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'Canada is very ill-prepared for the future': Medical Assistance in Dying for people with mental illnesses has left experts worried

Elderly woman is comforted by a medical professional during the Covid-19. Focus is on their hands. The medical staff is holding the woman's hand.

Medical assistance in dying (MAiD) was legalized in Canada in 2016. In light of the Carter decision, the Supreme Court of Canada (SCC) struck down the sections in the Criminal Code that prohibited assisting a person to die. Canada had joined a handful of countries, like Benelux, that now allowed assisted suicide.

However, after the Truncheon case challenged the constitutionality of death being “reasonably foreseeable”, the Parliament decided to revise their MAiD legislation and Bill C-7 came into force in March 2021.

The Bill not only expands who can ask for assisted death, but also allows people with mental illnesses as their sole underlying illness to qualify for MAiD.

Before, only those whose death was naturally foreseeable—called "Track One" patients—qualified for medically assisted death. These are the patients with terminal cancer or other diseases. The new law allows patients whose death is not reasonably foreseeable to qualify for MAiD—"Track Two" patients—given that the new safeguards in place are met. For instance, track two patients require a minimum 90-day assessment period.

The second biggest change introduced by Bill C-7 is that people suffering solely from grievous and irremediable mental illnesses also qualify for MAiD now.

The law comes into effect on Mar. 14, 2023.

The recent rise in cases of vulnerable people seeking MAiD in Canada in the last few months has left experts worried as they think the expanded legislation will only make matters worse.

Why is this problematic?

According to Dr. Kerry Bowman, a Canadian bioethicist and conservationist, the Tier Two applications are surfacing much deeper ethical questions than previously asked.

"Some of the factors that are now driving requests for medical assistance in dying are not medical—they're social, cultural, and political factors," Bowman said.

I don't mean to sound smug, but I saw this coming; it's getting very complicated. And once a government takes the position that some lives may not be worth living, it's a very hard position to hold in terms of justice.Dr. Kerry Bowman, a Canadian bioethicist and conservationist

Dr. Sonu Gaind, Chief of Psychiatry at Humber River Hospital and a member of the World Psychiatric Association, agrees with Dr. Kerry.

"I'm not a conscientious objector of MAiD, but I actually personally feel that the expansion is irresponsible," Gaind said.

"Part of the reason I'm concerned about this is that what MAiD initially came in for, it's now drastically changing to become something else—and most people are unaware of that."

In April, the case of a 51-year-old was reported by CTV News—she had opted for medical euthanasia because her housing benefits didn't allow her to get better housing which didn't aggravate her crippling allergies to chemicals. Another disabled woman applied for MAiD because she couldn't "afford to live".

A few months ago, another woman experiencing long-COVID symptoms for two years applied for medical euthanasia because her illness didn't qualify for the Ontario Disability Benefit Program (ODSP). She stated publicly that MAiD was exclusively "a financial consideration" for her—she couldn't afford to live without support.

“We’ve set up a system—and this is what the headlines are showing—where people who have decades to left to live and they are being fuelled by poverty, isolation, loneliness to seek MAiD,” Gaind said. “That’s dangerous to me.”

“Expansion activists, is how I would term it, have been able to push the policies getting broader and broader; and I honestly think that most Canadians are not fully aware of the implications of that right,” Gaind added.

MAiD and mental illness: What are the recommendations made by the panel and why are experts worried?

The expert panel on MAiD and mental illness submitted their final report on May 13, 2022 and a list of 19 recommendations were made. These recommendations were made according to the issues identified specific to psychiatric euthanasia—determining incurability, capacity, suicidality, and structural vulnerability.

For starters, it was recommended by the board that establishing incurability and irreversibility should be done on a “case-by-case basis” by looking at the treatment history for each patient.

Although many patients with mental illness do not respond to treatments, the evolution of many illnesses is difficult to predict and so “incurability and irreversibility” cannot be accurately predicted in all cases of mental illness. Therefore, it’s difficult to have a set standard to determine who qualifies and who does not.

However, Dr. Gaind believes that this recommendation is shocking.

“They have essentially said that it’s not possible to define the number of treatments or the length or the type of treatment that someone should have before getting psychiatric euthanasia—there’s lack of standards and a lack of evidence, and this is pretty concerning,” Gaind believes.

So now you have some doctors who set the bar too low for what’s 'incurable' and some who won’t administer MAiD because they believe something else—what that opens up is assessments that are completely arbitrary based on individual ideology. That's not medicine.Dr. Sonu Gaind, Chief of Psychiatry at Humber River Hospital

Another recommendation by the board states that MAiD assessors should understand that personal suffering is a subjective experience and that it should be assessed on a case-by-case basis. The patient also has the right to autonomy and refuse any interventions they do not wish to receive.

The idea of the patient’s “right to autonomy” has come under fire by experts as they believe it is false autonomy and actually puts vulnerable populations at risk.

“What drives the system here is the concept of autonomy, the personal choice of an individual and that’s very good. It’s a wonderful thing, but the downside of it is that now we’ve got people making requests because of poverty, housing, and structural vulnerability,” Dr. Kerry says.

Dr. Gaind agrees with Dr. Kerry and strongly believes that not only is it false autonomy, but the idea of autonomy in such cases is also misleading and deceptive.

“Those are strong words, I know,” Gaind says. “This is about the delusion that somebody in their state of suffering from mental illness believes that their wish for death is a fully autonomous, permanent choice.”

“MAiD is meant for something where there is medical evidence that a condition will not get better—and that is complete deception when making predictions of irremediability for mental illness. Evidence shows that predictions of irremediability cannot be made in cases of mental illness!” Gaind added.

Dr. Gaind believes that for someone in their transient state of suffering, which is also fuelled by marginalization and poverty, the system is deceiving these people into believe that they won’t get better when in reality, that prediction cannot be made with a 100% confidence when it comes to mental illness.

“I’m also not saying that everyone gets better, but it means is we still can’t predict who won’t. Someone with psychiatric euthanasia could’ve gotten better and regained their desire to live,” Gaind said.

“There is a huge difference between whether some people don't get better or whether we can predict in advance who won't get better. Got it? And that's the fallacy.”

A grim picture: Does it all boil down to economic cost for the government?

In a scathing article on Canada’s decision to allow medical euthanasia in The Spectator, Yuan Yi Zhu pointed out Canada’s eye on the savings Bill C-7 would create for the government.

According to Zhu, although the Canadian government insisted that assisted suicide is about “individual autonomy”, the country’s Parliamentary Budget Officer published a fiscal report about the costs savings Bill C-7 would create.

The report mentioned that Bill C-14 (the original MAiD legislation) would save the provincial governments almost $87 million, while the expanded Bill C-7 would save the governments a further $62 million—a total of $149 million.

While the cost of caring for chronic conditions is expensive to the government, administering MAiD costs only $2327 per case.

After the allegations after many activists that the government of Canada is progressively viewing people in terms of their “economic cost”, this report is an even bigger insult to the vulnerable populations seeking medical euthanasia today.

“The system says it’s saving millions of dollars—it doesn’t matter how pure someone’s intent was. At the end of the day, this just plays on ageism and ableism,” Gaind said.

To prove Dr. Gaind’s statement, one might only look at the generous payments made by the government of Ontario during COVID. Under the present government in Ontario, disabled people got an extra “one-time” payment of $600 for extra financial assistance, while university students received $5000 and unemployed populations received $2000 in CERB payments monthly.

Similarly, according to OECD Data (2019), Canada’s social expenditure (e.g. benefits for low-income households or for people with disabilities) is one of the lowest in the world. With only 18% of its GDP spent on social expenditure, it ranks behind Japan, the United Kingdom, Spain, Poland, Slovenia, France, and many other countries.

While the government might constantly argue that the MAiD legislation is only about one’s right to autonomy and modernizing Canada, the evidence points in a completely separate direction and confirms one’s belief that the government does not care about it’s disabled population.

As one ODSP activist once said, “this is state-assisted suicide”.

So, what’s the solution?

With concerns now rising that incurability and irreversibility cannot be predicted with confidence, Dr. Gaind believes that MAiD for mental illness should be off the table.

“To me, the question then becomes when you ask which mistakes do you want to be making? Letting someone live with suffering or letting someone die when they could’ve gotten better? To me, one wrongful death is too many. No one has a monopoly on suffering. We don’t abandon them in suffering, we help them best we can.”

Dr. Kerry, on the other hand, believes it’s difficult to discover where to draw the line. He believes that denying vulnerable populations access to MAiD because they’re low on income or their incurability cannot be fully determined still means we’re limiting their access.

“I don’t know the solution but I think Canada is very ill-prepared for the future we have ahead of us,” he said.