Canada's doctors are pleading with the federal government to put specific guidelines in its medically assisted dying law regarding patients who want to end their lives because of psychological suffering.
"There are still a lot of grey areas, and a lot of unknowns," said Jeff Blackmer, vice-president of medical ethics at the Canadian Medical Association.
"Before we sort of open that Pandora's box, we need to have a lot more clarity as to what would qualify, and exactly what the process would be."
A recent parliamentary report intended to give the government guidance on how to write the new law, to be passed before June 6, said patients should be able to access medical aid in dying if they have a "grievous and irremediable" medical condition that causes enduring and intolerable suffering.
The condition should not have to be terminal, and suffering can be physical or psychological, the report said, and those with mental illness or other psychiatric conditions should not be excluded if they meet other criteria such as consent.
Dr. Blackmer said doctors recognize that psychological suffering can be as painful as physical suffering. But he said he hopes the law will not leave the definition of it "open to interpretation," and will require the patients to see a psychiatrist or mental-health team throughout the process. They also want detailed regulations for the provinces.
He said many doctors are uncomfortable or experiencing "angst" at the thought of helping those with psychiatric conditions end their lives.
"We see patients all the time right now who come in [under] difficult circumstances, suffering psychologically, who want to harm themselves or kill themselves, and we help them through that," he said.
"Now we're being asked to flip that on its head, and not only not help them through it, but actually actively help them to commit suicide. And that is an extremely daunting prospect for physicians."
Conservative Senator Kelvin Ogilvie, the co-chair of the parliamentary committee, said the report follows the direction of a Supreme Court ruling in February, 2015, that struck down the Criminal Code ban on physician-assisted dying because it infringed on Charter rights. The ruling did not omit those whose suffering is solely psychological.
"The other alternative is for people to take their own lives under horrific conditions," Mr. Ogilvie said.
He added that the report recommended the patient be competent at the time of the request and at a follow-up evaluation, and includes a period of reflection. Two doctors must approve it.
"We were clearly advised in testimony that individuals with a range of very extreme psychological conditions are capable of cognizant awareness," he said.
Not all of his colleagues agree. Conservative Senator Denise Batters, whose husband, Dave, died by suicide in 2009 after a battle with anxiety and depression, wants the government to remove the recommendation for psychological suffering alone.
"I certainly don't deny that psychological suffering can be extremely painful. Unfortunately, I witnessed my husband go through it. Absolutely it can. However, to my mind there are very big differences between the two," said Ms. Batters, who was not on the committee.
"Most psychological suffering can be treated, and often treated very well. And there is such a more complex decision-making process for the mentally ill."
Tarek Rajji, a psychiatrist and chief of geriatric psychiatry at the Centre for Addiction and Mental Health in Toronto, recommends patients be referred to an independent agency, such as a provincial consent and capacity board, to make the decision about whether a medical condition is "irremediable."
He said the centre is struggling with how to define mental illness as incurable, because doctors see the potential for change when a patient sometimes cannot.
"We always work towards recovery," he said.