amid concerns of a lack of evidence of ‘irremediable’ mental illness, as well as the absence of necessary public awareness, training, protections and safeguards and evaluation frameworks that must be established to ensure the health and safety of both patients and physicians.

The Association of Chairs of Psychiatry in Canada, which includes heads of psychiatry departments at all 17 medical schools, recently issued a joint statement calling for a delay to the expansion of MAiD, saying more time is needed.

Several leading psychiatrists are also raising alarms and are calling for a pause of MAiD for mental illness. Dr. Valerie Taylor, Psychiatric Chair at the University of Calgary, says that the MAiD expansion is happening too quickly. She suggests that the provinces and territories are not ready for the expansion, and she would like to see a pause to ensure the legislation is implemented appropriately. ⁽³⁾

Joining her, is Dr. Jitender Sareen, head of the University of Manitoba’s psychiatry department, who recently shared his group’s concerns that the upcoming MAID expansion is happening without sufficient guidelines and safeguards for patients and psychiatrists. ⁽³⁾

Beyond the concerns raised above, CASP is extremely concerned about expanding MAiD in the current health environment. At present, there are growing concerns about the state of Canada’s health care system. Since the pandemic, health care systems have experienced increasing demands and are now taxed and overburdened, resulting in excessive wait times for medical care, including mental health care. Expanding MAiD to include mental illness, when access to timely care and treatment for mental illness is at an all-time low, is absolutely unconscionable.

The Canadian Mental Health Association (CMHA) is a national mental health organization focused on advocating to ensure that all people with a mental illness have both the conditions they need to recover, and the mental health care they need to be well, as outlined in their Statement on MAiD for mental illness. Statement on upcoming changes to Canada’s Medical Assistance in Dying (MAiD) law – CMHA National.

In addition to CMHA’s Statement on MAiD for mental illness, and in response to a lack of mental health care for many Canadians, the organization recently launched a call for Universal Mental Health Care. Its ‘Act for Mental Health’ campaign is supported by a network of Canadian organizations, including CASP, and presses leaders for Universal Mental Health Care for all Canadians.

Considering the above concerns and the many experts voicing similar concerns, CASP calls for a pause to the expansion of MAiD for mental illness. It is the organization’s hope that, as a caring society, we can work together to ensure people living with mental illness are provided timely and equitable access to mental health care, treatment, and support before we hastily introduce options for them to prematurely die, through MAiD for mental illness.

Note: The concerns outlined in this statement are in addition to those cited in CASP’s previous statements regarding MAiD.

February 2021 Statement on Recent MAiD Developments – Canadian Association For Suicide Prevention.

December 2020 Statement on the Expansion of Medical Assistance in Dying to those without a Reasonably Foreseeable Death – Canadian Association For Suicide Prevention.

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