The association representing the lead psychiatrists at Canada’s 17 medical schools is calling on the federal government to delay the expansion of assisted dying to people with mental illness, joining an increasingly vocal group of doctors who say proper safeguards are not yet in place.
A statement to be released Thursday by the Association of Chairs of Psychiatry in Canada says more time is needed to develop high-quality standards of care, doctor training and expert consensus, before allowing Canadians to apply for a medically assisted death with mental illness as their sole condition.
“It needs to be slowed down,” said Valerie Taylor, the psychiatric chair at the University of Calgary and president of the association. “There are still many, many unmet questions.”
In mid-March, Canada will become one of only a few countries that allows euthanasia for mental disorders – a step that will make the country’s assisted dying legislation among the most liberal in the world.
With only months to go, a growing group of psychiatrists, including many who work with marginalized patient populations and specialize in the most severe mental health disorders, have either expressed opposition to the expansion or raised serious concerns that the health care system is not ready.
A grassroots petition calling for a delay until 2024 has also been signed by more than 80 psychiatrists and will be sent shortly to members of the federal cabinet, including the Health and Justice ministers.
“A pause would allow more time for responsible and mindful ongoing consultation and research,” said Angela Ho, a psychiatrist at the University of Toronto and president of the Ontario Psychiatric Association, which has joined calls for a delay.
To date, the federal government has given no indication that a delay is being considered. In response to questions this week, a spokesperson for Health Minister Jean-Yves Duclos said the government is “aware of concerns expressed by some experts” that greater protections are needed, and would continue to collaborate with provinces and territories to ensure that there is “a strong framework to guide assessors and providers” before MAID becomes available for mental illness.
When medical assistance in dying became legal in 2016, after a Supreme Court decision, only patients with a terminal illness were eligible. In late 2019, a Quebec judge ruled that this legal restriction was unconstitutional, and Parliament amended the MAID legislation to include adults who didn’t have a reasonably foreseeable death.
The change took effect immediately for Canadians with physical illnesses, but was paused for cases based solely on mental disorders to give more time to study the issue. That two-year study period officially ends on March 17.
According to Dr. Taylor, her colleagues – who oversee issues such as curriculum, research and clinical care in the psychiatric departments at the country’s medical schools – are not wading into the debate about the merits of the legislation itself. They are highlighting their concern, she said, that doctors won’t have the necessary tools and training when the law automatically changes next year.
For instance, the law requires that a person must have an irremediable condition to qualify for MAID. But for many psychiatrists, this is a highly contentious issue, because research suggests it is difficult, if not impossible, to accurately predict who will recover from a mental disorder. The psychiatric chairs association said experts will need to agree on “operational” definitions of irremediability for different mental disorders, “because these definitions do not currently exist.”
Another unresolved issue for psychiatrists is how clinicians can reliably identify suicidal patients from those rationally seeking an assisted death. The association is calling for the “highest standards of care” to guide doctors through those assessments.
“There’s much more finesse and sophistication required in the implementation, and how it is going to be rolled out across Canada,” Dr. Taylor said in an interview. For instance, she said, what are the consequences if the decision-making process differs between provinces? Are psychiatrists treating people with symptoms of suicidal ideation expected to refer them to MAID providers if they request it? How will the system ensure a patient has access to recommended treatments or social supports before receiving MAID?
Jitender Sareen, the head of the psychiatry department at the University of Manitoba, said that while expert groups are working diligently to resolve these issues, that daunting task is unlikely to be finished by March – let alone properly disseminated to doctors on the front lines.
He pointed out that any new medication or complex treatment would require clear safety precautions. “Would we just say, ‘Well, okay, now it’s available?’ Or would we have a process to make sure the standards are there, and then educate and train before we make it available?”
In an October letter to the parliamentary committee studying the assisted dying legislation, Mr. Duclos suggested that federally funded physician training for MAID, including the module related to mental disorders, would be released starting in early 2023. However, leaders of the curriculum team at the Canadian Association of MAiD Assessors and Providers have said the training won’t be fully launched until next fall.
The parliamentary committee itself is also behind schedule. It was supposed to submit a final report of findings and recommendations in October, but only stopped hearing testimony in late November. The group of MPs and senators are now scheduled to report back mid-February, a month before the law changes.