A new law due to take effect in March has divided citizens of Canada, which already has one of the most liberal assisted death laws in the world, and which offers the practice to terminally and chronically ill patients.
Under the updated legislation, assisted dying would also become accessible to people whose only medical condition is mental illness, making Canada one of about half a dozen countries to permit the procedure for that category of people.
Critics say the law is a sign that the country’s public health care system is not offering adequate psychiatric care, which is notoriously underfunded and in high demand.
However, reports The New York Times, the government has defended its actions by pointing to a 2019 court decision in Quebec that officials say mandates the expansion, while politicians have accused the state of promoting a “culture of death”, and suggesting it should rather focus its health policy on expanding mental healthcare.
Jason French is among those in favour of the decision, and wanting assisted dying with the help of a doctor.
He has severe depression and has tried twice to end his own life, he said.
“My goal from the start was to get better,” he said. “Unfortunately, I’m resistant to all treatments and … I can’t keep suffering. I can’t keep living my life like this.”
Dr John Maher, a psychiatrist in Ontario who specialises in treating complex cases that often take years to improve, said he was concerned that hopeless patients would opt for assisted death instead.
“I’m trying to keep my patients alive,” he said. “What does it mean for the role of the physician, as healer, as bringer of hope, to be offering death? And what does it mean in practice?”
Canada’s existing assisted death law applies only to people who are terminally ill or living with physical disabilities or chronic, incurable conditions. The Supreme Court decriminalised assisted death in 2015 and ruled that forcing Canadians to cope with intolerable suffering infringes on fundamental rights to liberty and security.
About 13 200 Canadians had an assisted death last year, a 31% increase over 2021. Of those, 463 people, or 3.5%, were not terminally ill, but had other medical conditions. Patients who are approved have the option to end their lives using lethal drugs administered by a physician or nurse, or by taking drugs prescribed to them.
There is still uncertainty and debate over whether assisted death will become available to the mentally ill as scheduled.
Amid concerns over how to implement it, Parliament has delayed putting it into place for the past three years and could delay it again.
Clinical guidelines were released to address those concerns last March, but some people involved in providing mental healthcare say they are inadequate.
Divisive
The proposed change to include the mentally ill has been particularly divisive among some psychiatrists, with Maher and others saying it muddles their efforts to prevent suicide.
But supporters say denying mentally ill people access to the same humane option to end their suffering amounts to discrimination.
“I have a very deep empathy for patients who suffer deeply,” said Dr Alexandra McPherson, a psychiatry professor at the University of Alberta and assisted death provider. She said she treated a small number of patients “with severe disabling mental health disorders who suffer as much as the patients I see in cancer care”.
Lisa Marr, a former paramedic diagnosed with post-traumatic stress disorder who lives in Nova Scotia, is desperate to take advantage of the new law.
She has bipolar disorder, depression and excoriation disorder, or skin picking, from anxiety and has made, she estimates, 15 attempts on her life but “always managed to pull myself out”.
“The only reason I haven’t done it yet, I think, is I’m waiting for this decision in March,” she added.
Canada amended its criminal code to legalise assisted death for the terminally ill in 2016, and in 2021, responding to the court ruling in Quebec, the country loosened the law to add other severely ill people experiencing “grievous and irremediable” conditions.
Eligible patients must wait 90 days before receiving an assisted death and be approved based on the assessments of two independent physicians. One of the assessors must be a specialist in the patient’s illness or have consulted with a specialist.
A panel of experts and a special parliamentary committee have worked to address concerns from the public and medical community, by laying out practice standards and advising clinicians and regulators.
The government has also funded the development of a training programme for physicians and nurses who assess patients for assisted death.
“The work has been done,” Dr Mona Gupta, the chair of a government-appointed expert panel – who is a psychiatrist and bioethics researcher at the University of Montreal – told a special parliamentary committee in November. “We are ready.”
Anyone in Canada seeking assisted death must be deemed by the physicians or nurse practitioners who assess them as not impulsive and not suicidal, and those who are mentally ill would need to be evaluated to show that their condition is “irremediable”.
But even some psychiatrists worry they may not always be able to determine if someone seeking an assisted death could actually get better or not.
“The research we have shows psychiatrists are no better at identifying who’s not going to get better,” said Maher, the psychiatrist in Ontario. “The challenge for us is it’s not a short term process. When people have been sick for years, healing takes years.”
The Centre for Addiction and Mental Health, Canada’s largest teaching hospital for psychiatric care and research, has said clinicians need more guidance to assist them in assessing who is acutely suicidal or capable of making a rational choice to end their lives.
“We’ve been clear that we have concerns about expansion at this time,” said Dr Sanjeev Sockalingam, chief medical officer at the centre, which has convened several professional groups to assist physicians in preparing for March.
See more from MedicalBrief archives:
Time to move past medicalised approach for assisted suicide
Assisted suicide ethical dilemma for psychiatrists
Austria submits draft legislation on assisted suicide
Euthanasia activist says SA doctors support legalising assisted dying