MAID panel focuses on mental illness
HEALTH Report makes recommendations on how to deliver end-of-life procedure as legalization looms
How does a doctor determine that a person’s mental illness is incurable?
That question is at the heart of a report released Friday by an expert panel tasked with making recommendations on protocols and safeguards for delivering medical assistance in dying (MAID) to Canadians solely on the basis of a mental illness.
That form of MAID is already set to become legal on March 17, 2023, due to a sunset clause added last year to the government’s Bill C-7, which expanded MAID eligibility in Canada.
The panel’s 19 recommendations are not binding, but are meant to help guide medical professionals and regulators when medically assisted deaths for those with mental illnesses becomes legal.
Psychiatrists are divided over whether the procedure can ever be carried out safely, and whether the incurability of a mental illness — one of the main criteria for accessing MAID — can ever be determined.
In Belgium and the Netherlands, the percentage of MAID requests made on the basis of a mental illness is small, said psychiatrist Dr. Mona Gupta, the panel’s chair, and the majority of requests with mental illness as the primary reason are rejected.
“The concerns that people raised in the debate about MAID for mental disorder, about whether or not this practice should be allowed, those were front of mind for the panel throughout this process,” Gupta told the Star.
The main criterion to be currently eligible for MAID is that the person must have an incurable physical illness that is in an advanced state of irreversible decline and is causing them intolerable suffering.
In order to determine if a person’s mental illness is incurable, the panel recommends that a medical professional assess attempts at treatments and social and community interventions made up until the point of the person applying for MAID, the outcome of those treatments, and the severity and length of the illness.
The panel said it’s impossible to establish “fixed rules” for how many treatments and other supports should be attempted, and over what period of time, before the person becomes potentially eligible.
“This will vary according to the nature and severity of medical conditions the person has and their overall health status,” the panel said. “This must be assessed on a case-by-case basis.”
Capacity to make the decision to apply for MAID was also studied by the panel. All adults, including those with mental disorders, are presumed by law to have the capacity to make decisions, the panel said.
But the panel noted “assessing capacity can be difficult, particularly in situations in which symptoms of a person’s condition, or their life experiences could subtly influence their abilities to understand and appreciate the decision they are to make.”
The panel pointed out that medical professionals are already called upon to assess a person’s capacity to make other crucial health-care decisions, such as refusing potentially life-saving treatment.
“When the assessment is so difficult or uncertain that the clinicians involved cannot establish that a specific individual is capable of giving informed consent, the intervention is not provided to that individual,” the panel stated.
The individual making the request for MAID based on a mental illness should also be assessed by a medical professional with expertise in their condition who is not on their treatment team, the report said.
The panel also touched on suicidality, stating that “it must be recognized that thoughts, plans and actions to bring about one’s death may also be a symptom of the very condition which is the basis for a request for MAID.”
Where suicidality is a concern, a medical professional must ensure among other things that the person has decision-making capacity and establish whether suicide prevention tools, including involuntary ones, are necessary, the panel said.
The office of Health Minister Jean-Yves Duclos said it recognizes that many of the expert panel’s recommendations fall within areas of provincial jurisdiction, and that “continued collaboration” with provinces and medical regulatory bodies on MAID will be important.
“Medical assistance in dying is an important, sensitive and personal issue for many Canadians and we are committed to ensuring that our laws reflect Canadians’ evolving needs as well as support their autonomy, equity, and safety,” said a statement from Duclos’s office.
The panel’s report will be sent to a special joint House-Senate committee that is currently studying areas of expansion for MAID eligibility, including allowing people to make advance requests for the procedure, years before it might actually be carried out.
That committee must deliver its interim report and recommendations by next month.