Dating whispers in Julie Leblanc’s mind when she’s feeling most desperate. She draws her thoughts when, for days, she forgets to eat or doesn’t shower. He thinks about it more than he knows he should. On March 17, assisted dying will become legal for Canadians with a mental disorder as a sole condition, and Ms. Leblanc can apply. He has been struggling with mental illness since he was 8 years old. At 13 she was prescribed her first trial of antidepressants. Now 31, she has tried too many drugs to count and has spent much of her life either in treatment or waiting on a list to receive them. Bouncing between doctors, she’s been given multiple diagnoses – depression, anxiety, PTSD, borderline personality disorder. She vacillates between wanting to die and trying to live, especially for her 11-year-old son who is being cared for by her parents. She tries to feel optimistic about the serious new psychiatrist, her third in a year, who patiently listened to her at their first appointment in September. But she is tired of retelling her story. It never seems to help. She feels trapped in despair and anxiety, while carrying the deepest sadness of all – her illness preventing her from being a good mother to her son. He has tried to kill himself in the past. But now she worries that suicide will be painful or that she will end up in a wheelchair, which happened to someone she knows. She has researched medical aid in dying online. MAID sounds peaceful, he says. And also very tempting. How, she wonders, could the same system that was meant to keep her alive help her soon die? When that option arrives in March, Canada will have one of the most liberal euthanasia laws in the world, joining only a handful of other countries that allow assisted dying for the mentally ill. It will be the most controversial expansion of MAID since a Supreme Court ruling led the federal government to legalize euthanasia in 2016. At the time, MAID was only for patients with foreseeable death, but Parliament – with Bill C- 7 – removed this requirement in 2021. The original version of the bill did not allow assisted dying for patients with mental disorders as a sole condition because, the government said at the time, there were outstanding questions about how illnesses such as depression could be safely included and which might is the future effects are. The Senate disagreed, removing that exclusion before the bill passed, but with a caveat: Parliament would study the issue for two years before any of those patients could receive MAID. With four months to go, there is still no consensus in the mental health community – and, in fact, doctors remain deeply divided. There are no definitive national standards, no transparent review process to track errors, and hospitals are still figuring out how to implement the change. Toronto’s Center for Addiction and Mental Health (CAMH), Canada’s largest psychiatric hospital, has said assisted dying should not be expanded without more study. And the Canadian Mental Heath Association has expressed serious concerns about expanding MAID without first increasing funding for mental health care. In Quebec, after public consultations, a legislative committee recommended against the province extending MAID to mental illness at all. Meanwhile, in Ottawa, the federal parliamentary committee reviewing the law was due to release recommendations in October. Instead, after months of emotional and polarized testimony from psychiatrists and researchers, lawmakers and senators will now report next February, just weeks before MAID’s automatic expansion. Disagreement among experts, an unclear law, the arbitrary legislative finish line – all of these would be troubling, even in normal times. But Bill C-7 was passed before the full effects of COVID-19 were known, before the pandemic ripped through the health care system and left it in tatters. The law requires that patients who request MAID be informed of possible treatment options that could relieve their pain. But that assumes they are readily available. Instead, wait times to see what mental health doctors have only Increased. Psychotherapy, a recommended treatment for most mental disorders, remains too expensive for many Canadians. Only in Toronto, it’s appreciated 16,000 people are waiting for supportive housing for mental illness and addiction. In Ontario, almost 6,000 patients with the most severe mental disorders are on a long-term list for specialist community-based care. The rising cost of rent and food it also places a heavy burden on people with chronic mental illness, who are often already the poorest in society – and the very candidates who will qualify for assisted dying under the new law. As life gets harder in Canada, it gets easier to die. For advocates, expanding MAID is about not distinguishing between mental and physical health, seeing patients as whole people capable of making their own decisions. Critics, on the other hand, suggest that MAID will become an easy fix for a broken health care system, offering death instead of hope and healing to society’s most vulnerable and marginalized citizens. Whether Canadians have fully discussed where we stand as a society on these ethical and medical issues is almost beside the point at this point. With March circled in red on the calendar, Canada is accelerating towards its own unique life-or-death experiment. The country must ensure that MAID expansion is safe for patients. Do we have time to do it right? “After all is said and done, the primary issue is: what does the patient want to do?” says Derrick Smith, a member of the Canadian Psychiatric Association’s assisted dying committee. Dr. Smith is among a relatively small group of psychiatrists currently participating in Canada’s MAID process.Ismail Ferdous/The Globe and Mail When MAID was first legalized in 2016, it came with a narrative that was comforting to many Canadians: faced with a painful, imminent death, patients – most of them in their old age – would choose, after discussion with their doctor, to die on their own terms, peacefully, with dignity and surrounded by their family. As the number of Canadians receiving MAID has steadily increased, this narrative has remained largely true. In 2021, there were 10,064 assisted deaths in Canada – a 32 per cent increase over 2020. The average age of Canadians who received MAID last year was 76. Two-thirds have a cancer diagnosis and nearly one-fifth have a heart condition. They tend to be wealthier Canadians – more likely, an Ontario study found, to be in the highest income bracket than the lowest. There were, in other words, people of relative privilege who wanted the same control in death that they had in life. Testifying in support of expanding MAID last spring, Derryck Smith, a BC psychiatrist, shared the example of a woman in her 40s who evaluated for MAID. She was the daughter of a judge, she said, who had struggled with anorexia for years. No treatment worked. private clinics in the United States failed to help. She had been hospitalized and tube fed against her will. She vowed to go home and starve if she wasn’t approved for MAID. Reluctantly, her father, interviewed by Dr. Smith, agreed to support her decision. Her condition was deemed incurable, her suffering unbearable, and she was given assisted death. Dr. Smith, who sits on the assisted dying committee for the Canadian Psychiatric Association and is a member of the Canadian Association of MAID Assessors and Providers, falls on the patient autonomy side of the debate. He recognizes that the health system is broken and underfunded. But he argues that if a person is capable of consent, meets the legal requirements and wants to die, it would be morally wrong to deny their right to choose. Otherwise, these patients are truly trapped: they cannot receive timely treatment to relieve their pain, and they cannot choose to end this suffering. “After all is said and done,” said Dr. Smith, “the primary question is: what does the patient want to do?” Mona Gupta, head of the federal expert panel, told a parliamentary committee last spring that the exclusion of MAID for people with mental illness, “suggests that, as a society, we don’t believe that people with mental disorders can ever really make their own the decisions for themselves”. But this moral argument raises another: Can a person freely choose to die if they do not have an equal opportunity to live in dignity? Unlike the judge’s daughter, people with chronic and serious mental illnesses don’t usually travel out of the country for high-end private care. Many of them won’t even have family doctors, let alone regular contact with specialists. Compared to the general population – and compared to Canadians receiving MAID today – they are far more likely to be unemployed and homeless. Their stories are often complicated by trauma, childhood abuse and addiction – their symptoms exacerbated by financial stress and loneliness. Rather than worrying about equal opportunities in death, says Sonu Gaind, chief psychiatrist at Humber River Hospital, society must first correct the wrongs its patients face in life. “It’s about the autonomy of the privileged at the expense of the marginalized,” he says. In the Netherlands, where euthanasia for both physical and psychiatric illnesses has been legal for 20 years, studies have shown that patients receiving assisted death for a mental health disorder tend to be younger and poorer than those with a physical illness. They are also much more likely to be women…
