Depression and MAID: Terminally ill patients are often depressed. But that doesn’t mean they’re incompetent.

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  • Gary Paine says:

    Where do we stand legally in terms of advanced planning for MAID at a time when we may be no longer able to say “now is the time”? I wonder, too, do insurance companies recognize MAID as a form of death suitable for policy payout?


    Medical assistance in dying (MAiD)
    should be modified to allow PROXIES
    to make the final medical decisions
    especially for patients whose mental powers
    become questionable just before death.

    If I am dying from brain cancer,
    there is no telling when I might lose
    the intellectual capacities to choose death.

    Read more discussion of allowing PROXIES
    to make the life-ending decisions
    when the patient can no longer choose:


    Canada’s new right-to-die law does not allow
    a future patient to choose death
    after the patient has lost mental capacity.
    The doctor might prepare the lethal dose,
    but the PATIENT must be able to cooperate
    up to and including the final moments of life.
    Sometimes patients have lost
    the right to medical assistance in dying (MAiD)
    just because they had to be deeply drugged
    to prevent the suffering caused by their terminal illness!

    But the terminal patient is NOT required
    to remain conscious and capable
    in order to receive most other forms of medical care:
    (1) When the patient is unconscious or semi-conscious,
    (2) when the patient has Alzheimer’s disease,
    (3) when the patient is an infant or child or never developed
    enough mental capacity to consent to medical procedures,
    the doctors are NOT prohibited from recommending
    the following life-ending decisions.
    And PROXIES authorize taking the final steps that bring death.

    1. All forms of COMFORT CARE can be provided to dying patients.
    This includes making adjustments in the levels of drugs
    used to control the various symptoms of dying.
    The doctor can increase the pain-meds
    even if this might shorten the process of dying.
    When the patient cannot approve any such changes,
    the PROXIES authorize what the doctor recommends.

    2. If the patient’s suffering cannot be adequately controlled
    by increasing the pain-medication,
    then the doctor might recommend TERMINAL SEDATION.
    Drugs will be given to the dying patient
    that will keep this person PERMANENTLY UNCONSCIOUS
    for whatever remains of the process of dying.
    Usually the patient is not fully able to consent
    when terminal sedation becomes the best treatment.
    But PROXIES are permitted to consent for their patient.

    3. Sometimes the patient has been maintained by life-supports.
    Oxygen or nutrition-and-hydration might be provided by tubes.
    When medical treatments and life-supports
    are no longer effective,
    they can be terminated upon recommendation of the doctor
    and the informed consent of the PROXIES.
    Once again, the patient is frequently NOT ABLE
    to participate meaningfully in this life-ending decision
    to terminate all forms of life-support.

    4. An Alzheimer’s patient might be kept alive by a feeding-tube.
    When would this patient be expected to give informed consent
    for ending this final form of life-support?
    Normally the PROXIES would make the withdrawal decision.
    The Alzheimer’s patient does not lose the right-to-die
    merely because he or she can no longer consent
    to any life-ending decision.

    Because the normal practices of terminal medical care
    already include these four kinds of proxy-decisions,
    perhaps the IMPLICIT PRINCIPLES for empowering proxies
    could be applied to medical assistance in dying (MAiD).

    However, this probably cannot be achieved
    by amending the national criminal code of Canada,
    where the MAiD exception now resides.
    Rather, the provinces and territories of Canada
    (which are responsible for all health-care regulations)
    might have to give EXPLICIT AUTHORIZATION
    to proxies to make life-ending decisions for their patients.

    With the written advance consent of their patient,
    proxies should be empowered to decide
    EXACTLY WHEN to approve the actions
    (like the four medical methods described above)
    that will bring their patient’s life to a peaceful end.

  • Amber says:

    Thank you for this. As someone that is currently considering applying for MAID, reading the personal stories like this are the most meaningful.

  • sam plover says:

    I do not think that for certain anyone can judge a person’s competence. Illness colors your world and so does depression. There are differences in depression that comes from physical illness. People that have a severe flu might look, sound and act depressed.
    To judge a person incompetent could do great harm and subject them to a miserable death that they did not want. So in the face of physical illness, and illnesses that the people doing the assessments have never lived with, is wrong and takes their autonomy away completely.
    If you erred and they were in fact incompetent, no one will ever know, but at the least, you as a human to another would not take their decision away from them.
    No matter how educated, practiced or intuitive, I’m sorry but we can all be dead wrong about a person’s speech patters, dress, behavior or looks.
    I would think one would have to be careful not to judge the very terminal competent as opposed to non linear diseases incompetent.
    And also the ongoing problem of colleague opinions.

    I’m glad to hear you respected her wish, but I do have a problem with one human granting another a wish or desire. A phd does not give me the expertise or right to make judgments that could hurt a lot of people. When someone requests MAID, and is denied by doctors, it would definitely cause an abandoned feeling I would think.
    And thus also for the family.
    And even that deep sadness would not be abnormal.

    I think we should treat grown up people as grown ups, the way you would want to be treated if in the same position.
    To say yay to one and nay to another, and it really does not matter on an experts judgment. If experts can be wrong as in the case of dehydration, so I would surmise they can be wrong if they judge incompetence.

    We know enough about even the ‘mental illnesses’ that it does not take away competence. It is just a matter of judgment passed onto another equal.

    • Ruth Potter says:

      Sam, I’m wondering if we had a legal letter signed and witnessed by our family that we were mentally competent at time of signing and then listed our desire for MAID whether it would improve our chances of getting it.

      • sam plover says:

        @Ruth Potter
        I can guarantee that the last words are not the law, but interpretations of law, hence the unequal distribution or applications. We do not hear of or from the many voices silenced. It is more a sad state of affairs than a success and as far as a family letter……don’t forget, we need a PHD in order to be able to determine rationality or competency of a person. We as a collective of non PHD holders, do not have the intelligence or qualifications to judge another person as competent, even though we do this as part of innate knowledge, intuition on any given interaction, including our abilities to judge a medical persons competence, which by the way is not limited to their scientific knowledge.

  • Maureen Taylor says:

    Thank you Dr. Lewis, for making the distinction between exogenous depression, such as Jane’s, and mental incompetence. Of course my late husband was depressed that he was going to die too soon from his brain tumour — who would NOT be? But he did not have a mental illness that could be “treated” and his wish for MAID was borne of a conviction that he had lived a fantastic life and wanted to die a good death. The law didn’t change in time to give him that, but I’m glad it was there for Jane and I’m glad you were there to assist her.


Ralph Lewis


Dr. Ralph Lewis is a psychiatrist at Sunnybrook Health Sciences Centre in Toronto, a psycho-oncology consultant at the Odette Cancer Centre in Toronto, and an assistant professor in the department of psychiatry at the University of Toronto. Dr. Lewis is the author of the forthcoming book Finding Purpose in a Godless World—Why We Care Even If The Universe Doesn’t. He lives with his wife and children in Toronto.

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