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Should Canada Extend MAID to People with Mental Illness?

A psychiatrist weighs in on a question Parliament will need to settle soon

On March 17, 2021, Parliament passed Bill C-7, which repealed the “reasonable foreseeability of natural death” criterion to allow medical assistance in dying (MAID) for people who might otherwise live naturally, if intolerably, for decades. The bill also excluded from eligibility people with mental illness as their sole underlying medical condition. The exclusion was to be repealed automatically two years later but was deferred by Parliament to 2024 and subsequently deferred again to March 17, 2027.

Mohamad Elfakhani is the chief of psychiatry at the London Health Sciences Centre, Victoria Hospital, and an associate professor in the department of psychiatry at Western University. I spoke with him on issues surrounding MAID for people with mental illnesses.

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Some say that mental health conditions can cause as much suffering and pain as physical conditions.

I don’t know of anything, really, that is as painful as a deep depression. It can be physically painful, with symptoms of low energy, fatigue, the inability to get out of bed, to motivate oneself, to enjoy anything. It’s felt physically: when a patient talks about anxiety, for instance, they describe it as butterflies in the stomach, as nausea. The connection between mind and body is strong. I’ve heard of patients who had been depressed before but who had also experienced a heart attack or a stroke, maintaining that their major depressive episode was more painful than those. It can be.

A doctor never hears a patient say, “I had a heart attack and now I’m suicidal.” They might for a patient with a stroke, if the person lost enough function, maybe. But then depression is part of the stroke experience to the point that, now, prescribing antidepressants is best practice for most post-stroke patients.

MAID is different, as it’s a calculated, planned-out process where a patient feels there’s no more hope for recovery. That can be different than having suicidal thoughts.

The distinction, then, is between an acute pain and a sustained, hopeless one? Many of those I’ve interviewed about MAID, including physicians, mention that much suffering abates when the patient knows they have some control over when and how they go.

The first time I heard that concept, in 2011, way before I’d ever heard about MAID in Canada, I was in my first or second year of residency. A case was presented of a young woman who had picked a date that she was going to end her life, and her family was describing this immense level of comfort that came over her: she was extremely depressed and isolated, and then, suddenly, she was out and walking about and engaging with them. Knowledge of the date she would die gave her a sense of comfort.

The psychiatrist presenting the case described this as the scariest thing one could see as a psychiatrist—when people get to that point of peace—because one feels helpless as a physician. It’s a dangerous spot. A doctor always wants to maintain the hope that they can help the patient. But certain death takes that possibility away.

I don’t think I’ve had a patient who actually ended up acting on the date of their plan, but I’ve had a number of patients that set a date, get to that date, surround themselves with family, and then kick the date down the road another six months. Yet the process gives them a sense of peace, just knowing that they have a........

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