Opinion

Mental health and MAID: An ongoing challenge

Since March, Canadians living with chronic illness or disability have had access to medical assistance in dying (MAiD) even if their deaths are not reasonably foreseeable. The passage of Bill C-7 makes this possible with just a 90-day assessment period (that can be shortened if needed); a second eligibility assessment by a medical practitioner with expertise in the condition causing the person’s suffering; and two clarifications of “informed consent.”

Yet, despite this ground-breaking change, there remains a continued mental illness exclusion, specifically till 2023. During this two-year period, the federal government intends to collaborate with experts in the field to develop specific criteria for Canadians who seek access to MAiD but whose sole underlying medical condition is a mental illness.

This conversation of mental illness and MAiD is a complex one and rightfully so. To form strict, infallible criteria for legislative purposes, we must be able to define the specific conditions of an illness, its response to treatment and overall trajectory.

When considering whether one qualifies for MAiD, buzzwords like “grievous and irremediable” come to mind. Trying to classify mental illness as grievous is certainly doable. After all, many Canadians will attest to the gravity of their mental illness and the incredible emotional and physical suffering it causes them.

However, it is whether mental illness is incurable, terminal and irreversible that is far more difficult to ascertain. For schizophrenia alone, roughly a third of patients will respond well to treatment with no further episodes of psychosis, another third will remain stable with continuous antipsychotic treatment and the final third will become completely resistant to treatment. As such, how each patient responds to treatment and the precise trajectory of the illness is highly variable.

The reality is we currently do not have enough medical evidence to objectively state whether one’s mental illness, a leading cause of disability in Canada and a significant cause of our nation’s morbidity and mortality, is irreversible. This presents a significant barrier to incorporating mental illness in MAiD.

In fact, by the time Canadians have reached 40 years of age, one in two will have had a mental illness or substance use disorder. Clearly, mental illness is a nation-wide problem.

Research suggests an obvious interplay of social determinants of health and psychosocial flavour to mental illness. Specifically, Canadians with mental illness are less likely to have primary care physicians. Moreover, many Canadians commonly experience wait times of 6-12 months for mental health counselling and specialty psychiatric hospital services. Many provincial health insurance plans and public drug plans do not cover the latest medications and psychotherapy – a significantly helpful non-pharmacologic form of treatment for mental illness.

In the face of these statistics, it may be premature to begin providing MAiD for those with mental illness when there is simply so much work for Canada to do when it comes to improving mental health care.

“Whether mental illness is incurable, terminal and irreversible that is far more difficult to ascertain.”

As per the Health Care Consent Act, a person is considered capable of providing consent if able to comprehend information about the treatment being offered and can appreciate the consequences of accepting or declining treatment in a particular situation. Although having a mental illness does not preclude individuals from being able to make their own health-care decisions and have capacity, there is appropriate concern that individuals with mental illness may experience impairment in their ability to clearly and fully understand their illness process and the associated risks and benefits of treatment. For instance, for those acutely experiencing a psychotic or depressive episode, death may be highly desired.

Complicating this situation is the fact that even in those whose symptoms have been controlled with treatment, the impact of these illnesses can leave persistent feelings of hopelessness and thus a continued desire to die.

Therefore, in such delicate circumstances, it is imperative to formulate robust tools that can help health-care practitioners better understand and assess capacity specifically in the context of mental illness and offering MAiD.

To better understand the implications of offering MAiD to those suffering from mental illness, it may be helpful to observe how MAiD, or Euthanasia/Assisted Suicide (EAS), has been experienced by our European neighbours, where the practice is already legalized in some countries for those with mental illness.

Specifically, a case review in Belgium showed that of 100 requests for EAS by those with mental illness, most were women with an average age of 47 with depression and/or a personality disorder. Of these 100, only 35 went through with EAS. Of the 65 remaining, 49 withdrew their request while eight continued with their original request, with six dying by suicide, and two of natural causes. In follow-up the next year, 48 of the 57 people still living had placed their requests on hold. Another study in the Netherlands found that physicians disagreed on whether an individual met all of the EAS criteria in 24 per cent of cases.

Thus, we must deeply review the cases and specific criteria of those countries that have legalized MAiD for those with mental illness to both learn from these countries and improve upon their approaches.

And while we work toward learning how to offer MAiD to those suffering from mental illness in the safest way possible, we must also improve our current mental health care services.

Specifically, government investment in equitable and accessible community mental health and addiction services, developing a first-ever national suicide prevention strategy and conducting expert research on the matter, can help develop evidence-informed practices and keep Canadians safe now.

Perhaps, while on this two-year parliamentary review, the government should consider inclusivity in its approach, whereby those with lived experience of mental illness, family members, Indigenous groups and other marginalized populations’ voices are heard and considered in this important decision-making process.

After all, this is all of Canada’s problem.

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Author

Meera Mahendiran

Contributor

Meera Mahendiran is a Family Medicine resident at the University of Toronto. She is passionate about providing holistic and culturally sensitive palliative care.

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