Why the surge in medically assisted deaths?

If the current trend continues, Canada will become the world leader in medically assisted death next year. And we have no idea why. That ought to give us pause as we once again grapple with extending medical assistance in dying (MAID) to people who suffer from mental illness alone.

It has certainly given Ottawa pause, as it tabled a bill last Thursday to delay the extension until 2027. That’s the second delay in as many years, and it follows the recommendation of the Joint Committee on Medical Assistance in Dying, which cited “conflicting testimony” about Canada’s readiness for MAID for mental illness.

Although the committee was itself conflicted, with three of its members writing a scathing dissenting opinion, a further delay is reasonable given both the dramatic rise in MAID provisions and our limited understanding about what’s driving the increase.

The most recent (fourth) annual report on MAID notes that assisted deaths in Canada grew by an average of 31.1 per cent each year between 2019 and 2022. In 2022 alone, just six years after MAID was legalized, it accounted for more than 13,000 deaths, or four per cent of all Canadian deaths.

According to an analysis by the Investigative Journalism Bureau and the Toronto Star, that makes Canada the fastest MAID adopter in history. By comparison, it took the Netherlands 14 years before assisted deaths reached the four per cent milestone.

It’s not clear why uptake has increased so dramatically in Canada. But it ought to be clear before we extend MAID to other vulnerable groups, especially given anecdotal reports that some people are choosing an assisted death due to a lack of economic or social supports.

The annual report doesn’t discuss that issue, but some data do present cause for concern. For instance, of those who received MAID in 2022,17 per cent cited loneliness or isolation as one cause of their suffering.

While that probably wasn’t the only cause, it suggests a lack of social support could be contributing to the decision to seek MAID. And given the strong association between loneliness and isolation and mental illness, inadequate social support could prove fatal if MAID is extended.

Furthermore, although roughly half of those who withdrew their request for MAID did so because they found palliative care measures sufficient, such measures are not universally available or accessible.

Nearly 20 per cent of MAID recipients did not receive palliative care, and of these, care was inaccessible for one in eight. This raises the spectre that a small but significant number of people may be seeking an assisted death as a substitute for unavailable palliative care.

This is particularly concerning since patients with brain illnesses are the least likely to receive palliative services: According to the Canadian Institute for Health Information (CIHI), in 2021-2022 just 39 per cent of dementia patients received palliative care in the last year of their lives.

Patients with serious mental illness are similarly underserved by end-of-life care. The emergent field of palliative psychiatry does offer palliative services for those with severe, persistent mental illness, and it could therefore reduce the number of psychiatric patients requesting an assisted death.

However, given the novelty of palliative psychiatry, there remains a disparity in the provision of palliative care for physical and mental disorders so that care is not assured.

Finally, the CIHI reports that unhoused people face significant barriers in accessing palliative services. Since people with mental illness are at high risk of homelessness, this could exacerbate the difficulty they have in accessing critical health services, including those of a palliative nature.

Extending MAID at this time could therefore produce a perfect storm, one in which mental illness, homelessness, and a lack of palliative health care are all swept up together, and together they could result in numerous patients requesting — and receiving — an assisted death.

And as long as that remains a possibility, we’re not ready to extend MAID to those with mental illness.