Canada Backtracks on Euthanasia for the Mentally Ill | Best Countries

For a year, Agata Gawron had March 17, 2024, circled on her calendar.

The 44-year-old resident of Canada’s Saskatchewan province has struggled for three decades with anorexia, clinical depression and PTSD. Her kidneys are failing, and she has a host of other ailments, including osteoporosis and strokes, that she says make her body feel “like a prison.” Still, she says the physical pain is tolerable compared with the “mental anguish” she experiences daily.

“It’s like I’m running a marathon, but there’s no finish line,” says Gawron, who works as an engineering project coordinator.

On March 17, Gawron – who weighs just 79 pounds but does not have a terminal medical diagnosis – was hoping to become eligible for medical assistance in dying after many years of waiting.

Now it seems she won’t get that chance, at least for another three years.

Though Canada legalized medical assistance in dying, or MAID, in 2016, the law has excluded eligibility for those whose only medical condition is mental illness. That exclusion was set to expire in March, paving the way for Gawron and others to petition for a death on their own terms.

But in late January, Canadian Minister of Health Mark Holland announced the move would be pushed back further, citing concerns that the country’s health system wasn’t “ready” for the MAID expansion.

“The Government of Canada recognizes that mental illness can cause the same level of suffering as that of physical illnesses,” the health department said in a statement. “However, in its consultations with the provinces, territories, medical professionals, people with lived experience and other stakeholders, the Government of Canada has heard – and agrees – that the health system is not yet ready for this expansion.”

On Feb. 29, Bill C-62 took effect, formally postponing eligibility for those with mental disorders until March 17, 2027.

While some cheered the decision, the reversal of course has left Gawron and others like her reeling and isolated. “I am noticing my symptoms progressively deteriorating now at a faster pace than even just a year ago and I cry inside knowing that the one path I thought I could take is now being redesigned,” she says.

In the meantime, debate in the country continues over when and whether suffering from a mental disorder can warrant a medically assisted death.

The conversation around assisted death first picked up steam in Canada in 2015. That year, the Supreme Court of Canada ruled that the country’s ban on assisted dying violated Canadians’ rights to life, liberty and security, prompting a change to the criminal code and the eventual passing of legislation in 2016 that laid out formal requirements for the procedure.

As the law currently stands, Canadians who wish to die with medical assistance must have a serious and incurable illness or disability, must be in an “advanced state of irreversible decline” and must have “enduring and intolerable physical or psychological suffering” that cannot be alleviated in ways the person finds acceptable. Though the vast majority of MAID patients choose lethal injection by a medical provider, self-administering the life-ending drugs is permitted everywhere in Canada except Quebec.

In 2016, the first year the law was enacted, 1,018 Canadians died with medical assistance, according to Health Canada, a federal institution responsible for standards of care. In 2021, that number jumped to 10,000, accounting for 3.3% of all deaths in Canada that year. Since the legislation passed, nearly 45,000 Canadians have died with medical assistance.

For the first five years of the law’s life, only those with irremediable conditions and a “reasonably foreseeable” natural death were eligible: Upward of 60% of Canadians who died with medical assistance as of 2022 had cancer, and nearly 80% had received palliative care of some kind.

But beginning in March 2021, by way of additional legislation, eligibility was expanded to include those for whom a natural death was not “reasonably foreseeable.” That year, over 200 individuals with conditions such as Parkinson’s disease, multiple sclerosis and chronic pain received assistance in dying. However, none of them had a mental disorder as their sole underlying condition. The bill excluded those with mental disorders for a period of 24 months, a delay that was later extended to March 2024.

Support for MAID remains high across Canada, with surveys finding a majority of Canadians approve of the practice generally. Public opinion on medical assistance in dying for those with a mental disorder, however, is more split, with some polls finding Canadians divided on the practice, and others finding strong support for it with “appropriate safeguards.”

Should the expansion eventually come to pass, Canada would join the ranks of a handful of countries – Belgium, Luxembourg, the Netherlands and Switzerland – where assisted death for people with chronic mental disorders is already in place.

Setbacks for MAID for Mental Disorders

The ongoing exclusion of people whose sole medical condition is mental illness has been subject to heated debate.

Sen. Stan Kutcher, a psychiatrist and member of Canada’s Special Joint Committee on Medical Assistance in Dying, continues to push back against the extension and argues that the exclusion of those with mental disorders as their sole underlying condition violates their rights – an opinion shared by others in favor of expansion. “All Canadians, regardless of where they live, who they love, what illness they have, have the same rights,” Kutcher said at a press conference in early February. “And this goes for people with a mental disorder.”

Dying With Dignity Canada, a group advocating for end-of-life rights, expressed frustration that the law was postponed once more. In a statement about the delay, the group said it “is disheartened and shares the frustration of the continued exclusion, stigmatization and discrimination based on diagnosis,” adding that from its perspective, “there have been three productive years of preparations, and the necessary work committed to by the Government is complete.”

For those with chronic mental disorders seeking medical aid in dying, the journey toward obtaining eligibility has been daunting, and the government’s recent delay incredibly frustrating.

Alex, a 25-year-old Ontarian who suffers from complex post-traumatic stress disorder and other psychological disorders, describes the legal delays as “stupidly bureaucratic” and says they’ve led to instances of self-harm and suicidal ideation.

In addition to severe psychological disorders, Alex, whose name has been changed due to privacy concerns, suffers from neurological and autoimmune disorders that they say are “progressively worsening,” resulting in constant pain that makes independence impossible.

Throughout their life, Alex has cycled through an array of medications, psychotherapies, psych ward stays and programs to no avail. MAID, they say, offers them and others an option that they consider “long overdue for a country that champions itself as a world leader on human rights.”

“Only suffering is guaranteed in life, and everyone deserves the dignity to relieve it in any way they personally consider in their own best interest,” Alex says.

After months of waiting, Alex says they’re “honestly at a loss for words” and that the delay has sent them into a “crisis headspace.”

Safeguards and Skepticism

While many are frustrated with the legislative limbo over MAID and mental disorders, others are relieved by the delay. Dr. Sonu Gaind, a psychiatrist who was the physician chair of the Humber River Hospital MAID team in Toronto for a 10-year term, is one of them.

“I’m appreciative that they have taken a step back from what they were planning this March because I think, honestly, this is the only responsible decision that could have been made,” Gaind says.

Gaind worries that allowing mental illness as a sole condition for MAID might further endanger the country’s most vulnerable, whom he says already lack access to mental health care and statistically face higher poverty rates and other social stressors relative to their neurotypical counterparts.

Health care practitioners then risk providing MAID “to people who are at much higher risk of social distress and marginalization,” and who are “seeking MAID not to avoid a painful death but to avoid a painful life,” he says.

Indeed, Canada finds itself in the midst of mental health troubles. According to a July 2022 report, while roughly 63% of Canadians in the highest income quintile reported having their needs met for mental health issues, that number dwindled to just half among those in the lowest income bracket, meaning 14 fewer adults per 100 had their mental health needs met.

Proponents counter that legislators and providers alike have built guardrails into the system to prevent harm.

Dr. Mona Gupta – chair of an expert federal panel on MAID and mental illness that was tasked with recommending how MAID for mental disorders might be undertaken by health providers and systems – contends that safeguards against excessive or improper use of MAID are in place and growing.

Navigating the complexities of mental disorders, particularly when mental disorders are the sole condition of an assisted dying case, has been the subject of many months of work and contemplation for practitioners and policymakers, she says.

“More work, time, effort and energy have been put into assisted dying for people with mental disorders as a sole condition than all of the entire assisted dying regime,” says Gupta, a psychiatrist at the University of Montréal. “In terms of the metrics that the government set for so-called readiness, they were all met.”

Still, the move toward another delay was not entirely surprising to Gupta: “I think great pressure was applied to introduce yet another bill to extend the exclusion.”

A final report from Gupta’s panel, published in May 2022, serves as a blueprint for a series of educational and practice standards for hospitals and providers across the country’s 13 provinces who are responsible for assessing and administering MAID. The report includes a call for a “practitioner with expertise” on the patient’s condition, as well as a directive to refer potentially suicidal MAID requestors to support if they are deemed ineligible.

Per the recommendations, applicants whose conditions are not terminal must have assessments from two medical providers, be informed of alternate treatments and face a 90-day minimum assessment period. Beyond such conditions, Canadians seeking MAID face no additional legal requirements, though the practice standards highlighted by Gupta are intended to act as additional guardrails for the process.

Gaind argues that these “suggestions aren’t safeguards” and that “evidence shows us that you can’t actually make any reasonable predictions of irremediability in mental illness.” And he’s not the first to point out uncertainty surrounding that issue.

In early 2023, for example, Canada’s Center for Addiction and Mental Health – a Toronto-based psychiatric teaching hospital – wrote in a statement that “while the scientific evidence to date does not provide clear guidance on when mental illness can be considered irremediable, it does not eliminate this possibility.”

Meanwhile, as the country contemplates eligibility – now and potentially over the next three years – Gaind hopes time also is spent working to bring the country’s mental health support up to muster: “We have fellow Canadians who are in deep states of suffering,” he says. “What [can] we actually try to do to help them?”

Despite the delay, Gawron and Alex still eagerly await eligibility.

“I am going to aggressively protest for my right to die,” Alex says. “If I cannot have the right to live a dignified life with the most that can be offered to me as a citizen of a first world country, at least grant me the right to die without further dehumanization by stripping my autonomy any further.”

Gawron adds: “I just want to be free and am completely capable to decide my own destiny. I only ask for compassion and permission to leave quietly on my own terms.”