The federal government faces an agonizing choice next March, when it will have to decide whether to extend medically assisted death to people suffering from mental illnesses, or listen to the growing number of voices urging it to postpone this latest expansion of the country’s assisted-dying regime.
If and when Ottawa opens medical assistance in dying (MAID) to the mentally ill next year, it will be one of only a handful of countries to have done so.
Last week, the lead psychiatrists at Canada’s 17 medical schools urged the government to hold off, in order to buy time for a health care system that doesn’t appear to be prepared to handle requests for medically assisted deaths from people whose sole condition is a severe mental illness.
The biggest concern voiced by critics is that the law says a person must have an irremediable condition to qualify for MAID, but there is no consensus in the mental-health field on what qualifies as irremediable.
There is research that suggests it is very difficult to predict who will recover from a mental illness, and who won’t. One study published in October in the journal Psychological Medicine found that doctors are right only half the time; it concluded that “the objective standard for irremediability cannot be met.”
On the other side of the coin are people with severe depression, schizophrenia, post-traumatic stress disorder (PTSD) and personality disorders who have lived for years or even decades with their illness, tried multiple treatments and therapies, and have never gotten better.
Their lives can be hellish; a state of affairs that is often exacerbated by abuse, financial stress, solitude, homelessness and despair.
They and their advocates say they deserve to be able to end their lives in the same dignified manner as any person suffering from a “grievous and irremediable illness,” as the MAID law prescribes, such as advanced cancer or a degenerative disease.
In 2019, the courts struck down an additional condition in the law that said a person’s natural death had to be “reasonably foreseeable.”
That opened the door to assisted death for people with mental illnesses, but when Ottawa amended the MAID law accordingly, it put off expanding the regime to include mental illness for two years, in order to allow for more study. The delay ends next March.
Few argue against the principle of the MAID law. Thanks to the courts, it’s a settled issue anyway.
Few also dispute the notion that patient autonomy ought to be the government’s priority. The state should not be depriving people of the dignified end they are seeking, or treat them paternalistically.
But beyond the question of whether psychiatrists can accurately determine whether a person’s mental illness is truly irremediable lies another much more troubling one – one that was eloquently posed in a recent Globe and Mail examination of the issue: Can a person freely choose to die if they don’t have an equal chance to live with dignity?
Supports for people with chronic mental illnesses are slim on the ground in Canada, especially for those with lower incomes: There is a shortage of supportive housing; treatments and therapies can have waiting lists that extend into years; and many people can’t afford psychotherapy, which isn’t covered by medicare and can be punishingly expensive. The high cost of living isn’t helping, either.
The Toronto Star last month told the story of a man whose chronic but not terminal illness was exacerbated by poverty, childhood sexual abuse and mental-health issues. His government income left him with less than $200 a month after he’d paid his rent, and he was no longer able to walk the two flights into and out of his apartment. He qualified for MAID and died in July.
It is all too easy to imagine that some people suffering from severe long-term mental illnesses, especially those with limited financial resources, will resort to MAID in part because of their despair over a lack of adequate health care and social services.
That is not to say that their illness alone wouldn’t meet the conditions required for an assisted death. We should respect their wish to die with dignity. But we should be ashamed of a country that is failing to help them live the same way.