The shadow of death
Canada’s government looks into expanding MAiD eligibility to people with mental illnesses.
In May, an expert panel formed by Health Canada in 2021, in collaboration with researchers, stakeholders and clinicians, released a final report to the federal government recommending safeguards, protocols and guidance for providing MAiD (Medical Assistance in Dying) to persons with mental illnesses. This is in preparation for March 17, 2023, when the exclusion of mental illnesses in Bill C-7, An Act to amend the Criminal Code (medical assistance in dying) will be repealed. The expert panel released the 136 page report, admitting “We are aware these discussions can be contentious, and on the specific topic of MAiD for mental illness there is a full spectrum of views.”
The purpose of the panel was clearly stated. They were not to determine if MAiD should be offered to people with mental illnesses, but to make recommendations to the federal government on what procedural safeguards and procedures should apply.
Some experts challenged this purpose, since there is no scientific evidence to prove that the benefits of MAiD outweigh the harm for people with mental illnesses. The future is uncertain; what if recovery was possible? The panel responded by saying that argument makes an assumption “that death when future recovery is possible is a harm, and continued life with suffering is a benefit.” But they point out that society no longer decides what counts as benefit and harm in Canada – it’s now a question for individual values and Canadian law. The expert panel admitted that Canadians are divided: “No system of safeguards, protocols and guidance will satisfy everyone because people differ in terms of how they make the compromises between the competing values at the heart of this practice.” Nevertheless, Canada may soon be the third country to offer MAiD services for those with mental illness as their sole underlying diagnosis, along with the Netherlands and Belgium.
MAiD in Canada
Since 2016, MAiD has been available for all Canadian patients who are 18 years or older and who have a “grievous and irremediable medical condition” which causes “enduring physical and psychological suffering that is intolerable to them,” and “whose natural death has become reasonably foreseeable.” Mental illness could be part of the reason for seeking MAiD, but the primary reason has to be a physical, medical condition. Healthcare providers such as nurse practitioners do not have to provide these services but they are required to, without bias, refer their patients to those who can. MAiD services come with stringent safeguards, policies and procedures, such as witness signatures, written patient consent, waiting periods, assessments from at least two independent assessors, and suggested alternative forms of treatment for the patient. Until the last moment, patients can also withdraw their request at any point. Then, at the appointed time, a practitioner can either give the drug cocktail to directly cause a patient’s death or provide drugs for the patient to self-administer.
Who is accessing MAiD?
Since 2016, a total of 13,946 patients have utilized MAiD in Canada. The average age of those accessing MAiD has been 75, and the most commonly reported causes of suffering have been cancer, respiratory issues and neurological conditions. There has been a steady increase in utilization of MAiD services in recent years. Interestingly, of the 7,336 written requests for MAID in 2019, 26 percent did not result in a MAID death because patients either died before receiving it, were found ineligible, or withdrew their request. Some may assume that those accessing MAID did not receive palliative care, but 82 percent of those who accessed MAiD did utilize palliative care for at least one or more months. Beyond their medical condition, the nature of the reasons why people access MAiD services included loss of ability to engage in meaningful life activities, loss of ability to perform activities of daily living and inadequate control of symptoms other than pain. Further, 53 percent expressed loss of dignity, 34 percent felt they were a burden on family, friends and caregivers, 14 percent reported isolation and loneliness and five percent reported emotional distress, anxiety or fear.
The difficulty of a diagnosis
For those accessing MAiD services for physical conditions, physicians and nurse practitioners must determine the course of an illness and also the terminal nature of the disease. For those set to access MAiD primarily for reasons of mental illness, clinicians would need to understand the trajectory of a mental health disorder up until the time of the MAiD request and assess the disorder’s incurability. This can be difficult as mental illness trajectories are often not linear, nor predictable. Further, mental disorders are often compounded by structural vulnerabilities and social determinants of health.The report addressed this complexity, but stated that social issues should be considered in all MAiD cases, irrelevant if a patient is choosing MAiD for physical or mental disorders, and are not unique to discussions on mental health.
Woven throughout the report are firsthand accounts, giving an idea of how difficult determining eligibility for MAiD might be. The panel determined 19 recommendations for the federal government to roll out MAiD for those with mental illnesses. They also suggested their report was not able to adequately address frail elderly with mental illnesses, persons with intellectual disabilities and those who are incarcerated. These particular populations need further consideration. Their conclusion stated that the report is “the beginning of the process, not the end” (5.0). They identified that there are more issues to explore.
Canada’s mental health crisis
There are many Christian concerns about the theological, ethical and social impacts of MAiD, such as those expressed by the Gospel Coalition and the Evangelical Association of Canada. Secular psychiatrists also express concerns that should mental illness alone render people eligible, potential unacceptable and unforeseen risks may also increase, such as greater discrimination against those with mental health disorders and deaths of patients that have not yet received the full range of mental health support. This is especially true in a healthcare environment which has long wait times for psychiatrists and counselors, and overwhelmed inpatient psychiatric facilities.
There is no doubt that we have a mental health crisis in Canada. As a bedside nurse of 15 years in British Columbia, I have seen the shifting reality in our hospitals. Those in acute mental crises wait hours and sometimes days in overcrowded emergency rooms, waiting for psychiatric doctors or nurses to assess them and for inpatient beds to become available. There are few psychiatric-specific emergency rooms dedicated for mental health patients. In over-filled emergency rooms, psychiatric patients wait for medical clearance by our emergency physicians, and for referrals to psychiatric doctors. These specialists are not always available and so patients simply have to wait. Often all the patients’ things are removed as they wait, in case they cause themselves harm. Unless there is a psychiatric nurse full time in the emergency room (which is not always the case), then there is little that bedside nurses can offer them. We are overworked and understaffed and have to respond quickly to many competing medical emergencies and have little to offer for psychological ones. Working in a pediatric emergency room, I have seen the rise of anxiety and depression among youth, the increase in self-harming behaviours and the incredible hardships that many patients and families face in navigating our over-burdened system. It is not always a straightforward path to care.
As I train to be a Nurse Practitioner, I have to ask: what do I think about this increasing eligibility? Nurse practitioners have the clinical responsibility to refer those who request MAiD to appropriate MAiD providers. As a Christian, what do I do?
In my next article, I will offer my thoughts on these questions.
Editor’s note: The sharp eyed reader might notice that “mental illness” and “mental disorder” are used interchangeably in this article. When the federal government asked the expert panel to convene, they asked for recommendations for eligibility for people with “mental illnesses”. The panel was a little more specific: they define a mental disorder as a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” that reflects a dysfunction. A mental illness, on the other hand, “lacks a standard clinical definition”, but is the term used by Bill C-7 and the government. Our interpretation of the report is that the panel wants to limit their recommendations to people with more clearly defined “mental disorders”, but uses “mental illness” to respond to the government in Bill C-7 speak.
Thank you for the thoughtful article. Maike’s illustrations are wonderful.